Integrating Advance Care Planning Into Admissions

Imagine being the new face in a residential aged care facility—amidst the swirl of paperwork, new faces, and unfamiliar routines, there's a quiet opportunity that often goes unnoticed: initiating Advance Care Planning. This period, although overwhelming, is a crucial moment when future care preferences can be thoughtfully discussed and documented. This blog explores how admissions staff can turn this 'teachable moment' into a compassionate, empowering experience using practical tools like the Legacy Vault app.

The Admission Period: A Crucial 'Teachable Moment' for Advance Care Planning

Admission to a residential aged care facility is a significant transition for both residents and their families. It is often a time filled with mixed emotions—relief, anxiety, hope, and uncertainty. While the process can feel overwhelming, it also presents a unique and powerful opportunity: a ‘teachable moment’ to introduce Advance Care Planning (ACP) as a natural and supportive part of settling in. For admissions coordinators, directors of nursing, and client liaison officers, recognising and harnessing this moment is key to embedding ACP into the culture of residential aged care.

Admission: An Intense Yet Receptive Time for Advance Care Planning

Research consistently shows that the period immediately following admission is when residents and families are most open to discussing future care preferences. The reality of moving into residential aged care often brings questions about autonomy, dignity, and what lies ahead. Rather than waiting for a medical crisis, introducing ACP during this phase allows for thoughtful, proactive conversations. Studies indicate that embedding ACP discussions early in the admission journey significantly increases completion rates and leads to better end-of-life outcomes, including reduced hospital admissions and greater satisfaction with care.

Framing ACP as Personalised Care, Not Bureaucracy

One of the most effective ways to engage residents and families in Advance Care Planning is to frame it as an integral part of personalised care planning, not just a bureaucratic requirement. Empathy is crucial. Staff should reassure residents that ACP is about understanding and respecting their wishes—ensuring their voice is heard from the very beginning. This approach helps overcome the common misconception that ACP is only relevant in times of crisis or at the very end of life. Instead, it becomes a positive, empowering process that supports autonomy and peace of mind.

A Step-by-Step Model for Seamless ACP Integration

1. Introduce ACP as Part of ‘Settling In’: During the initial admission meeting, staff can gently explain that understanding care preferences is a standard part of welcoming new residents. Framing the conversation as “getting to know you and your wishes” sets a supportive tone.
2. Provide Resources and Time: Offer clear, accessible information about Advance Care Planning. Allow residents and families time to reflect, ask questions, and discuss privately. This respects their need for space during a busy period.
3. Offer a Structured Tool to Document Wishes: Provide a simple, user-friendly workbook or digital tool for residents to record their care preferences. This ensures clarity and consistency in documentation.
4. File and Share Securely: Once completed, ensure the ACP document is securely stored and easily accessible to all relevant care staff. This guarantees that care preferences are honoured throughout the resident’s stay.

Empowering Staff Through Training and Support

Staff confidence is critical to successful ACP integration. Ongoing staff training in Advance Care Planning helps admissions teams approach these conversations with sensitivity and clarity. Training should focus on communication skills, cultural competence, and strategies for handling emotional responses. Empowered staff are better equipped to ease tensions and guide families through the process, making ACP a seamless part of the admission experience.

Overcoming Barriers: A Story of Early ACP Engagement

Consider the story of “Margaret,” a fictional resident who moved into an aged care facility after a hospital stay. During her admission, the admissions coordinator introduced ACP as part of the welcome process. Margaret and her daughter were initially hesitant, fearing it meant Margaret was “giving up.” With gentle guidance, they learned that ACP was about ensuring Margaret’s wishes were known and respected. Together, they completed an ACP document, which later provided comfort and clarity when Margaret’s health declined. The family expressed gratitude for having had the conversation early, rather than during a crisis.

The Evaheld Ecosystem: The Ideal ACP Toolkit for Admissions

Modern digital solutions can make ACP integration even more seamless. The Evaheld Legacy Vault app acts as a private, easy-to-use digital workbook for new residents, allowing them to document their care preferences securely and at their own pace. For aged care facilities, the Evaheld partner dashboard enables admissions teams to track ACP completion as part of the onboarding workflow, ensuring no resident’s wishes are overlooked. This approach not only streamlines the process but also demonstrates a facility’s commitment to individualised, proactive care from day one.

By recognising admission as a crucial teachable moment and providing the right tools and training, residential aged care facilities can make Advance Care Planning a seamless, empowering part of every resident’s journey.

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.

Step-By-Step Model for Seamless ACP Integration in Admissions

Advance Care Planning (ACP) is increasingly recognised as a cornerstone of person-centred care in aged care facilities. Embedding ACP into the admission process ensures that residents’ care preferences are understood and respected from the outset. The following step-by-step model provides a practical, evidence-based framework for admissions coordinators, directors of nursing, and client liaison officers to make ACP a natural, supportive part of every new resident’s journey.

1. Introduce Advance Care Planning as Part of ‘Settling In’

The admission period, though often overwhelming, is a unique teachable moment. Residents and families are already considering future care needs, making this an ideal time to gently introduce ACP. Admissions staff should frame the conversation as part of ‘getting to know you’ and ensuring the facility understands the resident’s values and wishes. This approach normalises ACP, reducing stigma and anxiety.

“We want to make sure we know your preferences, so your care always reflects what matters most to you.”

2. Provide Accessible Resources and Allow Time for Reflection

Information overload is common during admissions. To support informed decision-making, provide residents and families with clear, accessible resources about Advance Care Planning and Advance Care Directives. Allow them time to review materials, reflect, and ask questions. This might include:

• Printed brochures in plain language
• Short videos explaining ACP and its benefits
• Details of who to contact for further discussion

Staff should reassure families that there is no rush, and that the facility is available to support them throughout the process.

3. Offer Structured Tools to Document Care Preferences

Once residents and families are ready, provide a structured, user-friendly tool to document care wishes. Digital solutions like the Evaheld Legacy Vault app serve as private, interactive workbooks where residents can record their Advance Care Directive and other preferences at their own pace. This empowers residents to express their values clearly and confidently, and ensures nothing is overlooked.

For admissions teams, the Evaheld partner dashboard integrates seamlessly into the onboarding workflow. Staff can track ACP completion, send reminders, and ensure that every new resident’s preferences are captured—minimising the risk of anyone falling through the cracks.

4. Securely File and Share Completed ACP Documents

Once the Advance Care Directive is completed, it must be securely stored and easily accessible to clinical and admissions teams. Digital filing through platforms like Evaheld ensures documents are protected yet available when needed, supporting seamless clinical care and reducing the risk of unnecessary hospital transfers. Facilities should have clear protocols for:

• Uploading and storing ACP documents in the resident’s file
• Ensuring relevant staff can access documents during care planning and emergencies
• Regularly reviewing and updating ACP as residents’ wishes evolve

5. Hypothetical Example: Smoother Care Planning Outcomes

Consider the case of Mrs. Lee, a new resident who moves into an aged care facility. During admission, the coordinator introduces ACP as part of the settling-in process. Mrs. Lee and her daughter receive a simple brochure and are given access to the Evaheld Legacy Vault app. Over the next week, they use the app to document Mrs. Lee’s care preferences, including her wishes regarding hospital transfers and end-of-life care. The admissions team tracks completion via the partner dashboard, ensuring the document is filed and accessible. Months later, when Mrs. Lee experiences a health crisis, staff quickly access her Advance Care Directive, enabling care that aligns with her values and avoiding unnecessary hospitalisation. This proactive approach reduces stress for both family and staff, and demonstrates a commitment to individualised care.

6. Addressing Common Barriers and Practical Strategies

Despite the benefits, several barriers can impede ACP integration during the admission process:

• Lack of staff confidence: Regular training and role-playing can help staff feel more comfortable initiating ACP conversations.
• Time constraints: Embedding ACP into the standard admission checklist ensures it is not overlooked, and digital tools streamline documentation.
• Resident or family reluctance: Emphasising ACP as a routine part of care, rather than a crisis-driven task, helps normalise the process.
• Documentation challenges: Using structured digital platforms like Evaheld reduces paperwork and ensures documents are never lost or inaccessible.

By following this stepwise model, aged care facilities can make Advance Care Planning a seamless, supportive, and empowering part of every admission, supporting best practice and person-centred care from day one.

Evaheld’s Legacy Vault and Partner Dashboard: Digital Innovations Enhancing ACP

Integrating Advance Care Planning (ACP) into the admission process of residential aged care is both a challenge and an opportunity. The admission period is often overwhelming for new residents and their families, but it is also a crucial “teachable moment” when future care preferences are front of mind. Digital tools like Evaheld’s Legacy Vault app and partner dashboard are transforming this experience, making ACP a natural, supportive part of settling in and ensuring that no resident’s wishes are overlooked.

Legacy Vault App: A Simple, Private Digital Workbook

The Legacy Vault app is designed as a user-friendly, private digital workbook that empowers residents to document their care preferences at their own pace. Whether completed remotely before arrival or onsite with support from client liaison officers, the app guides users through the process of recording their values, wishes, and specific instructions for future care. This approach addresses common barriers such as paperwork overwhelm and privacy concerns, providing a secure space where residents feel comfortable sharing personal information.

• Ease of Use: The app’s intuitive design makes it accessible to users of all digital skill levels, with clear prompts and the ability to save progress and return later.
• Privacy and Security: All information entered is encrypted and stored securely, ensuring that residents’ sensitive details are protected and only shared with authorised staff.
• Flexibility: Residents can complete their ACP documentation with the support of family, friends, or staff, either in the comfort of their own home or during the admission process at the facility.

Partner Dashboard: Streamlining the Admission Process for Staff

For admissions coordinators, directors of nursing, and client liaison officers, the partner dashboard is a powerful tool that embeds ACP into the onboarding workflow. This dashboard provides a real-time overview of each resident’s ACP status, ensuring that no one falls through the cracks and that every new admission receives the attention they deserve.

• Workflow Integration: The dashboard tracks completion of ACP documentation as a standard step in the admission process, reducing the risk of missed or incomplete plans.
• Compliance and Quality: Facilities can demonstrate organisational compliance with ACP requirements, supporting accreditation and quality improvement initiatives.
• Improved Communication: Clinical staff can access up-to-date ACP documents instantly, ensuring that care is aligned with each resident’s wishes from day one.

Reducing Risks and Enhancing Care Consistency

One of the most significant advantages of digital ACP tools is the reduction in risk associated with lost, incomplete, or inaccessible documents. By storing all ACP information securely in the Legacy Vault app and making it available through the partner dashboard, facilities can ensure that every resident’s preferences are respected, even during staff transitions or emergencies. This consistency supports truly person-centred care and reduces the stress of last-minute decision-making during medical crises.

User-Friendly Design Encourages Resident Adoption

The Legacy Vault app’s straightforward interface and clear language are designed to encourage adoption by residents, regardless of their comfort with technology. The step-by-step guidance and ability to involve trusted family members or staff help residents feel supported throughout the process. Privacy features, such as secure logins and controlled sharing, further build trust and confidence in the system.

Anecdote: Streamlining Admissions with Evaheld

“As an admissions coordinator, I used to spend hours chasing paper forms and following up with families about incomplete ACP documents. Since introducing Evaheld’s Legacy Vault and partner dashboard, I can see at a glance which residents have completed their plans and which need extra support. It’s made the admission process smoother for everyone and given families peace of mind that their loved one’s wishes are known and respected.”

Empowering Aged Care Facilities Through Technology

Evaheld’s ecosystem exemplifies how digital innovation can empower residential aged care facilities to deliver better, more individualised care. By embedding ACP into the admission process with tools like the Legacy Vault app and partner dashboard, facilities can reduce staff workload, improve compliance, and ensure every resident’s voice is heard from day one. These solutions align with evidence-based strategies for ACP implementation, supporting timely, person-centred care planning and strengthening communication between clinical staff and residents.

Proactive ACP Conversations: Benefits Beyond the Paperwork

For admissions coordinators, directors of nursing, and client liaison officers, the admission period into residential aged care is a pivotal moment. While it can feel overwhelming for new residents and their families, this transition is also a unique opportunity—a “teachable moment”—to introduce Advance Care Planning (ACP) as a natural part of settling in. By embedding ACP into the admission journey, facilities can deliver care that is truly person-centred, supporting both organisational quality standards and the emotional wellbeing of residents and their loved ones.

Why Admission Is the Ideal Time for Advance Care Planning

Initiating ACP at admission, rather than waiting for a medical crisis, significantly reduces anxiety for residents and families. Research consistently shows that early conversations about end-of-life planning and care preferences empower individuals to make informed decisions, clarify their wishes, and nominate substitute decision-makers. This proactive approach not only supports clinical best practice but also demonstrates a facility’s commitment to individualised, respectful care from day one.

“We felt a huge sense of relief knowing Mum’s wishes were documented before anything happened. It took away so much uncertainty for our family.” — Family member, residential aged care resident

A Step-by-Step Model for Seamless ACP Integration

1. Introduce ACP as Part of “Settling In”
   Begin by framing ACP as a standard, supportive part of the admission process. Explain that understanding each resident’s care preferences helps the team provide care that aligns with their values and wishes.
2. Provide Resources and Time
   Offer accessible information about Advance Care Directives and the benefits of end-of-life planning. Allow residents and families time to consider their options, ask questions, and discuss their choices privately.
3. Offer a Structured Tool to Document Wishes
   Use a clear, easy-to-follow ACP tool or digital workbook. The Evaheld Legacy Vault app, for example, enables residents to privately record their preferences, nominate substitute decision-makers, and update their Advance Care Directive as needed.
4. File and Track ACP Documentation Securely
   Ensure completed ACP documents are stored securely and are easily accessible to clinical staff. The Evaheld partner dashboard allows admissions teams to track ACP completion as part of the onboarding workflow, ensuring no resident falls through the cracks.

Clinical and Organisational Benefits of Proactive ACP

Embedding ACP into the admission process yields measurable benefits for both residents and facilities:

• Reduced Hospital Transfers: Evidence shows that proactive ACP can reduce emergency department visits and hospital bed days by up to 40%. This means fewer unnecessary hospital transfers and treatments that may not align with the resident’s wishes.
• Improved End-of-Life Outcomes: Facilities with high ACP uptake report better alignment between resident wishes and actual care received, leading to higher satisfaction among residents and families.
• Emotional Relief for Families: Families consistently report a sense of relief and reduced stress when ACP is completed early, knowing that their loved one’s care preferences are documented and respected.
• Supports Clinical Audits and Quality Standards: Proactive ACP demonstrates compliance with organisational and regulatory standards, supporting accreditation and continuous improvement initiatives.
• Empowers Staff: When ACP is part of the standard admission workflow, staff gain confidence and clarity in discussing end-of-life planning, leading to more positive engagement and better outcomes for all involved.

Person-Centred, Palliative Approach from Day One

Integrating ACP at admission reinforces a palliative, person-centred approach to care. It ensures that each resident’s voice is heard and respected, and that their care preferences guide all clinical decisions, including during hospital transfers or changes in health status. By making ACP a seamless part of the onboarding process, facilities foster trust, transparency, and genuine partnership with residents and their families.

Evaheld: The Ideal Toolkit for ACP at Admission

The Evaheld ecosystem offers practical tools to support this proactive approach. The Legacy Vault app provides a simple, private digital workbook for residents, while the facility’s partner dashboard enables admissions teams to monitor ACP completion as part of their workflow. This ensures that no resident’s wishes are overlooked, and that every new admission is supported with dignity, clarity, and compassion.

Staff Training: Building Confidence to Support ACP Discussions

Effective Advance Care Planning (ACP) integration within residential aged care facilities relies heavily on the confidence and competence of staff. For admissions coordinators, directors of nursing, and client liaison officers, the admission period is a unique “teachable moment” where future care planning is naturally top of mind for new residents and their families. Staff training is a documented facilitator for successful ACP implementation, ensuring that these crucial conversations are handled with sensitivity and professionalism from the outset.

Embedding ACP in the Admission Journey

Staff training programs should be designed to make ACP a seamless part of the admission process. This involves equipping staff with both the knowledge and the practical skills to introduce ACP as part of “settling in and ensuring we know your preferences.” By providing a clear, step-by-step model, staff can confidently guide residents and families through the process:

1. Introduce ACP as a standard component of the admission conversation, framing it as a way to honour the resident’s values and wishes.
2. Provide resources and time for residents and families to consider their options, ensuring they do not feel rushed or pressured.
3. Offer a structured tool to document preferences, such as the Evaheld Legacy Vault app—a secure, private digital workbook tailored for new residents.
4. File the completed document securely and ensure accessibility for all relevant staff, using tools like the Evaheld partner dashboard to track completion and follow-up as part of the onboarding workflow.

This proactive, routine approach is less stressful than having the conversation during a medical crisis and demonstrates a facility’s commitment to individualised care from day one.

Building Skills and Confidence Through Training

Staff training is critical for overcoming barriers to ACP uptake. Research consistently shows that routine staff education sustains quality ACP conversations and improves documentation rates. Training programs should focus on:

• Communication skills: Teaching staff how to initiate and navigate sensitive conversations with empathy and clarity.
• ACP knowledge: Ensuring staff understand the legal, ethical, and organisational policies underpinning ACP in aged care facilities.
• Role-playing and case studies: Using real-life scenarios to build confidence and competence, allowing staff to practice responses and refine their approach in a safe environment.
• Addressing barriers: Providing strategies for managing family dynamics, cultural considerations, and differing levels of health literacy among residents and families.

These elements not only improve staff knowledge and adherence to organisational policies but also support consistent ACP delivery across shifts and teams. When staff feel prepared, they are more likely to engage proactively in ACP discussions, leading to increased documentation and better outcomes for residents.

Ongoing Support and Organisational Commitment

Initial training is only the beginning. To maintain high competency levels, facilities should provide ongoing support, regular refreshers, and access to up-to-date resources. This might include:

• Scheduled refresher sessions as part of mandatory training cycles
• Peer mentoring and debriefing opportunities after challenging conversations
• Access to digital resources and decision aids, such as the Evaheld Legacy Vault and partner dashboard
• Clear organisational policies that embed ACP as a routine, not optional, part of care

By normalising ACP within the organisational culture, staff are empowered to approach these discussions with confidence and consistency. This not only aligns with evidence-based practice and quality standards but also ensures that every resident’s preferences are respected and documented from the very start of their aged care journey.

Leveraging Digital Tools for Seamless Integration

Incorporating digital solutions like the Evaheld ecosystem into staff training and the admissions workflow further streamlines ACP integration. The Legacy Vault app offers a straightforward, private way for residents to record their wishes, while the facility’s partner dashboard enables admissions teams to monitor progress and ensure no one falls through the cracks. Training staff to use these tools as part of their standard practice enhances both efficiency and the quality of ACP documentation, supporting a truly person-centred approach in residential aged care.

Conclusion: Embedding Advance Care Planning as a Cornerstone of Compassionate Admission

The admission process into residential aged care is a time of transition, often marked by a mix of anticipation, uncertainty, and emotional vulnerability for residents and their families. While this period can feel overwhelming, it is also a unique and powerful opportunity—a “teachable moment”—to engage in Advance Care Planning (ACP) in a way that is both supportive and empowering. By embedding ACP as a cornerstone of the admission process, facilities can ensure that every resident’s care preferences are understood, respected, and documented from the outset, setting the stage for truly individualised care.

A structured, stepwise approach to ACP integration during admission not only streamlines the process but also reduces stress for all involved. Rather than waiting for a medical crisis to prompt difficult conversations, introducing ACP as part of “settling in and ensuring we know your preferences” makes it a natural, expected, and compassionate component of care. This proactive method demonstrates a facility’s commitment to dignity, respect, and personalised care, reinforcing trust with residents and their families from day one.

Research consistently shows that structured ACP integration improves the quality of individualised care in residential aged care settings. When ACP is embedded into the admission workflow, supported by clear procedures and digital tools, it becomes a seamless part of the resident’s journey. The process begins with a sensitive introduction to ACP, followed by the provision of accessible resources and time for reflection. Residents are then offered a structured tool to document their wishes, which is securely filed and made readily accessible to care teams. This approach ensures that no one falls through the cracks and that every resident’s voice is heard and honoured.

Digital solutions, such as the Evaheld ecosystem, are transforming how ACP is managed within residential aged care. The Legacy Vault app serves as a simple, private digital workbook, empowering residents to record their care preferences in their own time and words. For admissions teams, the facility’s partner dashboard provides a clear, real-time overview of ACP completion as part of the onboarding workflow. This not only streamlines the process but also ensures accountability and continuity, making it easier for staff to support residents and families throughout their care journey.

The ongoing role of trained staff cannot be overstated. Staff training in both the principles and practicalities of Advance Care Planning is vital to maintaining ACP as a living, evolving part of quality care. When staff are confident and equipped to facilitate these conversations, they can approach ACP with sensitivity and skill, fostering a culture where care preferences are regularly reviewed and updated as needs change. This commitment to ongoing engagement is what transforms ACP from a one-off task into an enduring pillar of resident-centred care.

For aged care managers and leaders, the call to action is clear: make Advance Care Planning an integral part of your admission process. Invest in staff training, adopt digital tools that support seamless documentation and tracking, and create an environment where every resident feels safe and empowered to share their wishes. Reflect on the profound emotional and clinical benefits of early ACP—reduced anxiety for families, fewer unwanted interventions, and a deeper sense of peace for residents knowing their preferences will be honoured.

The journey towards embedding ACP as a cornerstone of compassionate admission is both a responsibility and an opportunity. It is a chance to lead the way in delivering care that is not only clinically sound but also deeply respectful of each individual’s values and choices. By embracing structured processes, leveraging innovative digital tools like Evaheld, and prioritising ongoing staff development, residential aged care facilities can set a new standard for dignity, respect, and personalised care.

In closing, the vision is hopeful and empowering: a future where every resident’s care preferences are at the heart of their experience from the very first day. By making Advance Care Planning a seamless part of the admission process, aged care providers can ensure that every resident’s journey is guided by compassion, clarity, and genuine partnership. The time to act is now—let ACP become the foundation upon which truly person-centred care is built.

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TL;DR: Incorporating Advance Care Planning as a routine part of the residential aged care admission process reduces stress, respects resident preferences, and supports personalised care from day one.