Improving future care planning (FCP) discussions and documentation in Hospital at Home (H@H)

Introduction:

The West Lothian H@H team is based at St John’s Hospital, Livingston providing acute assessment and care to approximately 130 patients monthly, the majority of whom are frail. Future care planning should be included in clinical interactions,1,2 and all members of the multidisciplinary H@H team should have the competence and confidence to do this well for every patient.

Aims:

1. To improve the quality and rate of FCP discussions with patients and families, including resuscitation, escalation to hospital and preferred place of care (PPC).
2. To improve the communication of FCP discussions with other health professionals in our immediate discharge letters (IDLs).

Methods:

All members of the H@H team attended a locally developed interactive FCP workshop, including didactic and simulation-based elements, between September and November 2025. Feedback was collected via electronic survey. We introduced a new standardised IDL format which included a dedicated FCP section.

We compared IDLs of all patients discharged in October 2024 to October 2025, specifically reviewing documentation of decisions regarding resuscitation, escalation to hospital and PPC.

Results:

120 IDLs (October 2024) and 120 (October 2025) were analysed. FCP documentation on IDL improved from 54% to 75%. Resuscitation decision documentation decreased slightly from 92% to 88%, but PPC documentation improved from 77% to 92%.

Regarding the FCP training, all participants would recommend this workshop to a colleague and reflected that they valued the opportunity to practice conversations in a supportive environment. Patient feedback regarding FCP conversations has also been positive.

Discussion:

FCP training tailored to H@H needs, and a dedicated section on discharge letters have resulted in an improvement in FCP discussion and documentation from 2024 to 2025. Feedback has been positive, and staff view this as a key part of their role.

References:

1. Healthcare Improvement Scotland. Hospital at Home Guiding Principles for Service Development, October 2025.
2. Healthcare Improvement Scotland. Ageing and Frailty standards, November 2024.