Advance Care Planning in Northland | Te Whatu Ora - Te Tai Tokerau

Advance Care Planning in Northland

Advance Care Planning (ACP) is a process of discussion and shared planning for future healthcare (and end-of-life care). It involves an individual, whānau and health professionals and is about identifying what matters to you.

ACP gives people the opportunity to develop and express their preferences for future care based on:

  • Their values, beliefs, concerns, hopes and goals
  • A better understanding of their current and future health
  • The treatment and care options available

Although ACP work has been happening in Northland for a number of years, a submission was made to ELT in April 2018 and a later submission in late 2019 to establish ACP resources so that ACPs could be rolled out across Northland. Approval was given by ELT for ACP Project Management, SMO and Nurse Coordinator resource and to establish an ACP project to implement ACP’s via the Whanau Tahi ACP tool.

Northland DHB is committed to implementing ACP by ensuring resources and education are available to support the development of skills and knowledge of staff and of the population of Northland. The vision is that ACP will be normalised into everyday clinical practice and included in all care plans for people living with long-term conditions.

Health Quality Safety Commission (HQSC)

The Health Quality & Safety Commission works with clinicians, providers and consumers to improve health and disability support services.

Their vision is hauora kounga mō te katoa - quality health for all.

Their programme areas include advance care planning, adverse events, aged residential care, building leadership and capability, infection prevention and control, medication safety, mental health and addiction, trauma, patient deterioration, consumer engagement, primary care and mortality review.

HQSC provides a framework, guidance and a selection of resources to assist DHB’s with their rollout of ACP’s across their regions.

The Health Quality and Safety Commission (HQSC) National Advance Care Planning (ACP) and clinical communication training strategy (2018-2020) provides a national standardised approach to ACP planning (as available on the HQSC website) and DHB resources to guide a standard approach to ACP implementation. Eighteen (18) of the 20 DHBs, including the NDHB, contribute to this national programme.

HQSC have provided Northland DHB advice, resources and support as requested during the ACP project:

Northland ACP Programme

Northland Future Health Care Planning Governance Group (formerly Northland ACP Steering Group)

  • The Northland ACP Steering Group was established in 2011/12 to provide oversight of the ACP programme and ensure the implementation of ACP goals and objectives across Northland
  • The group was refreshed in late 2016 and renamed the Northland Future Health Care Planning Governance Group to incorporate the continuum of care - advance care planning, end of life care, and last days of care
  • The Governance Group is led by Northland's Acting Director of Nursing and Midwifery
  • The Northland Future Health Care Planning (FCP) Governance Group provides strategic oversight of work in Northland pertaining to health care planning focusing on advance care planning (ACP), end of life care (EOLC), last days of life, and resuscitation treatment decisions.

The vision of the FCP Governance Group is the development of a culture that is patient and whanau centric, where patients and families are empowered to articulate decisions about their health care, supported by clinicians who are confident to engage and document patient priorities with an overarching commitment to the principles of Te Tiriti O Waitangi; including recognition of cultural practices and development and implementation of culturally appropriate approaches to future health care planning. A significant focus is related to ACP.

ACP Project Governance Group

  • The ACP Project Governance Group was established in January 2020 to provide oversight of the ACP project and ensure the implementation of ACP goals and objectives as per the ACP project plan. The ACP Project Governance group consists of the Project Sponsor (the Acting Director of Nursing and Midwifery), ACP Nursing Lead/Nurse Consultant/Manager of Health of Older People, Clinical Lead/SMO, Maori Directorate representation, Primary Care representation and Consumer representation.

ACP Project Working Group

  • The ACP Project Working Group was established in 2020 at the same time the ACP Project Governance group was established. The role of the working group is the development and the implementation of the ACP project plan. The working group consists of a Project Manager, Clinical Lead/SMO, the ACP Nurse Coordinator.and Admin Support.

ACP Project Plan

  • The ACP Project Plan has a timeline from January 2020 until December 2021 after which all phases of the project plan should be at the BAU (Business as Usual) stage. The roll out phases of the project include working with (but not exclusively) the following groups:
    • ARC Facilities
    • Secondary Care Services
    • GP Practices
  • Work will also happen concurrently throughout the length of the project with additional groups/organisations/iwi to address equity issues.
  • Work will also happen concurrently throughout the length of the project to promote ACP’s to the General Public.


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