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Community Anticipatory Care Planning Nursing Team
The Service
• Delivers person centred outcome focused holistic assessment to help people remain well and safe at home.
• Emphasis on building resilience and making the person the expert in their health and well being.
• Self management planning and education to assist people to take control and responsibility .
• Identifies resources that can help people stay connected to their communities .
• Update information systems for District Nursing/General Practice /Key Information Summary/Social Work
Patient Identification and Referral
• No strict referral criteriaExamples – High SPARRA
Housebound Long Term Conditions Recent unscheduled admission Carer stress ................
• Referral from Health ,Social and 3rd Sector
What’s Different ?Outcomes focused Assessments • Do not focus on the services available but on what
the individual wishes to achieve. • Personal outcomes should first and foremost be
understood as what matters to the person and why (Cook and Miller, 2012).
• Getting the right care at the right place at the right time.
Case Management of the individual to achieve this
ACP assessment = Good Conversation
Malnutrition Assessment
Activities of daily living
Medication Review
Falls Assessment
Benefits reviewMoving and Handling
Power of Attorney Clinical assessment
Environmental assessment
Social assessment
Self management planning
Carers Assessment
Key Components of ACP
Cognitive assessment
Patient Feedback
• Dad and family now feel clear about the path forward and care/hospital options.
• Following the visit I felt much more confident about my future.
• Nice to know that someone will listen and is interested in what we think as we get older.
• We feel well looked after and that we are not alone anymore in finding the help we need.
• I feel more in control.
Patient Stories
• Complex MS patient • Multi agency involvement• No further Hospital admissions• Referral by GP• ACP assessment• Medical ACP• DNACPR• Collaborative working • Key information summary update• Regular review
Patient Stories• Newly diagnosed
Meniere’s disease• 3 readmissions to hospital • Referred by ANP• ACP assessment• Patient education• Self management plan • Physiotherapy and
occupational therapy• Reablement support• Carer support