PresCare - Introducing Advance Care Planning in a Community Aged Care Setting

Imagine if you were suddenly injured or became seriously ill, who would know your choices about the health care you would want? This means thinking now about what health care you would want in the future and communicating your wishes. PresCare Queensland, through a Decision Assist grant, has introduced Advance Care Planning to their suite of services for their community care recipients, expanding on the existing service offered to their residential care recipients. By planning ahead, PresCare care recipients now have the opportunity to ensure the treatment and care they may require in the future is in line with their wishes; their loved ones won’t have to make difficult decisions on their behalf and decisions about their healthcare are not made in a crisis situation.  Care recipients are able to discuss their beliefs and values, and have their preferences and decisions documented in the Advanced Care Plan.

Preparing for any situation involves planning

As a Ministry of the Presbyterian Church, PresCare has provided services to Queensland communities for over 85 years. PresCare supports more than 5,500 clients in communities as far north as Cairns down to Coolangatta.  For this project, piloted in the Brisbane South area, PresCare partnered with Metro South Palliative Care Services, within Metro South Hospital and Health Services. In 2015, the Metro South Office of Advance Care Planning was established within the Metro South Palliative Care Services.

The aim was to improve client and carer outcomes around end of life care through a planning approach. This involved improving the knowledge, understanding and confidence of community nurses around advance care planning.  A mentorship arrangement was established with the staff from the Metro South Palliative Care Office of Advance Care Planning. This included the community nurses attaching palliative care case conferences and receiving one-on-one onsite training and telephone support. 

PresCare worked collaboratively with Metro South Palliative Care Services to adopt the QLD Health “My Care, My Choices” Statement of Choices document for care recipients to document their advance care plans.  This collaborative partnership resulted in approval for the PresCare logo to be added to the QLD Health document for PresCare care recipients.

For the acute hospitals, timely access to the information contained in a care recipient’s advance care plan has historically been challenging.  A significant development in the project has been the opening up of communication channels resulting in the transfer of the ACP information between the community and acute sector.  A simple communication pathway for the transfer of the ACP information was established with the Metro South Office of Advance Care Planning as well as an information booklet and the care recipients displaying ACP fridge magnets and wallet cards to alert paramedics to the presence of a completed Advance Care Plan.  

Opening communication channels was key

This project was introduced as part of the suite of Consumer Directed Care services provided by PresCare to their care recipients receiving home care packages.  As a result, it has been recognised that completing an ACP in a community setting may require multiple discussions and subsequent visits with care recipients before completion.   

Importantly for care recipients, advance care planning offers peace of mind, that by articulating their wishes, they will receive the right care, at the right time, in the right place.

Note, The Advance Care Planning - Statement of Choices is a valuable resource which includes treatment options, personal values, declaration, substitute decision maker/s, doctor declaration, and a checklist.

Dee Jeffrey, Manager Service Improvement & Innovation