Delivering advance care planning at residential aged care facilities - the right care at the right place, at the right time

Date & Time

Nov 11th at 10:20 AM until 10:35 AM


Collaborative health & practice 


Rating ( votes)

Chair: Jacinta Russell

Pam deKlerk (1), Kerrie Shepherd (1), Alvin Tang (1), Rebecca Kwok-yee Pang (1), Alice Urban (1), Craig
Wotherspoon (1)

1 Peninsula Health, Residential In Reach Service, PO Box 52 Hastings Road, Frankston VIC 3199,

Peninsula Health's Residential In-Reach (RIR) program provides service to more than 40 Residential Aged Care Facilities (RACFs) within the Frankston and Mornington Peninsula region, with the catchment having one of the highest numbers of RACFs in the state (DPS Guide, 2012). RIR service delivers a step-wise method in delivering sustainable Advance Care Plan (ACP) systems across RACFs.

ACP clinicians developed an online competency-based training package for RIR staff to up-skill them in response to service gaps and promote the use of ACP.
A high-level consortium was formed, which included Frankston Mornington Peninsula Medicare Local, Peninsula Home Hospice, ACP services and local RACFs, this provided oversight to the following goals:

  • the 'Link Nurse' model;
  • the design of local ACP education;
  • standardised ACP tools used across all services;
  • an ACP policy/guideline framework and
  • GP engagement campaign and evaluation and review processes.
Ten RACFs participated in the project, with more than 200 files audited pre and post implementation. Following roll-out, overall compliance has improved by 206% and the completion of Medical Enduring Power of Attorney has increased by 35%. New RACFs have shown interest in engaging ACP implementation at their RACFs.

The approach to increase implementation of ACP is through a practical, step-wise approach, including standardised ACP policy, guidelines and practical ACP documentation across all RACFs. The project improves use of ACP and centres on respecting clients' choices within the RACFs. The step-wise approach also lifts ACP awareness, improves staffs capacity and underpins organisation change in adopting ACP in practice across various settings.