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Implementation Guide to Advance Care Planning in Canada: A Case Study of Two Health Authorities

Calgary Health Region, Care at the End of Life (CEOL) Initiative

Logic Model, April 2007 - March 2008
	Objectives	Activities	Outputs	Culture Shift
Guiding Principles/Assumptions: 1. Death is a natural and inevitable part of life. 2. The experience of dying of death both includes and transcends the health care system. 3. Individuals living with advanced illness, together with their families, benefit from care that includes a focus on end-of-life care issues. 4. Individuals and their families bring unique sets of values and beliefs that guide them in making decisions regarding end-of-life care. 5. When provided with the appropriate education and skill development regarding end-of-life care, the quality of work experience of health care practitioners in enhanced. 6. Community collaboration is essential in developing a holistic understanding of death and dying for individuals within a community. 7. Providing quality end-of-life care is a cost-shifting rather than a cost-saving endeavour. 8. Both community and health system leadership are essential to influence the culture shift required for success in this project. Internal Inputs/Resources: .9 FTP Project Manager; .3FTE palliative Physician; .5 FTE QI Consultant; .62 FTE Admin Support (×2); 3.75 FTE Education Specialists; 1 FTE Policy Implementation Coordinator; Physical space and office infrastructure through Southeast Community Portfolio, Senior Health - Administrative Leadership from Director and Medical Director; Seniors Health and Palliative Care. External Inputs/Resources: Advisory Groups - CEOL Advisory Committee; Community CEOL Task Group; Policy Implementation Advisory Committee; Collaborative Partnership/Mentorship from Palliative Care, Fraser Health Services. Resource Experts - Calgary Health Region's Legal Affairs, Communications, Health Policy, and Quality Safety and Health Information; Consultants from Respecting Choices ^®, Gundersen Lutheran Medical Center, Wisconsin.
	Objectives	Activities	Outputs	Short-Term Outcomes One year (April 2007-March 2008)	Long-Term Outcomes Two to Five Years (April 2008- March 2012)	Impacts Six to Ten Years (April 2012-March 2017)
Associated Influence	Systematize consistent ideal practice in advanced care planning (ACP)	Continue and expand implementation of My Voice - Planning Ahead as the Calgary Health Region's and Calgary community's vehicle for facilitating ACP discussions in target population where opportunities exists	Number of programs implementing My Voice - Planning Ahead Percentage of targeted patients that have ACP discussion Percentage of targeted patients that have advance directives Number of resources distributed Number of internal/external website hits	Patients find the discussions beneficial (ongoing) Clinicians find the ACP process and accompanying documents beneficial (ongoing) Increase in the number if programs/service units implementing the My Voice - Planning Ahead program	Patients' families find the ACP process beneficial Increase in percentage of target patients having ACP discussions Increase in percentage of target patients completing advance directives Increase in systemic support for ACP across the region Increase in awareness and use of ACP in the community When medically appropriate, patients' wishes as identified in their advance directives are followed across the continuum of care All chronically ill patients are provided the opportunity to have an ACP discussion	Support from community leaders and engagement of community partners is evident through uptake of Calgary Health Region's ACP activities 75% of senior, acutely ill patients and healthy adults are provided the opportunity to have an ACP discussion
		Continue and expand implementation of a training program for My Voice - Planning Ahead in target areas based on a "train the trainer" model	Number of discussions facilitators trained Number of trainers trained	Increase in clinicians' ACP awareness/basic knowledge Increase in clinicians' comfort, confidence, knowledge and skill in ACP facilitation (ongoing) Increase in the number of trained discussion facilitators Facilitators integrate training into practice Policy Resource Team established	Every program/service unit serving chronically ill patients has a multidisciplinary health care team prepared to facilitate ACP discussions	Support from community leaders and engagement of community partners is evident through uptake of Calgary Health Region's ACP activities 75% of senior, acutely ill patients and healthy adults are provided the opportunity to have an ACP discussion
	Develop regional policies related to end-of-life (EOL) care that are standardised across the region and support best practice for care at the end of life	Implement the Advance Care Planning : Goals of Care Designation (Adult) Policy (ACP:GCD Policy)	Number of clinicians trained (Basic and in-depth) Number of trainers trained Number of tools and forms developed and available regionally	Electronic health record and paper records adapted to meet ACP: GCD Policy 80% of clinicians receive basic policy education Clinicians increase their awareness, knowledge and application of the policy Systemic support for policy in place Shift from old designation to new (all sector) Policy tools are field tested by clinicians and revised ACP:GCD Policy tools and forms are developed and regionally available Process for determining, documenting, transferring and enacting goals of care designations determined	ACP:GCD Policy is fully implemented and supported Information related to care decisions at end-of-life transfers with patients across service streams Decrease in appropriate transfer across the continuum of care When medically appropriate, patients' wishes as identified in their medical chart and/or advance directives are followed across the continuum of care Clinicians find the policy process and tools beneficial Increase in patients and family awareness of ACP:GCD Policy tools and goals care designation Effective use of ACP:GCD Policy tools and forms by clinicians Increase in percentage of appropriate goals of care designations	Regional policy consistently address issues related to care at the end of life Decrease acute care utilisation by Long-Term Care and Designation Assisted Living patients
Direct Influence	Extend palliative and hospice care to a broader patient population	Collaborate with Hospice and Palliative Care and Home Care to identify and address gaps in service and extend care to broader patient population	Percentage of palliative and hospice beds accessed by non-cancer population	Increase access to hospice and palliative bed for a broader population base	Implementation of strategies to increase sharing of palliative and hospice services	Appropriate palliation and EOL care services are offered to individuals facing the end of life and to their families, regardless of disease progress, age or setting
	Promote planning that includes palliative care with all program services	Collaborate with leaders in Long-Term Care and Seniors' Health to embed CEOL strategies in program best practice/services	Number of clinicians trained to provide best practice EOL care	To be determined	To be determined	EOL care is defined and implemented in best practice standards for all disease groups/areas of service Health system monitor EOL care indicators and resource utilization in program planning and quality improvement initiatives
		Collaborate with leaders in Chronic Disease Sectors to embed CEOL strategies in program best practice/services	Number of palliative specialists placed within Chronic Disease and Long-Term Care programs	To be determined	To be determined	EOL care is defined and implemented in best practice standards for all disease groups/areas of service Health system monitor EOL care indicators and resource utilization in program planning and quality improvement initiatives