Community Healthcare

Creating person-centred care: Advance Care Planning within a Transition Care Program

4 Apr 2014, by Informa Australia

P14A31 ImageAdvance care planning is not new. Its benefits have been experienced in Australia and throughout the world for many years. In order to deliver more person-centred care to improve patience experience, healthcare professionals should recognise the advantage of the Advance Care Planning program.

Meagan Adams, a Registered Nurse in Critical Care Nursing, and the Advance Care Planning Coordinator at Bendigo Health, joins us for a discussion on the importance and challenges of the ACP program, and how the ACP program will assist in developing a successful Transition Care Program.

In March 2014, the Victorian Department of Health launched Advance Care Planning: Have the Conversation – A strategy for Victorian health services 2014-2018. Why is it important for us to recognise the significance of Advance Care Planning (ACP)?

Meagan: Incorporating advance care planning into usual clinical practice is important because health services are responding to a range of changing needs and demands including:

  • delivering person-centred care which focuses on collaboration between health workers, the person and their family or carer, and is centred on respecting  the person’s wishes and needs and
  • caring for an ageing population where a longer life may be in a state of compromised health with an extended period of chronic progressive disease, discomfort and increasing dependence with loss of cognitive ability.

Without ACP, medical treatments, that are unlikely to succeed or not wanted by patients, are frequently instituted and/or continued, which may include invasive life support and surgical interventions. 

What are some of the challenges when implementing ACP within a Transition Care Program (TCP)?

Meagan: Some of the challenges that may be encountered when implementing ACP into a TCP include:

  • The time required to facilitate the conversation and support patients to complete the documentation
  • Knowing the ‘right words’ and way to have a difficult conversation and the confidence to facilitate the process
  • Understanding the documentation and the legal status of the process and the documents

Bendigo’s ACP Program is based on the Respecting Patient Choices (RPC) Program, which enables doctors, nurses and allied health workers to discuss ACP helpfully and sensitively with patients and their families. How will this assist in developing a successful TCP ACP model? 

Meagan: The RPC Program is very well established now and provides us with a solid evidence-based practice. It incorporates well developed education, tools and process models.

Using a consistent model enhances the transferability of the developed Advance Care Plans through the healthcare system and into the community, and facilitates community acceptance and infiltration.

These are essential elements in TCP as it works across the acute, community and residential sectors. 

You will be hosting a workshop with Rosemary Sims, Acting Manager of Transition Care Program from Bendigo Health at the 3rd Annual Transition Care Conference, on the topic of Advance Care Planning within a Transition Care Program. What is the key message that you would like to deliver to the workshop audience? 

Meagan: Advance Care Planning within a TCP is beneficial and achievable. We will be looking at the key challenges in the implementation process, the strategies to overcome these, and present many practical tips and advice for how you may start this process within your own program.

The workshop Advance Care Planning within a Transition Care Program will take place on Wednesday 28th May at the Melbourne Marriott Hotel.  For more information about this workshop and the 3rd Annual Transition Care Conference, please visit the event website.

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