Navigating the Future of Advance Care Planning: A Strategic Imperative for Hospice and Palliative Care Leaders

The following content is a guest blog authored by Maria D. Moen, SVP of Innovation & External Affairs at MyDirectives, an NHPCO Strategic partner. 

In a world where we crave and even expect a level of control over every aspect of our lives, it's only natural that this desire includes our healthcare decisions. People want to have a say in their medical journey, not be moved through the healthcare system as a voiceless traveler. Advance care planning (ACP) is an essential process in enabling a person to capture and record their treatment preferences, which can then be used as a guide for healthcare providers, caregivers, family members, and loved ones when it becomes necessary. 

Rebecca Sudore, MD, a respected researcher and leader in advance care planning, succinctly defines ACP as "a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care." Seems simple enough and a concept that we can all get behind.

Building and Maintaining Trust in the Patient-Provider Relationship

In hospice and palliative care, trust is the cornerstone of the patient-provider relationship. To maintain and strengthen this trust, it's essential that patients' wishes are not only documented and kept updated, but also readily accessible to others who would treat them during a health crisis or emergency. This requires a seamless availability of ACP documents across the broader care continuum. This kind of access and approach works to build patient trust in their healthcare providers, by instilling confidence that their healthcare providers will respect and honor their wishes.

Leveraging Technology to Streamline Care and Enhance Patient Outcomes

Healthcare is loaded with clinician burden due to repetitive, time-consuming tasks that can interfere with delivering personalized care. By embracing technology throughout the ACP process, providers can automate many time-consuming processes, allowing them to focus on what truly matters to patients: delivering compassionate, personalized care.

A well-structured ACP process should include:

• Comprehensive Documentation – At the time of intake or admission, inquire whether the patient has existing ACP documents. If they do, be sure to collect them and review them carefully with the patient and/or their healthcare agent to ensure they align with the patient’s current values and goals of care. It’s crucial to keep these documents current, reflecting any changes in the patient's wishes or preferences for the care they want to receive.
• Accurate Record Keeping – The patient’s chart or electronic health record should include copies of their ACP documents with key elements highlighted in the record that can become time-sensitive such as CPR status, designated healthcare agents and their contact information, and any specific treatment preferences.
• Visibility Across the Care Team – It’s essential that this information be easily accessible to every member of the care team. Digital systems are particularly effective at providing quick reference points, as well as more detailed information, when it is urgently needed.
• Broad Access and Sharing – Solidify the trust patients have placed in your team by ensuring that their ACP documents are available not only to the immediate care team but also to others those patients will encounter during their healthcare journey. This might be family members and friends but should also include other healthcare providers across the care continuum. Go beyond your own specific care location to ensure ACP forms can be easily found by medical teams. This may include uploading documents to state health information exchanges, their patient portal, or any other secure digital platforms, such as personal health record systems or large-scale registries of ACP documents.

The Imperative of Digital Advance Care Planning

Given the complexity of today’s healthcare and the mounting pressures to maximize reimbursement, quality, and outcomes all while minimizing risk, the shift to digital ACP document creation and access is not just a convenience — it’s a necessity. Here’s why digital ACP systems are especially critical for hospice and palliative care providers:

• Portability and Accessibility – Digital ACP documents can seamlessly follow the patient across different care settings, ensuring their wishes are respected no matter where they receive care. This eliminates the risks associated with paper forms, which can be misplaced or inaccessible in a crisis, and tangibly demonstrates commitment to the patient even when they are being treated by other medical teams.
• Verification and Authentication – Digital systems provide a clear audit trail that reduces risk by verifying who created the document, when it was signed, which version is current, and who has accessed it. This enhances the authenticity and reliability of the documents and increases the confidence of the provider using them to inform treatment.
• Interoperability and Integration – Digital ACP documents can be securely yet easily made available across different providers, healthcare systems, health information networks, and with trusted individuals, ensuring that everyone connected is working from the most current information. This is particularly important in complex care environments where multiple providers may be involved in a patient’s care.

Creating a Personalized Healthcare Experience

Hospice and palliative providers must deliver care that is not only clinically sound but also deeply personalized. Modernizing advance care planning through digital solutions to honor the patient voice as part of a larger ecosystem of care is a crucial step in achieving this goal. By ensuring that every patient’s healthcare journey is guided by their values, preferences, and goals of care, providers can create a more compassionate, patient-centered care journey that fulfills the expectations of both patients and partners in care.

Shaping the Future of Care

Embracing digital ACP document options reflects a foundational shift towards patient-centered care, where individuals are empowered to shape their healthcare journey. For hospice and palliative care providers, it’s not just about keeping pace with technology; it’s about ensuring that every patient’s voice is heard and respected, especially in their most vulnerable moments. By integrating these modernized approaches to personalized care into your organization, you can build stronger patient and family member relationships, improve the outcomes of the care your patients receive, and fulfill your commitment to providing the highest standard of compassionate care to those you serve.

 

About the Author

Maria D. Moen is the Senior Vice President of Innovation & External Affairs at MyDirectives and a seasoned advocate for leveraging technology to enhance patient outcomes and streamline healthcare operations.

About MyDirectives®

MyDirectives is the premier provider of digital advance care planning (ACP) solutions and the only national registry and repository for highly secure, cloud-based storage for anytime, anywhere access across the healthcare continuum.