Anticipatory care planning in primary care for people living at home or in a care home

Implementation of an integrated care planning and electronic care coordination intervention in primary care for people living at home or in a care home at risk of deteriorating or dying: a mixed-method study across Scotland (4-ACP)

Status

Active, not recruiting

Phases

Unknown

Study type

Interventional

Source

ISRCTN

Registry ID

ISRCTN54516639

Enrollment

Registered

2022-04-13

Start date

2022-09-01

Completion date

Unknown

Last updated

2025-01-28

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

Advance/anticipatory care planning for people at risk of serious illness or death due to a pre-existing long-term condition or frailty Not Applicable

Interventions

As an implementation study, the intervention treats GP surgeries as the "participants" in the intervention. A package of support materials (4-ACP) is made available to participating GP surgeries to us

Eligibility

Sex/Gender

All

Inclusion criteria

Inclusion criteria: GP surgeries participating in the implementation: 1. Located in one of the four participating health boards 2. Currently delivers anticipatory care planning Patients taking part in qualitative interviews to evaluate the impact of anticipatory care planning: 1. Registered with participating practices 2. Has had an ACP conversation at the participating practice within the last 6 months or is a proxy for someone who has 3. Adult (over the age of 16 years) 4. Has the capacity to consent Healthcare professionals taking part in qualitative interviews: 1. Working at a participating GP surgery 2. Has the capacity to consent

Exclusion criteria

Exclusion criteria: For participating practices there are no exclusion criteria For individuals: 1. Lacking the ability to consent 2. Lacking the ability to communicate 3. Interview considered physically or emotional risky by a healthcare professional with knowledge of the patient 4. Interview considered potentially risky to the researcher by a healthcare professional with knowledge of the patient 5. Participant under the age of 16 years

Design outcomes

Primary

Measure	Time frame
Patient and/or linked informal carer attitude about the acceptability of anticipatory care planning (ACP), assessed using qualitative interviews at two timepoints within 6 and 12 weeks of having an ACP conversation. Inductive thematic analysis is used to determine qualitative content.	—

Secondary

Measure	Time frame
There are no secondary outcome measures	—

Countries

Scotland, United Kingdom

Outcome results

None listed

Source: ISRCTN (via WHO ICTRP) · Data processed: Feb 4, 2026