Helping Patients Prepare for Future Health Decisions

In the whirlwind of a typical GP consultation, finding time to discuss advance care planning (ACP) can feel like a luxury few can afford. Yet, these conversations are crucial, especially for ageing patients and those managing chronic illnesses. This post unpacks a pragmatic, step-by-step ACP workflow designed to fit seamlessly into busy GP clinics, making the process both manageable and meaningful. Along the way, we'll explore how digital tools like the Evaheld Legacy Vault transform patient preparation, turning a daunting topic into a collaborative journey between doctor and patient.

Understanding Advance Care Planning in Primary Care

Advance Care Planning (ACP) is a structured process that enables patients to discuss and document their preferences for future health care. In the context of primary care ACP, these conversations are particularly important for ageing individuals and those living with chronic illness. ACP ensures that patient wishes are understood and respected, especially if they lose the capacity to make decisions in the future. For general practitioners (GPs), practice nurses, and practice managers, embedding ACP into routine care supports a truly patient-centric conversation and aligns care with individual values.

ACP as a Progressive Conversation

A common misconception is that Advance Care Planning is a single, lengthy discussion or a one-off form to complete. In reality, ACP is best approached as an ongoing dialogue that unfolds over time. This progressive approach fits naturally within the continuity of care provided in primary care settings. Each interaction—whether during a 75+ health assessment, a chronic disease management review, or a routine check-up—offers an opportunity to introduce, revisit, or refine ACP discussions.

Recognising the time pressures in general practice, it is important to frame ACP as a series of manageable conversations rather than a single event. This allows patients to reflect on their values and preferences at their own pace, while GPs can guide the process without overwhelming their consultation schedules.

Importance of ACP for Ageing and Chronically Ill Patients

Older adults and patients with chronic illnesses are most likely to face complex health decisions in the future. For these groups, ACP is not just a formality—it is a critical tool for ensuring that care aligns with their goals and wishes. By proactively engaging in ACP, primary care teams can help patients avoid unwanted interventions and reduce the likelihood of unnecessary hospitalisations.

Supporting Preference-Aligned Care and Patient Autonomy

Advance Care Planning empowers patients to make informed choices about their future care. When preferences are clearly documented and communicated, healthcare teams can deliver care that truly reflects what matters most to each individual. This not only supports patient autonomy but also provides clarity and reassurance to families and carers during challenging times.

GPs as Trusted Guides in ACP Initiation

Research consistently shows that patients trust their GPs to guide them through sensitive health decisions. This established trust is a key advantage in initiating primary care ACP. GPs are uniquely positioned to start these conversations, drawing on their ongoing relationships and understanding of each patient’s health journey. By normalising ACP as a routine part of care, GPs can reduce anxiety and encourage open, honest dialogue.

Dispelling Common Misconceptions about ACP

• ACP is only for the terminally ill: In fact, ACP benefits anyone who may face future health decisions, especially older adults and those with chronic conditions.
• ACP is a one-time event: ACP is most effective when revisited regularly as circumstances and preferences evolve.
• ACP replaces clinical judgement: ACP complements clinical expertise by ensuring care aligns with patient values.

Impact on Patient Outcomes and Healthcare Utilisation

Effective Advance Care Planning in primary care leads to better patient outcomes. Patients who engage in ACP are more likely to receive care that matches their preferences, experience greater satisfaction, and have reduced rates of unnecessary hospital admissions. For clinics, structured ACP processes can streamline care coordination and improve overall quality of care.

Integrating ACP into Workflow: The Evaheld Legacy Vault

To support time-conscious workflows, GPs can introduce ACP during routine assessments and provide patients with an information pack or recommend a trusted digital tool such as the Evaheld Legacy Vault. This acts as “patient homework,” allowing individuals to reflect and prepare before a dedicated, billable consultation. The Evaheld partner dashboard further assists clinics in managing their ACP patient cohort efficiently, ensuring follow-up and documentation are seamlessly integrated into practice operations.

Plan ahead with confidence — create your free Advance Care Plan in the Evaheld Legacy Vault to record your healthcare wishes, appoint decision-makers, and give your loved ones clarity, comfort, and peace of mind.

Navigating Time Constraints: ACP Workflow for Busy GP Clinics

Advance Care Planning (ACP) is a vital aspect of proactive patient care, especially for ageing populations and those living with chronic illness. However, time pressures in general practice are a well-recognised barrier to meaningful ACP integration. Standard consultations, often limited to 15 minutes, leave little room for in-depth discussions about future care preferences. Recognising these constraints, a staged and structured ACP workflow can help busy clinics embed ACP into routine care without overwhelming clinicians or patients.

Acknowledging Time Pressures in General Practice

General Practitioners (GPs) and their teams operate under significant time constraints. The reality is that ACP cannot be comprehensively addressed in a single, brief consultation. Instead, it should be viewed as a progressive conversation, unfolding over multiple encounters. This approach not only respects the practical limits of clinical workflow but also enhances patient engagement, allowing individuals time to reflect and discuss their values with family or carers before formalising their wishes.

Introducing ACP During Routine Assessments

One of the most effective strategies for ACP integration is to introduce the topic during existing touchpoints, such as the 75+ health assessment or a chronic disease management plan review. These appointments are already designed for comprehensive care planning and are ideal opportunities to raise ACP in a non-threatening, routine context. GPs, as the most trusted source of medical guidance, play a crucial role in normalising these conversations and setting the stage for further discussion.

A Staged Workflow for ACP Discussions

Implementing a staged workflow ensures that ACP is manageable for both clinicians and patients. The recommended process is as follows:

1. Initial Introduction: During a 75+ health assessment or chronic disease review, briefly introduce the concept of ACP. Explain its importance and how it supports patient-centred care.
2. Patient Preparation: Provide an information pack or direct the patient to a trusted digital tool, such as the Evaheld Legacy Vault. This serves as the patient’s “homework,” allowing them to consider their preferences and document key information at their own pace.
3. Dedicated Consultation: Schedule a longer, billable consultation (minimum 16 minutes for Medicare eligibility) specifically for ACP. This session focuses on reviewing the patient’s reflections, answering questions, and formalising their wishes in the medical record.

This staged approach spaces out discussions naturally, reducing pressure on both the clinician and the patient. It also increases the likelihood of meaningful, well-considered ACP documentation.

Benefits of Separating Introduction and Formalisation

Separating the initial introduction from the formal ACP conversation offers several advantages:

• Patients have time to reflect, discuss with family, and engage with digital tools like Evaheld Legacy Vault.
• The dedicated follow-up consultation is more productive, as patients arrive prepared with questions and preferences.
• Clinics can schedule these longer consultations as billable services, supporting sustainable ACP integration and revenue capture.

Team-Based Support and Workflow Management

Practice nurses and managers are essential in supporting the ACP workflow. Nurses can introduce ACP during assessments, distribute information packs, and assist with scheduling follow-up appointments. Practice managers can use tools such as the Evaheld Partner Dashboard to track patient progress, manage cohorts, and ensure timely follow-up. Best practice alerts and structured scheduling further improve ACP uptake and workflow efficiency.

By embedding ACP into routine clinical workflow and leveraging digital tools for patient preparation, busy GP clinics can overcome time constraints and deliver high-quality, proactive care that aligns with patient values and preferences.

The Evaheld Legacy Vault: Patient Homework to Drive Productive Consultations

Advance Care Planning (ACP) is most effective when it unfolds as a series of conversations, rather than a single, pressured event. For General Practitioners (GPs) and practice teams, the challenge lies in balancing the importance of ACP with the realities of limited consultation time. Digital ACP tools, such as the Evaheld Legacy Vault, offer a practical solution by empowering patients to prepare in advance, ensuring that in-clinic discussions are focused, meaningful, and efficient.

Integrating Digital Patient Preparation Tools into the Provider Workflow

A structured workflow helps embed ACP into routine care for ageing patients or those with chronic illness. A recommended approach is:

1. Introduce ACP during a 75+ health assessment or chronic disease management review.
2. Recommend the Evaheld Legacy Vault as a trusted digital patient preparation tool, providing an information pack or direct digital access.
3. Schedule a dedicated, longer consultation (potentially billable) to discuss the patient’s reflections and formalise their ACP documentation.

By positioning the Evaheld Legacy Vault as “patient homework,” GPs can enable patients to reflect on their values, preferences, and care wishes at their own pace, outside the time constraints of the clinic.

How Patients Engage with the Evaheld Legacy Vault

The Evaheld Legacy Vault is designed for simplicity and accessibility. Patients receive a secure link or printed instructions from their GP, allowing them to log in from home. The tool guides them through a series of prompts and questions, encouraging them to consider:

• What matters most to them in life and care
• Who they trust to make decisions if they are unable
• Specific medical interventions they would or would not want
• Personal, spiritual, or cultural wishes

Patients can take their time, discuss with family, and return to the tool as needed. This reflective process means they arrive at the next consultation better prepared, with clear ideas and questions to discuss.

Benefits: Focused Consultations and Improved Documentation

Digital ACP tools like the Evaheld Legacy Vault reduce the pressure on in-clinic time. When patients have already considered their values and preferences, the GP can focus on clarifying details, addressing concerns, and formalising documentation. This leads to:

• More productive consultations – less time spent on basic explanations, more on meaningful discussion
• Higher documentation rates – patients are more likely to complete ACP forms when prepared
• Patient empowerment – individuals feel heard and involved in their care planning

“Since introducing Evaheld as part of our ACP workflow, patients come to their appointments ready to talk about what matters to them. It’s made our conversations more focused and rewarding for both sides.” – Practice Nurse, NSW

GPs as Trusted Guides: Recommending Evaheld

Patients consistently report that GPs are their most trusted source for health advice. By recommending the Evaheld Legacy Vault, GPs reinforce their role as guides and advocates, supporting patients to take an active role in their future care. The tool’s clear language and guided prompts make it accessible for a wide range of patients, including those less familiar with digital technology.

Clinic Partner Dashboard: Managing and Monitoring ACP Engagement

The Evaheld partner dashboard provides clinics with a real-time view of patient progress. Practice managers and nurses can:

• Track which patients have started or completed their ACP homework
• Send reminders and support resources as needed
• Identify cohorts requiring follow-up or additional support

This administrative oversight ensures no patient is left behind and supports a proactive, team-based approach to ACP.

Engaging the Care Team: Collaborative Roles in ACP Delivery

Advance Care Planning (ACP) is most effective when it is woven into the fabric of team-based care. In busy general practice settings, a collaborative approach not only improves workflow efficiency but also ensures that all patients, regardless of background or health literacy, have equitable access to ACP support. By involving practice nurses, practice managers, and leveraging digital tools and electronic health records (EHR), clinics can deliver proactive, patient-centred care that respects individual values and preferences.

Team-Based Care: Enhancing Workflow and Patient Outcomes

ACP should not be seen as a one-off conversation, but as a progressive dialogue that unfolds over time. Given the time constraints of standard consultations, team-based care enables GPs to introduce ACP in a structured yet flexible manner:

1. Initial Introduction: The GP introduces ACP during a 75+ health assessment or chronic disease management review, setting the stage for future discussions.
2. Patient Preparation: Practice nurses or managers provide patients with an ACP information pack or direct them to a trusted digital tool, such as the Evaheld Legacy Vault. This “patient homework” empowers individuals to reflect on their values and preferences outside the clinic, making subsequent consultations more productive.
3. Dedicated Consultation: A longer, billable appointment is scheduled for formal ACP discussion and documentation, ensuring the patient’s wishes are clearly recorded and accessible.

This workflow distributes responsibilities across the care team, improving patient follow-through and reducing the burden on any single clinician.

Empowering the Team: Training and Resources

To maximise the effectiveness of team-based care, all staff should have access to training and resources that clarify their roles in ACP delivery. Practice nurses are well-placed to initiate conversations, answer questions, and support patients in using digital tools like the Evaheld Legacy Vault. Practice managers can coordinate scheduling, manage resources, and oversee the integration of ACP into routine care pathways. Ongoing education ensures that every team member feels confident and capable in supporting ACP, regardless of their clinical background.

Promoting Health Equity in ACP

Health equity is a cornerstone of quality ACP delivery. Team-based care models are uniquely positioned to address barriers faced by patients from diverse backgrounds, including those with limited English proficiency, low health literacy, or complex social circumstances. Strategies to promote equity include:

• Offering ACP materials in multiple languages and accessible formats
• Providing interpreter services during ACP discussions
• Ensuring all patients are routinely offered ACP, not just those perceived as “ready”

By embedding health equity into ACP processes, clinics can reduce disparities in chronic illness management and ensure every patient’s voice is heard.

Communication and EHR Integration: Seamless Handover and Documentation

Effective communication is vital for seamless handoff and follow-up in ACP. Regular team meetings, shared care plans, and clear documentation protocols help prevent duplication and ensure that every team member is informed of a patient’s ACP status. Leveraging EHR integration allows for:

• Centralised storage of ACP documents, accessible to all relevant staff
• Automated reminders for follow-up discussions or document reviews
• Population health management through cohort tracking, such as with the Evaheld partner dashboard

These strategies not only streamline workflow but also enhance the patient experience, building trust and satisfaction with the care provided.

Overcoming Barriers: Billing, Workflow Confusion, and Patient Hesitancy

Clarifying Medicare Billing Requirements for ACP Consultations

One of the most common challenges for general practice teams integrating Advance Care Planning (ACP) is navigating the billing requirements for these conversations. Under current Medicare guidelines, ACP consultations are billable provided the discussion lasts at least 16 minutes. This time capture is essential for reimbursement and ensures that the consultation is recognised as a dedicated, structured service. Practices should ensure all team members are aware of these requirements and have clear protocols for documenting the start and end times of ACP consultations. Accurate documentation not only supports compliance but also improves documentation rates for quality improvement and audit purposes.

Addressing Workflow Confusion: Structured Provider Workflow

ACP can initially disrupt established clinic routines, especially when squeezed into already time-pressured appointments. However, a structured provider workflow can minimise disruption and support sustainable integration. A practical approach is to introduce ACP during routine touchpoints such as the 75+ health assessment or chronic disease management plan review. At this stage, the GP or nurse can provide an information pack or recommend a trusted digital tool like the Evaheld Legacy Vault as “patient homework.” This allows patients to reflect on their values and preferences in their own time, before returning for a dedicated, longer consultation. This workflow not only aligns with billing requirements but also streamlines clinic operations by reducing the need for multiple, fragmented discussions.

Strategies to Sensitively Broach ACP with Hesitant Patients

Patient hesitancy is a well-recognised barrier to ACP. Many patients may feel anxious or believe ACP is only relevant when death is imminent. GPs, as trusted guides, play a crucial role in normalising these conversations. Approaching ACP as a routine part of proactive care—rather than a sign of impending decline—can help reduce fear and misunderstanding. Using phrases such as, “We ask all our patients to think about what matters most to them, so we can provide care that respects their wishes, no matter what happens,” can help. Providing the Evaheld Legacy Vault as a preparatory tool empowers patients to consider their preferences privately, making the follow-up consultation more comfortable and productive.

Case Study: Overcoming Barriers in Practice

A regional clinic in Victoria faced significant workflow confusion and low documentation rates when first implementing ACP. By introducing ACP during annual health assessments and using the Evaheld Legacy Vault as a standard patient resource, the clinic streamlined its process. Patients completed their “homework” at home, and dedicated ACP consultations were scheduled for at least 20 minutes, meeting Medicare billing requirements. The clinic’s use of the Evaheld partner dashboard enabled easy tracking of patient progress and improved documentation rates for compliance. Within six months, the clinic reported increased staff confidence, higher patient engagement, and a measurable rise in completed ACP documents.

Tools and Prompts to Support Documentation and Compliance

• Use digital tools like Evaheld Legacy Vault to guide patients through ACP reflection and documentation.
• Leverage the clinic’s partner dashboard to monitor patient progress and follow up on incomplete plans.
• Standardise documentation templates within the clinical software to ensure all Medicare billing requirements are met.
• Provide staff with quick-reference guides outlining the minimum consultation time and required documentation elements.

Benefits of Embedding ACP in Routine Care

Normalising ACP as part of routine care not only improves patient outcomes but also enhances clinic efficiency and compliance. When ACP is introduced proactively and supported by structured workflows and digital tools, it becomes a seamless aspect of patient-centred care—rather than an additional burden. This approach supports sustainable integration, higher documentation rates, and ultimately, better alignment of care with patient values.

Real-World Impact: Patient Outcomes and Practice Efficiency

Integrating Advance Care Planning (ACP) into the clinical workflow of general practice delivers measurable benefits for both patients and clinics. By adopting a structured approach—introducing ACP during routine assessments, leveraging digital tools like the Evaheld Legacy Vault for patient preparation, and formalising preferences in a dedicated consultation—GP clinics can transform patient care and operational efficiency.

Reducing Unwanted Hospitalisations and Readmissions

Effective ACP ensures that patient preferences are documented and accessible, reducing the likelihood of unwanted hospital admissions and emergency interventions. When patients’ wishes are clearly recorded and communicated, care teams can avoid unnecessary treatments and hospital transfers, particularly in end-of-life scenarios. Studies show that ACP reduces unplanned hospitalisations, with patients more likely to receive care aligned with their values, leading to improved quality of life and reduced stress for families and clinicians.

Improving Patient Satisfaction Through Preference-Aligned Care

Patients consistently report higher satisfaction when their care aligns with their expressed wishes. By positioning ACP as a progressive conversation—initiated during a 75+ health assessment or chronic disease review, supported by the Evaheld Legacy Vault as “patient homework,” and finalised in a longer, billable consultation—GPs reinforce their role as trusted guides. This approach empowers patients, fosters trust, and ensures that care decisions reflect what matters most to each individual. The result is a more personalised, compassionate patient experience.

Enhancing Documentation and Clinical Workflow Efficiency

Structured ACP workflows, especially when integrated with electronic health records (EHR), dramatically improve documentation rates. Data indicates that ACP documentation completion rates can rise from 11.5% to 76% with EHR integration. The Evaheld partner dashboard further streamlines this process, allowing clinics to track patient progress, manage cohorts, and ensure that ACP documents are up to date and readily available. Centralised ACP registries and digital tools mean patient preferences are accessible 24/7, supporting continuity of care across settings and providers.

Financial Benefits Through Appropriate Billing

ACP can be incorporated into existing Medicare billing structures, such as health assessments and chronic disease management plans. By scheduling dedicated, longer consultations for ACP discussions, clinics can appropriately bill for this essential service. This not only compensates for the time invested but also supports the sustainability of proactive, patient-centred care. Ongoing ACP engagement justifies continued investment in staff training and digital infrastructure, reinforcing the clinic’s commitment to high-quality care.

Longitudinal Benefits in Proactive Care Practices

• Continuity of Care: Patients with documented ACP are more likely to receive consistent care over time, reducing fragmentation and improving outcomes.
• Reduced Emergency Interventions: Preference-aligned care minimises crisis-driven decisions, supporting planned, coordinated care pathways.
• Family and Carer Support: Clear documentation lessens the burden on families during critical moments, reducing conflict and uncertainty.

ACP Engagement and Community Wellbeing

Widespread ACP engagement contributes to public health by promoting informed decision-making and reducing unnecessary healthcare utilisation. Clinics that champion ACP foster a culture of proactive, values-based care, benefiting not only individual patients but the broader community. As more practices adopt structured ACP workflows, the collective impact on community wellbeing and healthcare system sustainability becomes increasingly significant.

“Integrating ACP into routine practice is not just about ticking a box—it’s about ensuring every patient’s voice is heard, every time.”

Looking Forward: The Future of Digital ACP in General Practice

As general practice continues to evolve, digital advance care planning (ACP) is poised to become an integral part of proactive, patient-centred care. For GPs, practice nurses, and practice managers, the future promises new tools and workflows that make ACP more accessible, efficient, and meaningful for patients—especially those living with chronic illness or approaching older age. The next generation of ACP delivery will be shaped by technology, teamwork, and a renewed focus on patient empowerment.

One of the most significant developments is the emergence of AI tools that support predictive risk identification. These technologies can analyse patient data to flag individuals who may benefit from an ACP conversation, such as those with complex chronic conditions or recent hospital admissions. By highlighting high-risk patients, AI can help GPs initiate timely discussions, ensuring that ACP is not left until a crisis occurs. This approach aligns with the time-conscious reality of general practice, where every minute counts and proactive care can make a substantial difference.

Equally important is the integration of ACP documentation with electronic health records (EHR). Seamless EHR integration ensures that a patient’s wishes are easily accessible to all members of their care team, both within the clinic and across the broader health system. This not only improves documentation rates but also enhances care continuity, particularly during transitions between primary, acute, and aged care settings. Policy changes on the horizon may further support universal ACP documentation sharing, reducing fragmentation and supporting patient autonomy.

The future of digital ACP will also be shaped by public-private initiatives aimed at improving health equity. By leveraging government support and private sector innovation, these partnerships can expand access to ACP resources for diverse communities, including those who may face barriers due to language, culture, or digital literacy. Such initiatives can help ensure that ACP becomes a standard part of care for all Australians, regardless of background or location.

Advancements in patient-centric digital platforms will continue to empower individuals to take an active role in their care planning. Tools like the Evaheld Legacy Vault exemplify this shift, providing patients with a secure, user-friendly space to reflect on their values, document their wishes, and prepare for meaningful conversations with their GP. When recommended as “patient homework,” these tools allow patients to arrive at their dedicated ACP consultation informed and ready, making the process more efficient and productive for both patient and clinician. For clinics, the Evaheld partner dashboard offers a practical way to manage and track the ACP journey across their patient cohort.

Training and team-based approaches will also underpin the future of ACP in general practice. As new digital health technologies are adopted, ongoing education for GPs, nurses, and practice staff will be essential. This will ensure that the whole team is confident in using digital tools, facilitating conversations, and supporting patients through the ACP process. Collaborative care models, supported by technology, will help embed ACP as a routine, rather than exceptional, part of chronic illness management.

Ultimately, the vision for digital ACP in general practice is one of seamless integration—where technology, policy, and teamwork converge to make advance care planning a natural extension of everyday care. By embracing AI tools, EHR integration, and patient-centred platforms, clinics can support their patients’ wishes, reduce unnecessary interventions, and strengthen the trusted relationship at the heart of general practice. The future is not only digital, but decisively human, with GPs guiding patients through some of the most important decisions of their lives.

TL;DR: This post outlines a streamlined ACP integration workflow for GP clinics, balancing time pressures with patient preparation using digital tools, to enhance proactive, preference-aligned care.

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