It is very important for care home residents to be given to opportunity to have conversations about their wishes. This is why we have started a new project across the Health Board to train staff within these Homes to have good conversations and help residents, their friends and family create realistic Future Care Plans which will help ensure the right thing is done at the right time by the right person to achieve the best outcome.
Please find more information about the project below.
What is the project?
The My Health, My Care, My Home Framework identifies the importance of Future Care Plans (previously Anticipatory Care Plans) for all Care Home residents in Scotland.
Based on a project in NHS Lothian, called “7 Steps to ACP”, this pilot has been created to support care home staff, residents and families engage in good conversations and the creation of meaningful plans.
3 parts to the project:
- Family meeting to explain Future Care Planning ( online, in person or on video)
- Education for care home staff including training example
- Completing a Future Care Plan for all residents including the “3 Questions”
Listen to Dr Jude Marshall talk more about the project and the benefits it can bring to residents, families and staff.
What are the 3 Questions?
It can be helpful for us to think about some scenarios which might occur, and what we should do in these situations. This means everyone understands what the plan is, if a crisis occurs.
Therefore we would like to speak to you, and the people who matter to you, about what would be the best thing to do if any of the following three things happen:
- If you had a sudden collapse (such as a stroke or a heart condition,)
- If you had a serious infection that was not improving with an antibiotic tablet or syrup
- If you were not eating or drinking because you were now very unwell
We have three suggestions of possible plans for each of these situations:
- Keep you comfortable, treat any pain or other symptoms and care for you at home.
- Contact NHS24/GP (or family) to help decide whether to send you to hospital instead of dialling 999.
- Send you to hospital for investigations and treatment such as drips and treatment into vein.
You might wish to have different plans for each scenario, this is okay.
By thinking about these situations beforehand, we all have time to discuss what really matters to our residents and their friends and family. Everyone has the opportunity to ask questions and find out about what treatment can be delivered in our Care Homes – this might be more appropriate that sending people to hospital which can be stressful.
We can record the answers to the three questions in the Future Care Plan and share this information with other services including the GP.
What training do the staff get?
The care home staff can attend a training session which covers:
- The benefits of Future Care Planning
- Who should be having Future Care Plans
- How to have good conversations
- How to document and share the information
The session also includes the opportunity to watch a “live” conversation to help staff identifying helpful communication techniques.
This training is delivered by local teams – usually Care Home Liaison Nurses (CHLN) or Practice Development Nurses.
I’m a Care Home Manager, how can my Home get involved?
We are currently rolling out this programme across NHSGGC. If you would like to put your Home forward for training then please contact your local care home service (this might be CHLN or Practice Development Team) to let them know you are interested. They will let you know about approximate timelines.
In the meantime, you may want to have a look at our other resources for staff engaging and recording Future Care Planning conversations.
I am a resident/ I have a friend or family member who is a resident, how can I get involved?
We are currently rolling out this programme across NHSGGC. Ask your Care Home manager if the Home is already engaged in the project.
Even if the Home is not yet involved in the project, you can still have a Future Care Plan. The Home might have their own version of a plan, or you can also use the NHSGGC Summary Plan. You can also discuss the 3 Questions with friends and family and record what you would like to happen in the “views on hospital admission” box. We would strongly recommend having a conversation with the staff at the Home as well, as they will be able to tell you more about the care and treatment which is available within the Home.
Below are some more frequently asked questions about Future Care Planning in Care Homes.
What is a Future Care Plan?
A Future Care Plan is a record of someone wishes. It should be created over time and reflects conversations between a resident, the people that matter to them and the health care professionals that work with them.
What information is in a Future Care Plan?
The plan should include:
- a summary of the “thinking ahead” discussions
- a record of the preferred actions, treatments and responses that care providers should make following a decline in health
Some Future Care Plans include information about care at the end of life including where residents would like to be cared for and their wishes about different treatments including resuscitation. All these discussions should be had sensitively and with consideration and should include the people who the resident wishes to be there.
How can we help everyone prepare for these conversation?
Some people will not have considered these topics before. It is important that you give them time and space to reflect before having these conversations.
To start with, have a conversation with everyone to explain what Future Care Planning is. You can give them some information to read through and think about it. Let them know you would like to talk more about this in the future.
It is important to involve everyone in these discussions, however if a resident does not have capacity to make these decisions, then it may not be appropriate to give them this information. In these cases we should make every attempt to involve friends, family and carers in order to agree what would be best for the resident and respect their wishes.
You may feel like you don’t know enough about some topics to give advice to others. For example you might not feel able to answer some questions about DNRCPR, or you might be unsure of the level of support home care can give. If someone asks a question that you don’t know the answer to, be honest about this. Tell them you aren’t sure right now but you will find the information and get back to them. Talk to your colleagues to try and find out the necessary information or you can email ggc.HomeFirst@nhs.scot
Are there any leaflets to help explain what Future Care Planning means to resident’s friends and family?
There are lots of resources available on on resources page, however here is a lost of resources that might be particularly useful in Care Home settings.
Information Leaflets
Information for Residents – (PDF)
Information for Relatives and Friends – (PDF)
DISCUSS – A Guide For People Thinking About Their Future – PDF
DISCUSS – A Guide For People Thinking About Their Future – PDF (Black & White Version)
DISCUSS – A Guide For Friends, Family and Carers – PDF
DISCUSS – A Guide For Friends, Family and Carers – PDF (Black & White Version)
DISCUSS – A Guide For Staff – PDF
DISCUSS – A Guide For Staff – PDF (Black & White Version)
How do you complete a Future Care Plan?
There are different ways of recording Future Care Plans and each care home may differ. However it’s important to share this information with health and social care partners so that treatment plans reflect people’s wishes. The easiest way to do this, is to link with the GP who can update the Key Information Summary (KIS). This is an electronic record which NHS24, the Scottish Ambulance Service and hospitals can access.
To help transfer this information quickly and easily, all HSCPs in Greater Glasgow and Clyde use a Future Care Plan Summary to record Future Care Planning decisions. This mirrors the information on the KIS so GPs can if they wish quickly copy information to the KIS. It can be accessed either on Clinical Portal (specific Future Care Planning/ACP tab), or services can use an interactive PDF.
Some Care Homes have access to Clinical Portal. Unfortunately this is only available currently for HSCP Care Homes. These Homes can fill out the summary directly on there. Clinical Portal will automatically send the Future Care Plan to the GP and they can if they wish transfer the information to the KIS.
For Homes which do not have direct access to Clinical Portal. they can fill out this interactive PDF and email or post a copy to the GP.
Remember, if any changes are made at the Future Care Plan review, this information needs to be sent to the GP so they can update the KIS.
Guide to updating Future Care Plans on Clinical Portal (PDF)
Guide to updating Future Care Plans on Clinical Portal (Video)
Guide for GPs Updating eKIS from Future Care Plan Summary (PDF)
How can you use a Future Care Plan to make care and treatment plans?
People’s wishes and the wishes of those that matter to them, must always be taken into account when deciding on treatment plans. By doing this you will make a plan specific to this individual and based on what is important for them.
Many residents who live in a care home may choose to remain there if they become unwell. Their main priority might be comfort, and being in their own room, looked after by staff who know them well. However there will be some residents who may benefit from admission to hospital and would want to be transferred. If they do go into hospital it is important to send with them a copy of any previous discussions. If someone has a DNACPR form please send a copy with them.
What happens if someone changes their mind?
Anyone can change their mind, and as circumstances change, what is important to people might also change. This is why we think the most important part of the Future Care Planning process is the ongoing conversations with residents and the people that matter to them.
Final plans do not need to be made but recording the content of these discussions means these plans can be built on. We would expect that Future Care Plans would be reviewed perhaps every 6 months at the time of the resident’s reviews.
If you have any questions or would like more information please email ggc.HomeFirst@nhs.scot