4 Key Elements in a Comprehensive ACP Program

October 7, 2022

The right Comprehensive Advance Care Planning (CACP) program can be transformative for clinicians that manage patients with serious illnesses. When done correctly, CACP can be of tremendous value to both clinicians and the patients they serve — and it’s worth getting it right. 

Given that the current clinician-led CACP model proves to be difficult in delivering widespread patient participation, practices should look to implement dedicated advance care planning (ACP) programs for their patients through a trusted CACP partner such as Iris. 

Below are the 4 key elements that Iris CACP can provide to your practice and patients. 

1. The Right Support at the Right Time

It’s crucial that seriously ill patients receive the right level of support at the right time. Rather than waiting until the end of a patient’s care journey to initiate CACP discussions, research has shown that early ACP interventions yield bigger benefits for both clinicians and patients. 

The New England Journal of Medicine found that seriously ill patients who received early palliative care — of which ACP is a critical service — achieved:

  • Higher quality of life FACT-L scores (a key indicator of quality of life for the study’s population) were 7% higher for the early intervention group compared to the control group.
  • Longer survival times – The early intervention group lived 30% longer on average, despite being 64% less likely to receive aggressive treatment. 

2. In-depth Conversations

At its core, CACP is deeply human. Exploring a patient’s core values takes guidance, compassion, and patience, and synthesizing this information into concrete care goals is a complex, individualized process. 

Unfortunately, clinician’s internal resources often lack the time and training to conduct CACP thoroughly for each patient and their loved ones.

While some clinicians state that they offer CACP services in their office, the services often are not as robust as they could, and should, be. Key questions for evaluating the robustness of CACP services include:

  • How much time is provided to think through and discuss care options?
  • Does the discussion offer assistance to work through complex decisions?
  • Are loved ones and caregivers involved in the discussion and decision making process?
  • Is the clinical staff specially trained in the emotional, medical and legal elements of ACP? 

These considerations directly influence how thorough and personalized the CACP process will be, making them vitally important to individuals and their families as they evaluate their options.

Click here to listen to Dr. Sarah Mullins, Senior Medical Director for Aledade, as she shares her experience with Iris CACP.

3. Document Validation & Processing
Ensuring that advance directives are completed in accordance with state and federal guidelines and distributed to the point of use can be the deciding factor in whether or not an individual’s care wishes are actually carried out. 

Iris documentation specialists are:

  • Deeply familiar with the state and federal ACP documentation requirements
  • Able to independently verify that documents are completed and error-free
  • Proactive in confirming documents have been received by their various points of use
  • Able to advise individuals and family members on how and when to leverage ACP documents during health events

Additionally, a high-quality ACP program should go above and beyond the standard documentation required by state and/or federal law, adding supplementary notes and documentation to describe patient wishes in more detail. 

Iris’ documentation specialists ensure that all documentation is executed correctly and completely, and then shared widely to patients, family members, caregivers and clinicians for future use.  Without meticulous attention to detail during this important step, patients and their loved ones risk all of their hard work being disregarded when it matters most — a potentially devastating consequence that can and should be avoided from the outset. 

4. Ongoing Conversations and Documentation Updates
It is rare that clinicians or care managers follow up with individuals about their ACP decisions throughout their care journey. But the truth is, ACP should not be a one-and-done process. Instead, it should be an ongoing conversation that accounts for the changing variables that influence one's goals of care, including: 

  • New diagnoses
  • Major personal events 
  • Major health events

Iris’ high-quality CACP program provides continuous outreach by facilitators, proactively helping patients revisit and revise their goals of care over time. 

When it comes to ACP, not all care plans are created equal. Iris specializes in creating high-quality, personalized care plans for each patient and their unique goals and wishes. Iris’ team of trained ACP experts ensure each of the four elements above are accounted for in every care plan, providing patients with a tailored and person-centered experience.