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Advance care planning initiatives in NSW

Advance care planning is seen as part of the patient journey, especially within the Integrated Aged & Chronic Care redesign program of NSW Health.  

Several Area Health Services have included strategic implementation of advance care planning in their redesign strategies.  

Where advance care planning has been implemented and outcomes evaluated, the patient journey and the experience for family and other loved ones has been demonstrated to be extremely positive.

The Department of Health is supporting each area health service in a three-stage implementation model:

  • Stage 1 – Supporting advance care planning in residential aged care facilities
  • Stage 2 – Chronic & complex patients
  • Stage 3 – Other identified patients in the acute setting

Area Health Services will need to build key partnerships with aged care services providers, as well as local Divisions of General Practice, and general practice liaison staff in their areas.  

NSW Health recognises that both knowledge and skills training are required for the implementation of advance care planning.  

At the same time, it is acknowledged that acute care facilities will need to prepare systems to support the transfer of relevant advance care planning related information across the contexts of care, particularly the interface between the primary and secondary care settings.

Area Health Services have received funding towards an advance care planning project officer for 12 months, to initiate the program, and have been asked to nominate an Area Health Service advance care planning project team.  

Area Health Services have been encouraged to comprise teams including Area Health Service project officer, executive sponsor, a clinical champion and representation where possible from local GP Division(s) and residential aged care facilities.  

The implementation of advance care planning will be further supported by NSW Health through:

  • ‘Train the trainer’ workshops,
  • Resources and materials
  • High level communication strategy.
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