This document outlines an agenda and materials for an event on Anticipatory Care Planning (ACP). The event will include presentations on realistic aging, early interventions and better outcomes, innovations in Ayrshire, and a film/workshop. The document discusses the national action plan for ACP in Scotland, which aims to raise awareness, share information, ensure carer support, and increase access to key information summaries. It emphasizes that ACP is everyone's responsibility and should recognize opportunities through various life stages and conditions. The document advocates for person-centered care with personal ownership through developing support materials, documentation, and testing approaches to advocacy and power of attorney.

1. Anticipatory Care Planning
Making it Happen
Let’s Think Ahead
Stuart Cumming, ACP Lead
Janette Barrie, ACP Lead
16th November, 2016

2. Anticipatory Care Planning (ACP)
Time to Make it Happen
9.30-9.45 Welcome and Introduction -Diane Murray
9.45-10.00 Making it happen –recap
10.00-10.15 Setting the (Music) Scene
10.15- 11.00 Realistic Ageing (Martin Wilson)
11.00-11.15 Coffee to go
11.15-12.45 ACP Workshops (2 of 3)
Early Interventions, better outcomes
Children and Young Adults
Ayrshire Innovations
12.45- 13.30 Lunch
13.30-14.10 Tests of Change
Advocacy
Power of Attorney
ACP Nursing Team
ACP Technology
14.10-15.30 Seven Songs for a Long Life- Film and Workshop
(Amy Hardie)
15.30-15.35 Close

3. Quick recap...how we got here
ACP Task and Finish
Group
Improvement
Collaboratives
Living Well in
Communities
National
ACP Programme Board
National Action Plan
for ACP

4. National Action Plan for ACP
Ensure delivery of ACP for all who would benefit :
1. Raise awareness and profile of ACP and mainstream ACP principles
within health and care
2. Share Information
Supporting people to develop their plan
Design ACP material for individuals
Focus on early intervention
Supporting professionals to work together
Increase access to the Key Information Summary (KIS)
3. Work to ensure carer support aligned with ACP

5. What do we mean by ...ACP ?
Working with
individuals and
their carers
Right info
Right Action
Right Time
Right person
Person centred
and pro-active
Improving
understanding
situation and
condition
Having the
right
conversations
Co-ordination
of care
Identifying
those who will
benefit
Make informed
choices

6. Trajectory
Onset
Crises Phase
Acute Phase
Stable Phase
Unstable Phase
Downward
Phase & Frailty
Dying Phase
Making it Happen- Recognising opportunities
(Adapted from McCorkle& Pasacreta 2001)
ACP
Opportunity
ACP
Opportunity
ACP
Opportunity
ACP
Opportunity
ACP
Opportunity
ACP
Opportunity
ACP
Opportunity
ACP
Opportunity

7. Think Ahead Think ACP- ACP Triggers-
Condition Situation and Assessment
• Elderly and living alone, housebound
• Complex physical, mental health or social support needs
• Infants, children and young people with complex and palliative
care needs
• Unscheduled care access
• Carer stress
• Condition(s) specific (disease registers)
• Risk predictive tools (SPARRA, frailty, complexity, lifecurve)
• Collaborative assessment

8. Raising the Profile
• National Workshops
• ACP Programme Board
• SGHD
• International Foundation of Integrated Care
• Networking across Scotland

9. Primary
Care
Mental
Health
CHAS
&Childrens
Services
Local
Authorities
The
Alliance
Advocacy
Palliative
Care
Carers
Unscheduled
Care
Scottish
Government
Scottish
Care
LWIC
Housing
SCVO Older
Peoples
Services
Health
Inequalities
Technology
Collaboration
Rehab
Teams
Public
Health
ACP
Is
everyone’s business

10. Person-centred care
with personal
ownership
Developing Support Material
Documents and Apps

11. Tests of Change
Advocacy
Developing and Testing
Documentation
and App
Power of Attorney
Identifying
vulnerable
individuals
Early
intervention
Ways of Working
Care Homes and Care Inspectorate
Professional
Education
Media
KIS
and ECTP

12. 8.4%
4.1%
4.9%
5.9%
4.4%
4.1%
3.5%
7.3%
6.6%
4.5%
5.5%
4.6%
6.5%4.4%
Current % of ACPs per
population
The value of a
KIS....?
ACP/KIS Group set up
NSS Commissions
-ACP Data Gathering
-and KIS
Links with whole system and ReSPECT
Potential 30-50%
reduction in admission