Background Within a care home with nursing reviewing the use of ACP to prevent inappropriate hospital admissions at end of life and the use of ACP to prevent delayed discharge from a General Hospital back to the care home.

Review of admission data from a care home to general hospital and on the number of admissions resulting in hospital deaths compared to care home deaths during the last 2 years.

Aim To highlight the importance of ACP, relationships with the hospital discharge team and community multi-disciplinary teams and how it successfully prevents inappropriate delayed discharges back to the care home setting.

Method We reviewed hospital admissions over the last 2 years, including who had an ACP, the interactions between the care home with the hospital, the length of hospital stay, and an audit of the feedback received from relatives and residents.

Also looking at more recent work providing ‘step up’ and ‘step down’ beds to support a local district general hospital and how having an ACP in place benefits patients.

Results This review is on-going (will be completed by end of March 2013) but early results suggest that where an ACP is in place the resident returns to the care home more quickly and both resident and family are more satisfied with the episode of care.

Discussion Challenges in the practicalities such as extracting information from different teams of professionals involved in the resident's care. The importance of building positive relationships with hospital wards and discharge teams.

Ensuring correct documentation re ACP goes into hospital with resident.

Conclusion The benefits of developing good cross boundary relationships with hospital teams and the importance of ACP helping prevent delayed discharges.