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