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    • Enabling System-Wide Advance Care Planning
    • Raising Awareness of Advance Care Planning
    • Stepping up diabetes
  • Leadership and innovation
  • Updates and key documents
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Enabling System-Wide Advance Care Planning

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
Download ACP Flyer
Download ACP Poster
Download ACP Presentation
Download ACP Presentation

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

CoHealth

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Copyright 2016
  • The Collaborative
  • Projects
    • Back Pain
    • Chronic Heart Failure
    • Chronic Kidney Disease
    • Coordinated Community Care for Diabetes Project
    • Digital Health
    • Dyspnoea Pathway
    • Enabling System-Wide Advance Care Planning
    • Raising Awareness of Advance Care Planning
    • Stepping up diabetes
  • Leadership and innovation
  • Updates and key documents
  • Contact
The Collaborative