Anticipatory care planning and integration: a primary care pilot study aimed at reducing unplanned hospitalisation

Background Anticipatory care for older patients who are frail involves both case identification and proactive intervention to reduce hospitalisation. Aim To identify a population who were at risk of admission to hospital and to provide an anticipatory care plan (ACP) for themand to ascertain whether using primary and secondary care data to identify this population and then applying an ACP can help to reduce hospital admission rates. Design and setting Cohort study of a service intervention in a general practice and a primary care teamin Scotland. Method The ACP sets out patients' wishes in the event of a sudden deterioration in health. If admitted, a proactive approach was taken to transfer and discharge patients into the community. Cohorts were selected using the Nairn Case Finder, whichmatched patients in two practices for age, sex,multiplemorbidity indexes, and secondary care outpatient and inpatient activity; 96 patients in each practice were studied for admission rate, occupied bed days and survival. Results Survivors fromthe ACP cohort (n = 80) had 510 fewer days in hospital than in the 12months preintervention: a significant reduction of 52.0%(P = 0.020). There were 37 fewer admissions of the survivors fromthat cohort post-intervention than in the preceding 12months, with a significant reduction of 42.5%(P = 0.002).Mortality rates in the two cohorts were similar, but the number of patients who died in hospital and the hospital bed days used in the last 3months of life were significantly lower for the decedents with an ACP than for the controls who had died (P = 0.007 and P = 0.045 respectively). Conclusion This approach produced statistically significant reductions in unplanned hospitalisation for a cohort of patients withmultiplemorbidities. It demonstrates the potential for providing better care for patients as well as better value for health and social care services. It is of particular benefit inmanaging end-of-life care.