As the percentage of older adults on the island of Ireland increases, the complexity of care required to support those who choose to remain in the community has also increased. This situation can create challenges for patients, family carers, their General Practitioners, and community agencies.

The treatment and management of long-term health conditions is the greatest challenge facing health systems around the world today. A timely start in managing a patient’s long-term conditions facilitates anticipatory care planning in order to meet patient wishes and needs, relieve symptoms, and prevent future symptoms and problems. Anticipatory care planning through earlier identification of the needs of patients is evidenced to improve the quality of their life, to decrease the number of aggressive futile interventions and depressed mood, and even to prolong life.

A core aspect of anticipatory care is personalized care which describes a negotiated series of discussions between a patient and a health professional (perhaps with other professionals or family members present) to clarify goals, options and preferences, and to develop an agreed plan of action based on this mutual understanding.

Innovative approaches to patient care in the community such as Anticipatory Care Planning, which has the goal to address the growing challenge of providing high-quality comprehensive care for older adults, requires evaluation. This proposed study will evaluate one approach that will include primary care settings as the setting for Anticipatory Care Planning.

Study aim:

To determine the feasibility for a full trial protocol to evaluate the implementation and outcomes of an Anticipatory Care Planning (ACP) intervention in primary care to assist older adults identified as at risk for functional decline by developing a personalized support plan.

Design:  A feasibility cluster randomised control trial.

Setting and participants:

8 primary care practices, 4 in Northern Ireland and 4 in the border region of the Republic of Ireland to provide a total of 64 study participants (32 per study arm, 8 study participants per primary care practice). Following consensus guidelines, patients listed in these practices that are identified as 70 years of age or older and assessed as at risk of functional decline will be targeted for participation.

Anticipatory care intervention:

Refine and test the combination of three components for this intervention that will be delivered by a trained registered nurse: a) information collection by a patient assessment; b) conduct support planning dialogue on the basis of the patient assessment results between the patient, family carer and General Practitioner and other care practitioner; c) document the agreed support plan and identify follow-up review dates.

Study Outcomes:

A conceptual framework (RE-AIM) will guide the feasibility assessment of the ACP intervention. The feasibility study will provide a detailed evidence-based assessment on the potential impact of the ACP intervention on patient quality of life, mental health, healthcare utilisation, costs, perception of person centred care, and reduction of potentially inappropriate prescribing in an all-Ireland context. Formation of strategic cross-border partnerships will be developed and methodological and statistical considerations for a definitive randomized trial will be determined.

Practice recruitment is complete