Background An Anticipatory Clinical Management Plan (ACMP) is a proactive clinical plan, made in advance for a predicted clinical situation. ACMPs are the clinically-led elements of Advance Care Planning and include treatment escalation plans and decisions about cardio-pulmonary resuscitation. They require sensitive conversations about the individuals wishes and preferences, and provide guidance for treatment at a future date. A consistent approach is out-lined in regional guidelines.

Methods Process-mapping was undertaken by hospital and community colleagues to identify the blocks to effective anticipatory clinical management planning within the hospital and an action plan agreed.

Results Process-mapping highlighted the complexities of a process which spans different care-settings and organisations. Blocks identified included identification of individuals who may benefit; staff knowledge, skills and confidence; lack of patient alerts on clinical records; information sharing between organisations.

Conclusions Bringing together professionals from primary, secondary and social care highlighted both the complex nature of ACMPs but also the shared desire for collaboration to improve patient care.

A multi-professional, interactive, ACMP workshop has been developed and delivered to 77 members of staff (41 hospital, 36 community; 44 doctors, 34 other). This is well-evaluated. On-going work-placed base support is available for those who have completed training from the course facilitators. In response to feedback during training, both a clinical template and a prompt list are being piloted to support clinicians. A trust-wide treatment escalation plan is currently being implemented. Work is ongoing to establish electronics alerts on patient records and effective processes for information sharing between organisations. Education is supporting staff to gain the skills and confidence required to follow a shared-decision making model when planning for future anticipated clinical events. Digital solutions to information-sharing are required to ensure plans are shared effectively to support patient-centered care.