Third Age Health case study: Advanced care planning to improve care quality

Maryann residential care home and hospital has achieved huge success with their project to ensure all patients in their care have an advanced care plan (ACP) or medical care guidance plan (MCGP).

What is advance care planning?

Advance care planning is the process of thinking about, talking about and planning for future health care and end of life care. What matters most to consumers and their whānau should be at the centre of care planning and delivery. (Health Quality & Safety Commission, NZ 2022)

A medical care guidance plan is the same concept as an advanced care plan for people unable to make a decision about their own care and is created by the persons clinician and their whānau. (Health Quality & Safety Commission, NZ 2022)

Why was this quality improvement project important?

Maryann is a 48 bed facility and provides rest home, hospital and dementia level care in the Taranaki region.

The project began in 2020 as the opportunity for quality improvement was identified by the facility leadership team. Michelle the nurse manager reported that the team felt this project was important to “make sure residents wishes were acknowledged and decrease future stress on residents and families in the case of health decline”. Michelle also discussed that this was “an opportunity to build partnership between whānau and residents to ensure cultural beliefs and values were respected”.

Michelle also stated that having a plan in place “made facility RNs feel supported and educated to care for patients and their families”.

Initial steps

The project was set up with the aim to provide seamless care to all residents by having a plan in place for each individual resident. This was especially important for patients who were no longer able to express their wishes.

To begin the project a collection of preliminary data was conducted in 2020 by the Maryann team. It was identified only 11% of residents at Maryann had any type of ACP in place.

Team focus on ACP

Following this data collection strategies were put in place by the facility team to shed light on the topic including:

  • Discussion sessions about overall goal with clinical team, GP’s and NP’s that support the facility
  • Allowing time at the 3 monthly GP/NP review to speak with residents and their whanau
  • Giving the patient/ whānau time before completing the process to think about their wishes
  • Have resource packs available and posters up for family and patients to understand ACP/MCG forms
  • Providing ACP education with a focus on communication for facility RNs

The progress of this project was regularly monitored by the facility management team alongside Third Age Health (TAH) Nurse Practitioner Wendy Walsh.

Wendy is employed by TAH and provides regular medical services to Maryann facility. From the beginning of the project Wendy was proactive with completing ACP and MCGPs and supporting the facility staff. Wendy reports feeling incredibly proud of the Maryann facility team and is passionate about working in partnership with the team and providing ongoing education.


As of July 2022 100% of patients enrolled under TAH NP Wendy have either an ACP or medical guidance plan in place and 86% of total residents (some registered with other local GPS) have an ACP or MCG on file.

This was achieved by the consistent effort and motivation of the facility team alongside the education and support from Wendy. The excellent relationship formed between Wendy has been a large factor in the success of this project. Michelle feels having support from a NP who takes a holistic approach to patient care is important. Both Michelle and Wendy discussed the importance of ACPs supporting “autonomy to residents and taking a holistic approach to care needs”.

Wendy stated that to create change the facility staff need to be “onboard and enthusiastic”.

What barriers were faced when addressing advanced care planning?

Michelle and Wendy discussed some of the barriers they faced when undertaking this quality improvement project:

  • Not all GP’s understanding the importance of ACP/MCGs in ARC
  • Financial aspects of clinician providing additional time to complete. Facilities that are a charitable organisation may find this difficult.
  • Families finding it difficult to have these conversations. Some needed extra time and education.
  • Family conflicts in decision making e.g. EPOA, wants and wishes.
  • Staff needing further education on the topic.

Wendy stated that the main barrier she faced was “the time it takes for staff education and getting families to come in to have these discussions”. Wendy reports “we acknowledge this conversation should start at admission as this is when family are present”.


Going forward the Maryann team plan to continue to set up all new residents with an ACP/MCG once they are settled into their new home.

Michelle shared advice for any other facilities looking to address ACP/MCG:

  • To view ACP/MCG as a key part of clinical documentation to help with future care
  • Make it part of facility policy on admission to hand out ACP resources and ask to be completed
  • During clinician admission assessment to revisit or complete ACP or MCG
  • A good folder/system to ensure ACPs are easily accessed.
  • Make sure clinical team are understanding and onboard

TAH are proud of what the Maryann team and Wendy have achieved with this project and endeavour to continue to support quality improvements such as this with all the facilities they provide services to. TAH aim to continue to encourage clinicians and facility teams to address advanced care planning as part of planned care at early stages of admission to ARC. Addressing ACP early aims to reduce the need for unplanned episodic care decisions which can cause stress on the patient and family as well as financial implications to the facility due to need for clinician call outs after hours/over the weekend.

Useful resources and tools

  1. Advance care planning Health Quality & Safety Commission, NZ
  2. What is advance care planning? Health Quality & Safety Commission, NZ
  3. Final chapter – Californians’ attitudes and experiences with death and dying California HealthCare Foundation, US, 2012
  4. Advance care planning in 5 steps Health Quality & Safety Commission, NZ
  5. Whenua ki te whenua – an advance care planning guide for whānau – page with info about the guide Health Quality & Safety Commission, NZ

For Clinicians:

  1. Shared goals of care form for ARC Health Quality & Safety Commission, NZ
  2. Serious Illness Conversation Guide Aotearoa  Health Quality & Safety Commission, NZ
  3. Advance Care Planning Training Manual  Health Quality & Safety Commission, NZ
  4. Advance Care Planning training workshops  Health Quality & Safety Commission, NZ
  1. Advance care planning- a guide for the NZ health care workforce Ministry of Health, NZ
  2. Regional HealthPathways NZ
  3. Health Navigator
  4. Poi Project

Articles about Advance Care Planning and the impact on ARC

Effective health care for older people living and dying in care homes: a realist review

An economic model of advance care planning in Australia: a cost-effective way to respect patient choice

Predicting unplanned hospital visits in older home care recipients: a cross-country external validation study


Madelaine Young

Clinical Change Corordinator

Third Age Health