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Advance Care Planning Is a Community Effort in 2022

Advance Care Planning Is a Community Effort in 2022

A successful advance care planning (ACP) approach can’t be accomplished when different healthcare organizations and providers each create their own, individual solutions. Rather, to provide the best quality care to patients, there must be communication and collaboration across the entire healthcare ecosystem. That means hospital systems, skilled nursing home facilities, palliative care organizations, home health and hospice agencies and long-term care organizations have to get on the same page.

doctor-on-pcOften clinicians and healthcare workers aren’t familiar with the specifics of ACP. When the topic of ACP or advance directives comes up, they’re not exactly sure what they’re supposed to be doing. A physician might add a digital ACP document to a patient’s medical record upon request. However, doing so doesn’t ensure that information will be available when needed.

Even with complex EMRs in place, many healthcare facilities don’t have a way to store, categorize, and access digital ACP documents. When an emergency strikes, healthcare workers don’t know:

  1. Whether their patient has a digital ACP document in place
  2. How to find it if it does exist

Adding to the confusion, there’s typically not a codified or clear process for what happens when patients arrive at a hospital from a nursing home or assisted living facility. While those patients might have some form of ACP document in place, getting that information from the nursing home or assisted living facility to the healthcare workers who need it isn’t straightforward. There are times when the document is never found or delivered.

Without digital ACP documents, confusion takes over

Effective digital ACP documents allow healthcare providers to access detailed information on the wishes of their patients at the exact moment they need it. When those documents don’t exist or are too difficult to recover, healthcare workers have to muddle through and do the best they can. Rather than focusing on providing care for their patients, they become responsible for tracking down advance directives that may or may not exist.

An unspecified process for ACP leaves patients’ actual wishes unclear or miscommunicated.


COVID-19 brought this issue to the forefront of conversations. During the pandemic, healthcare workers struggled with ambiguity as to whether or not patients in poor condition had ACP documents. Family members who previously might have been able to provide guidance were also frequently unavailable, multiplying the problem.

Questions at each step of the process

Even prior to COVID-19, there’s been a subset of patients who end up moving between:

  • Long-term care and assisted living facilities
  • Hospitals
  • Home health and hospice

With each step, a new organization is left trying to determine what types of interventions and treatments patients want and don’t want. They also have to figure out who has decision-making authority and responsibility if the patient suffers a medical emergency and cannot communicate. Each time, there’s an investigation into whether or not the patient has an ACP document or portable medical order such as an out-of-hospital DNR order or a POLST form.

Typically, there’s no coordination between different facilities or with hospitals to facilitate these investigations.

There’s a better way: Accessible digital ACP documents are good for everyone

When the population has access to digital ACP documents, the entire healthcare community benefits. If the different organizations within a community work together to ensure all their patients have completed digital ACP documents and portable medical orders like POLST forms (if appropriate) that are accessible 24/7 in all care settings, that creates an environment where:

  • Guesswork is removed from care, meaning patients receive the hospitalizations, treatments and interventions they want (and avoid those they don’t)
  • Medical personnel and staff experience improved morale and decreased burnout
  • Organizations find budget and time — that would otherwise be occupied providing high-cost, low-value, unnecessary and unwanted medical treatments and interventions — are freed up
  • Quality ratings are improved 
  • Compliance with quality measure requirements is ensured

But, in order to achieve these benefits, hospital systems, home health and hospice agencies, skilled nursing facilities, palliative care organizations and long-term care organizations must work together.

ADVault’s solutions build a bridge of communication between these different organizations, allowing patients’ voices to be heard and placed at the forefront of healthcare decisions. Doing so means everyone is able to work together in order to create the best possible outcomes. ADVault offers a full suite of healthcare provider tools to make creating or uploading, updating and retrieving digital ACP documents seamless and intuitive for healthcare organizations.

Without a digital ACP system in place, organizations will continue to scramble whenever a patient is admitted on short notice.

Let’s get started on digital ACP together

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