Enabling System-Wide Advance Care Planning

Aim: to systematically incorporate Advance Care Planning (ACP) as part of usual practice

Focus: encouraging discussions about future care before people reach an acute stage of illness and decisions have to be made under pressure

Initiative: bringing together service providers to improve systems for advance care planning across settings

Partners: The Collaborative – supported by RDNS, North and West Metropolitan Palliative Care Consortium and the Inner North West Melbourne PCP with

5 General Practices
4 Residential Aged Care Homes
2 Medical Deputising Services

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Four key elements:

Collaborative QI activity

Brings together all partners in a cross-sectoral approach
Uses model for improvement to identify changes and test activity within and between organisations.
Aims to incorporate ACP as part of usual care –within and across settings

Resources, tools, systems and processes

Now being tested in individual organisations including

Policies and procedures
Educational resources
Patient information

Cross-sectoral education and training

Education sessions across sectors and disciplines to build knowledge and confidence (through Decision Assist, Local Hospital Networks, Respecting Patient Choices®)

Engaging with key community groups to support consumers

Supported consumer focus groups with Health Issues Centre
Consumers participate in Project Management Committee
Engagement through partner organisations in 2016

Experience and impact so far

Working collaboratively across sectors has allowed greater understanding of current practice, issues, barriers and opportunities.

Following the first 3-month activity period project participants report increases in:

Awareness of ACP for staff, patients, carers and residents
Staff confidence to discuss ACP
Conversations about ACP, between staff and with clients/patients
Documentation of ACPs and improved processes for storage
Sharing of information between care providers and sectors
Clarity around staff roles in ACP