7-Steps Anticipatory Care Planning project

Edinburgh Health and Social Care Partnership Long Term Conditions Programme

The LTC Programme recognises the value of supporting people to improve clinical and personal outcomes by planning ahead for their health and care. Since 2016, their Anticipatory Care Planning (ACP) team has been providing dedicated project and improvement support in ACP for people living with long term conditions at home or in their care home. Read more about development of the 7-Steps here.

The 7-Steps Resources for ACP in Care Homes include the Anticipatory Care Questions (ACQ) and the RED-MAP communication guides.

The ACQ helps residents and/or their family/close friends think about how a resident would like to be cared for and what they would not want if their health were to deteriorate.
Plans can then be made about whether going to hospital would be right for this person, and about specific treatments, including CPR. There are 3 main situations:

  1. If you (your relative/friend) had a sudden illness (such as a stroke or heart condition), how would you (your relative/friend) like to be cared for?
  2. If you (your relative/friend) had a serious infection that was not improving with antibiotic tablets or syrup, how would you (your relative/friend) like to be cared for?
  3. If you (your relative/friend) were not eating or drinking because you/they were now very unwell, how would you  (your relative/friend) like to be cared for?

Talking about ACP

RED-MAP Guide to talking with care home residents about ACP (May 2020)

RED-MAP Guide to talking with relatives about ACP (May 2020

ACP leaflet for care home residents, their families and friends (to be added)
ACP leaflet for people living at home (to be added)

Staying in my Care Home or Going to Hospital (training video for staff made before COVID-19)

Other resources

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