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Anticipatory care planning and integration: a primary care pilot study aiming at reducing unplanned hospitalisation
- Authors:
- BAKER Adrian, et al
- Journal article citation:
- British Journal of General Practice, 62(595), February 2012, pp.84-85.
- Publisher:
- Royal College of General Practitioners
Anticipatory care planning involves the identification of patients at high risk of hospital admission and deriving anticipatory care plans (ACPs) for them which aim to shift the balance of care from hospital to community settings. ACPs provide a patient-centred, cost-effective approach to patients with multiple morbidities and illness trajectories that will deteriorate. The aim of this study was to investigate whether ACPs result in a reduction in the number of unplanned hospitalisations. Patients at high risk of admission to hospital were identified from a single general practice in Nairn, Scotland and offered an ACP. These individuals were matched with patients from a control practice. Proactive case management was provided by a case manager who was responsible for conducting the initial patient interviews and for overseeing the provision of care, including mobilising the extended primary care team, initiating home improvements, and accessing voluntary agencies. The findings showed that anticipatory care planning and case management was associated with fewer hospital admissions. In addition, the intervention also resulted in more patients being able to die at home rather than in hospital.