Anticipatory Care Planning

Throughout this series of blogs, you will hear repeatedly that our population is ageing and that is really good news.  However, we are also aware that the likelihood of having long-term, multiple chronic or complex conditions increases with age.  So, as healthcare professionals need to have models of care that are designed to meet the many needs of individuals.

Anticipatory Care Planning (ACP) is part of that support. So, what is Anticipatory Care Planning?  It’s about ‘thinking ahead’ and planning action or taking action before something happens.

It involves having detailed collaborative conversations between the person, their family and their care team about future care and preferred options. The process can also be used to explore how individuals can participate in their own care as an extension of self-management.

Anticipatory care planning conversations can be uncomfortable to initiate however with practice it becomes easier and as your experience develops you will become more confident in your approach.  Some people may wish to start the conversation themselves which is great, however others may experience anxiety when considering their future and may wish to avoid having such discussions until they are ready.  This is when your coaching skills will be of great value.

There will be many opportunities to start the process during care interactions and these conversations should focus on the person’s health, well-being and their actual clinical conditions in an attempt to reduce possible crises.  ACP’s also identify where  the person wishes to be  cared for and though collaborative discussion,  it helps identify their own personal outcomes.

Anticipatory Care Planning conversations are completely voluntary and are in no way  legally binding. We know people often change their wishes as circumstances change, so it is vitally important that care preferences are recorded in an ACP with any changes highlighted, dated and communicated to the wider care team.   Example ACP’s can be found at

Anticipatory Care Planning conversations should be:

  • Collaborative: Individuals and carers are at the centre of their ACP conversations
  • Ethical:  Respect for the person’s values, beliefs and preferences for care, by including what matters to them
  • Comprehensive: Clear communication of key information (e.g. individuals or care providers involved in care or support requirements)
  • Informative communication: Establishes a robust pathway of communication sharing (including e-sharing), which can be helpful to other colleagues, care providers or agencies involved in care. Improving individuals understanding of their health and well-being (health literacy) is essential to person-centred care models which incorporate effective communication, self-management and essentially patient safety
  • Self management approach:
    • Demonstrates the unique symptoms the person may experience and simple actions they can take to address them
    • Enables early identification of health change or health needs, and relevant interventions required to support recovery or reduce crisis
  • Personal:  Information that is important to the individual or carer
  • Relevant: Highly important matters e.g. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) status and  Power of Attorney
  • Realistic: Recovery goals that reflect the individual’s hopes, aspirations and preferences e.g. “Things that I must do to keep well” or “What is important to me and why?” Such measures may help to facilitate hope and encourage active participation in the ACP process.
  • Carer considerate: Enabling alternative arrangements or contingency plans in the event of the carer becoming unwell, thereby reducing the need for acute admission to hospital.

(Barrie, Steel & Loughlin 2019, in Essentials of Nursing Adults, Eds: Elcock, Wright, Newcombe & Everett, Sage, London)

Please take some time to watch some of the personal experiences of those who have undertaken developing an ACP before and hear how important this was to them.

Promoting Independence and Self Management

Almost half the population of Scotland have at least one long term condition (Scottish Health Survey 2014) and we know that the older people become, the more long term conditions they will develop.

It has been suggested that on average, the length of time someone with a long term condition spends with a healthcare professional is roughly 4 hours per year (NHS England 2006). For the rest of the time, they or their families are managing the condition and their circumstances at home.

For a more detailed background and more information check out the IFIC Scotland Webinar Integrated Care Matters, Series 4: Self Management and Co production

There are a number of techniques nurses can use to help people to self manage. By embedding these skills in our practice we can support people at every interaction to engage in the behaviours necessary to facilitate self management to the point where it becomes second nature.

These include:

1. Health promoting behaviours

2. Signposting to easy to read information and educational materials

3. Facilitate the person to set small achievable goals and plan actions to achieve these.

4. Peer Support

5. Provide a coaching role

6. Support unpaid carers and recognise the very important role they have.

As nurses we have a vital role to play in ensuring people have the right knowledge, skills and support when they need it. This will enable people to develop the skills and confidence to live as independently as possible and to live well despite their long term conditions. During the development of Scotland’s Self Management Strategy, the Health and Social Care Alliance (THE ALLIANCE), together with people living with long term conditions identified key stages when people said they needed more support to continue to self manage. The key stages are:

1. On diagnosis of a long term condition

2. Living for today

3. Progression

4. Transitions

5. End of Life

Please go and take a look at the Scotland’s Self Management Strategy entitled ‘Gaun Yersel’ which can be found at

Most people will say they self manage to varying degrees. For some this may be in the form of managing complex medication regimens, for others this may involve using highly technical skills and equipment. As a result people need different levels of support at different times to help them to self-manage their own conditions.

There are some excellent resources on Self Management and Co Production available at: Take a look and watch some of the very helpful videos.

In 2011, The Health Foundation published “Helping People help themselves” which looks at the evidence around self management.

The Key Points from this document are:

Evidence suggests that supporting self-management works. Supporting people to look after themselves can improve their motivation, the extent to which they eat well and exercise, as well as improving their symptoms and clinical outcomes.

Although many initiatives and different types of support are available, some are more useful than others. To encourage people to engage in self management activities the provision of information alone is unlikely to be enough to motivate behaviour change – more self-management approaches are necessary.

So, how do we know that people understand the health related information or instruction of techniques we provide to facilitate self management? There is an approach called Teach-Back. Its very simple and quick. After providing information about their condition or demonstrating a technique, all you have to do is ask the person to explain back in their own words what they have just heard or seen in order to demonstrate their understanding. If the person is unable to explain or describe the technique or information, then we should re-educate the person using different words until the person can show they understand. This is not a test for the patient, so asking the person to explain back what they have just heard should be done in a relaxed and friendly manner, avoiding technical jargon. Teach-Back has been shown to be a very useful technique to promote understanding and facilitate self management. It is a technique related to health literacy – for more about health literacy, look at the previous post on this blog site on Sensory Changes and Frailty.

For more information about teach-back go to

Sensory Changes and Frailty

As we age, our sensory systems gradually start to decline. For more information about the ways in which our senses are affected by age the following article from MedlinePlus Medical Encyclopaedia, called Ageing Changes in the Senses is a useful summary which you can access HERE

To understand the scale of the problem consider firstly the number of older people who wear glasses or contacts who are over 55. It’s also worth noting that it is estimated that 945,000 people in Scotland are deaf or have hearing loss and that more than 500,000 people in Scotland have a form of tinnitus.

Sensory impairment has been shown to have psychological, psychosocial,
and functional effects that may lead to social isolation, anxiety, depression, paranoia, and decreased self-esteem.

Dual sensory loss (DSL), the presence of both hearing loss and vision loss is particularly prevalent among ageing populations across the world with studies showing that more than 20% of adults older than 70 years are affected with that percentage increasing with advancing age. The interaction between the variety of visual losses and the variation in types of hearing loss means that there is a wide variation in each individuals needs. This makes it difficult for community staff who have very little cross disciplinary training to meet every need they encounter even though they are meeting older people with multiple sensory impairments every day.

However DSL also affects the ability of older people to perform Instrumental Activities of Daily Living (IADL’s). So although problems with dressing and bathing may occur using a ‘phone or grocery shopping, preparing meals, managing housework and money are far more likely problems and will limit the ability of frail older people to remain at home. The likelihood of identifying and intervening when such problems exist is not helped by older adults themselves, who tend to overestimate their capabilities. Not only are AIDL’s affected, frail older people with sensory impairments also experience poorer overall mobility and the more severe the loss the more likely functional and cognitive decline will occur.

What Can You Do?

The Importance of Hearing Aids. One of the most important things you can do is encourage the use of hearing aids. Kochkin and Rogin (2000) in a study conducted for the US National Council on Aging showed that individuals with hearing impairment who did not use hearing aids participated in statistically significantly fewer social activities and reported statistically significantly more anxiety, depression, emotional instability, and paranoia than individuals who used hearing aids.

However there is a huge stigma surrounding hearing impairment that generally manifests as a reluctance to acquire hearing aids or to participate in any other types of aural rehabilitation.

Consider the Persons Manual Dexterity? With advancing age comes diminished manual dexterity. This has direct effects on several aspects of
hearing aid use and aural rehabilitation, with the most obvious being hearing aid insertion, manipulation of the hearing aid controls, and handling of the battery. There is a strong association between poor manual dexterity and poorer hearing aid outcomes, like less daily use, and lower satisfaction with hearing aids. A study by Parving and Philip (1991) reported that 40% of hearing aid users by the time they were 90 could not use the
volume control wheel, 36% could not change the hearing aid battery, and 34% could not clean the hearing aid ear mould.

Consider the Person’s Health Literacy. DSL is also known to limit a person’s ability to understand and recall the information provided and to successfully integrate self-care into their daily life. It has
been shown that generally older people have the lowest health literacy and
related adverse health outcomes than younger people. Therefore, communication needs to be optimized to accommodate the sensory needs of older individuals to the extent possible.

  • To ensure this the environment needs to be optimized.
  • You need to speak clearly and make efforts to clearly enunciate and to increase the time between spoken words, decreasing your rate of speech.
  • Provide clear written materials. Remember literacy level and pitch to a reading age around 12. Written material should be 14 points and have wide spaces between the lines. A sans serif font should be used and multiple columns on a page should be avoided.

A more extensive guide with videos on how to communicate with someone with hearing loss can be found HERE

Provide/Use Assistive Devices. Like hearing loops, magnifiers with lights, video magnifiers, tactile devices (like vibrating alarm clocks, door bells etc). Whatever you think might help the person. See: and

Provide Redundancy. When delivering information use multiple perceptual channels (visual, auditory, and tactile). This increases the person’s opportunity to all information provided. Supplement anything you say with written materials which can be verbally repeated by carers, relatives etc. If you use low or high technology always buy/use technology with built in redundancy. The reason for doing this is that the circumstances of the person the assistive technology/device will change. As a result, you never know when you might need more functions/capabilities to be switched on.

Use Patient Teach-back. A useful method for verifying that the information you want the person to understand is understood to get the person to repeat back in his or her own words what was said or demonstrate the procedure you are trying to get them to learn/understand indicated by the provider. This way you can check the communication is understood and correct any misunderstandings. See

Further Information

See: Royal National Institute for the Blind Services page

and Action on Hearing Loss’s Guidance for Nurses.

Introducing Frailty

The definition of Frailty that we will use in this programme was introduced to you all on the first day. For us frailty is not an illness but a syndrome that combines the effects of natural ageing with the outcomes of multiple long-term conditions, a loss of fitness and reserves (Lyndon, 2014).

Older people who are living with frailty often say they have fatigue unintended weight loss, diminished strength and their ability to recover from illness or injury, even minor ones is greatly reduced. This can have a marked impact on the quality and length of their lives (RCN, 2019)

We also took sometime to look at this video from Age UK

In this video older people talk about their desire to remain independent and in control. For more information on Age UK’s research in this area visit

In the afternoon we looked in more detail at identifying and assessing frailty. The presentation that we used and all the information it contains is accessible to you below. The presentation was built using a Microsoft application called SWAY. There are different ways to view Sway presentations and a brief guide to viewing Sway is available HERE.

To view the content scroll down the bar at the side of the object or click the “open to full screen” symbol you will see in the right hand corner where other viewing options are also available. Note that anything that is underlined is an active internet link.

Anything that has a “play” arrow in the middle of the picture is a video.

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