Supporting Families Through Care Planning

Imagine stepping into a new home filled with hope but layered with uncertainty—this is the admission moment for many frail elders entering residential aged care. This blog unpacks why this overwhelming period is also a golden opportunity to introduce Advance Care Planning (ACP), blending empathy with procedure to empower residents and their families from day one.

Why Admission Is the Untapped 'Teachable Moment' for Advance Care Planning

The admission period into residential aged care is often described as overwhelming for frail elders and their families. Yet, this very transition presents a unique and powerful opportunity—a ‘teachable moment’—to introduce Advance Care Planning (ACP) in a way that feels natural, supportive, and empowering. For Admissions Coordinators, Directors of Nursing, and client liaison officers, recognising and harnessing this moment can transform the onboarding experience and set the tone for truly individualised care.

Admission: A Time of High Readiness for Future Planning

When aged care residents and their families arrive at a facility, they are acutely aware of the need to plan for the future. The move itself prompts reflection on values, preferences, and expectations for care. This readiness makes the admission period an ideal time to discuss ACP, as families and residents are motivated to ensure their wishes are known and respected. Research supports this approach, with early engagement in ACP linked to improved living well now and better future planning outcomes.

Step-by-Step Model for Integrating ACP at Admission

1. Introduce ACP as Part of Settling In: Frame ACP as a standard part of the admission process—“We want to ensure we know your preferences so we can provide care that truly reflects your wishes.” This approach helps normalise the conversation and reduces anxiety.
2. Provide Resources and Time: Offer clear, accessible information about ACP, including brochures, videos, or digital resources. Allow residents and families time to consider their options and ask questions, rather than rushing the process.
3. Offer a Structured Tool to Document Wishes: Use a simple, structured tool—such as a digital workbook or paper form—to capture the resident’s preferences and identify substitute decision makers. This step ensures that wishes are documented clearly and can be easily updated as needed.
4. File and Ensure Accessibility: Securely file the completed ACP document and make it readily accessible to clinical staff. Digital solutions, such as the Evaheld Legacy Vault app, streamline this process and support continuity of care.

Reducing Stress and Building Trust

Introducing ACP during admission is far less stressful than waiting for a medical crisis to occur. It allows residents and families to make thoughtful decisions in a calm environment, rather than under pressure. This proactive approach also demonstrates the facility’s commitment to person-centred care from day one, building trust and confidence in the care team.

One resident, Mrs. L, completed her ACP with the support of her admissions coordinator. Months later, when she experienced a sudden health event, her documented wishes helped staff avoid an unwanted hospital transfer, ensuring she received care aligned with her values. Her family expressed immense relief and gratitude for the early conversation.

Clarifying Substitute Decision Making Roles

The admission phase is also the optimal time to clarify substitute decision making arrangements. By identifying and documenting who will speak for the resident if they are unable, facilities can avoid confusion and distress during future health events. This clarity supports both residents and their families, ensuring everyone understands their roles and responsibilities.

Leveraging Digital Tools for Seamless ACP Integration

Digital platforms like Evaheld’s Legacy Vault app and partner dashboard are transforming ACP in residential aged care. In one study, 80% of aged care residents had ACPs available digitally, supporting seamless care alignment and reducing hospitalisations. The Evaheld ecosystem enables admissions teams to track ACP completion as part of the onboarding workflow, ensuring no resident falls through the cracks and that preferences are always accessible to care staff.

• Admission-based ACP increases documented end-of-life preferences.
• Staff training and confidence are key to recognising and leveraging this teachable moment.
• Digital tracking tools enhance accountability and care continuity.

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Step-by-Step Framework for Seamless ACP Integration in the Admission Journey

For Admissions Coordinators, Directors of Nursing, and client liaison officers, the admission period into residential aged care is a pivotal opportunity to introduce Advance Care Planning (ACP) in a way that feels supportive and empowering. While the transition can be overwhelming for new residents and their families, it is also a “teachable moment” where future care preferences are naturally front of mind. Embedding ACP into the onboarding process not only reduces stress but also demonstrates a facility’s commitment to individualised care from the outset. The following step-by-step framework provides a practical model for integrating ACP seamlessly, with digital tools like the Evaheld ecosystem enhancing efficiency and confidence for both staff and residents.

Step 1: Introduce ACP as Part of ‘Settling In’—Linking to Personalised Care

Begin the conversation about Advance Care Directives as a natural part of the admission process. Position ACP as a way to ensure the resident’s values, wishes, and preferences are known and respected from day one. Admissions staff can use simple scripts such as:

“As part of settling in, we’d like to talk about your care preferences so we can support you in the way that suits you best, both now and in the future.”

Framing ACP in this way helps normalise the conversation and reduces anxiety for residents and families.

Step 2: Provide Accessible Resources and Allow Time for Consideration

Offer clear, easy-to-understand resources about ACP and Care Planning. This might include brochures, visual aids, or short videos explaining the process and its importance. Encourage residents and families to take their time, review the materials, and discuss their wishes privately before making any decisions. Allowing this space respects their autonomy and ensures they feel supported rather than rushed.

Step 3: Offer a Structured Tool to Document Care Wishes Securely

Provide a structured, user-friendly tool for documenting care preferences. The Legacy Vault app within the Evaheld ecosystem is an ideal choice, acting as a private digital workbook for residents. This digital ACP tool guides users step-by-step through the process, making it easier to articulate and record their wishes. Research shows that using structured digital platforms leads to higher ACP completion rates and increases staff confidence in facilitating these conversations.

Step 4: File Completed ACP Documents Securely and Ensure Accessibility

Once the Advance Care Directive is completed, ensure it is filed securely and is readily accessible to all relevant clinical teams. The Evaheld partner dashboard enables admissions staff to track ACP completion as part of the onboarding workflow, ensuring no resident’s wishes are overlooked. Digital storage also streamlines retrieval and sharing, improving operational efficiency and clinical response during critical moments.

Staff Roles in Facilitating and Revisiting ACP Conversations

Admissions staff play a central role in initiating ACP conversations, providing resources, and guiding residents through documentation. Clinical teams should be trained to revisit ACP discussions as needed—such as after a change in health status or at regular care plan reviews—to ensure preferences remain current and relevant. This collaborative approach embeds ACP as an ongoing, living part of the resident’s care journey.

Practical Tips for Effective ACP Conversations

• Use scripting: Prepare key phrases to introduce ACP gently and confidently.
• Visual aids: Incorporate diagrams or checklists to clarify complex topics.
• Schedule follow-ups: Arrange dedicated times to revisit ACP, ensuring residents and families feel supported throughout their stay.

By following this structured, stepwise approach and leveraging digital ACP tools, residential aged care facilities can create a seamless, supportive admission experience that honours each resident’s unique wishes from the very beginning.

Evaheld Ecosystem: Revolutionising ACP with Digital Support

Transforming Advance Care Planning with a Digital Platform

The admission period into residential aged care is a pivotal moment for residents and their families. While it can feel overwhelming, it also presents a unique opportunity—a “teachable moment”—to introduce Advance Care Planning (ACP) as an integral part of settling in. The Evaheld ecosystem, anchored by its Legacy Vault app, is designed to make ACP a seamless, supportive, and empowering experience for all involved.

Legacy Vault App: A Private, Easy-to-Use Digital Workbook

At the heart of Evaheld’s digital platform is the Legacy Vault app. This secure, user-friendly digital workbook enables new residents to privately reflect on and document their care preferences at their own pace. By providing a safe space for personal reflection, the app supports autonomy and ensures that each resident’s wishes are captured accurately. This approach is particularly beneficial for individuals who may find traditional paper-based forms daunting or inaccessible, including those with mild cognitive challenges.

Step-by-Step ACP Integration into Admissions

1. Introduce ACP as part of “settling in”: Admissions coordinators can present ACP using the Legacy Vault app as a natural extension of getting to know the resident and their values.
2. Provide resources and time: Residents and families receive digital resources and guidance, allowing them to engage with ACP thoughtfully, without pressure.
3. Structured documentation: The app’s guided workflow helps residents clearly articulate their wishes, ensuring nothing is overlooked.
4. Secure storage and accessibility: Completed ACP documents are securely stored within the platform, accessible to authorised staff when needed.

Operational Efficiency and Staff Empowerment

The Evaheld partner dashboard is a powerful tool for admissions teams. It integrates ACP completion into the onboarding workflow, ensuring no resident falls through the cracks. Staff can easily track progress, send reminders, and manage documentation—all from a central dashboard. This digital approach increases operational efficiency, reduces paperwork, and mitigates staff workload during the busy admission period.

Research shows that digital ACP tools can increase documentation rates and improve accessibility. In one facility, ACP completion rates rose by 30% after adopting Evaheld’s digital platform. Additionally, studies report up to 80% digital ACP availability via QR codes, making it easier for staff to access critical information in real time.

Integration with My Health Record for Continuity of Care

A standout feature of the Evaheld ecosystem is its interoperability with My Health Record. Once a resident’s ACP is finalised in the Legacy Vault app, it can be securely shared with their national health record. This integration ensures that care preferences are available to clinicians across settings, reducing clinical risk and supporting continuity of care. Real-time data sharing minimises miscommunication and ensures that every care decision reflects the resident’s documented wishes.

Benefits for Residents, Families, and Facilities

• Resident empowerment: Residents have control over their ACP journey, supported by a private digital platform.
• Staff confidence: Structured workflows and easy access to ACP documentation increase staff confidence in delivering individualised care.
• Reduced miscommunication: Clear, accessible digital records minimise the risk of misunderstandings during care transitions.
• Streamlined workflows: Digital tools reduce administrative burden, freeing staff to focus on resident care.

Case Study: Measurable Improvements with Evaheld

A recent case study highlights the impact of Evaheld’s digital platform. After implementation, one residential aged care facility reported a 30% increase in ACP completion rates, with staff noting improved workflow efficiency and greater resident satisfaction. The integration of digital ACP tools into admissions not only supports compliance but also demonstrates a facility’s commitment to person-centred care from day one.

Addressing Common Fears and Misconceptions About ACP at Admission

Advance Care Planning (ACP) is a vital part of the admission process in residential aged care, yet it is often met with hesitation and misunderstanding. For admissions coordinators, directors of nursing, and client liaison officers, understanding and addressing these concerns is essential to supporting residents and families during this significant transition. By reframing ACP and providing practical, supported pathways, facilities can empower new residents to take an active role in their future care.

Reframing ACP: From ‘Giving Up’ to Living Well and Autonomy

One of the most common fears is that discussing ACP signals ‘giving up’ or expecting the worst. In reality, ACP is about living well—ensuring each resident’s values and preferences guide their care from the outset. Introducing ACP as part of “settling in and ensuring we know your preferences” helps normalise these conversations. It demonstrates that the facility is committed to individualised care and respects resident autonomy, not just at end-of-life, but throughout their stay.

ACP Is Not Just for End-of-Life: Ongoing Care Preference Setting

Another misconception is that ACP is only relevant when someone is nearing the end of life. In fact, ACP is an ongoing process that supports decision making at every stage of care. By positioning ACP as a tool for setting and updating care preferences, staff can help residents and families see its value in everyday wellbeing, not just during crises. This approach also aligns with best practice, where ACP is revisited regularly and updated as circumstances change.

Addressing Cognitive Impairment: Supported Decision Making

Concerns about cognitive impairment and decision making capacity can lead families and staff to delay or avoid ACP discussions. However, supported decision making enables residents with mild to moderate impairment to participate meaningfully in planning. Providing information in accessible formats, allowing extra time, and involving trusted supporters or substitute decision makers can make ACP more inclusive. Research shows that supported decision making expands participation and honours the rights of all residents, regardless of cognitive status.

Staff Training: Building Confidence and Reducing Uncertainty

Uncertainty about when and how to introduce ACP is a common barrier for staff. Comprehensive staff training is key to building confidence and ensuring a consistent, sensitive approach. Training should cover communication skills, legal and ethical considerations, and practical steps for integrating ACP into the admission workflow. Facilities that invest in ACP education see higher rates of uptake among residents and families, and greater staff satisfaction.

ACP as a Living Document: Value of Partial Documentation

Some families worry that if they cannot complete every detail of an ACP document immediately, it is not worth starting. It is important to reinforce that partial documentation is better than none. ACP is a living document, designed to be updated as preferences evolve. Encouraging residents to begin the process, even if only partially, ensures that some wishes are known and respected from day one.

Success Stories: Early ACP Eases Family Stress

Sharing real-life examples can help overcome resistance. Facilities report that when ACP is addressed early, families experience less stress and uncertainty during health crises. One facility shared,

“Having Mum’s wishes documented from admission meant we could focus on supporting her, rather than making rushed decisions in hospital.”

These stories highlight the practical and emotional benefits of proactive ACP, reinforcing its role as a cornerstone of quality care.

System-Wide Solutions: Tools and Technology

Normalising ACP requires system-wide approaches. The Evaheld ecosystem, including the Legacy Vault app, offers a seamless, private way for residents to document preferences. The partner dashboard enables staff to track ACP completion as part of the onboarding workflow, ensuring no one is overlooked. This integration supports a culture where ACP is standard practice, not an afterthought.

Real-World Benefits of Early ACP for Frail Elders in Residential Care

Advance Care Planning (ACP) is increasingly recognised as a cornerstone of high-quality, resident-centred care in residential aged care settings. For frail elders, especially those entering care, the admission period is a critical opportunity to initiate these important conversations. Making ACP a seamless part of the onboarding process delivers tangible benefits for residents, families, and care teams alike.

Reduces Unwanted Hospitalisations and Invasive Treatments Near End of Life

One of the most significant outcomes of early ACP is the reduction in unnecessary hospital transfers and invasive interventions at the end of life. Research consistently shows that residents with documented ACP are less likely to experience unwanted hospitalisations or receive treatments inconsistent with their wishes. This not only minimises distress for frail elders but also supports a more comfortable and dignified end-of-life experience within the familiar environment of the residential care facility.

Aligns Clinical Care with Resident’s Stated Preferences

Early ACP ensures that the care delivered aligns closely with each resident’s values, goals, and preferences. By introducing ACP as part of the admission journey—framed as “settling in and ensuring we know your preferences”—facilities demonstrate a commitment to individualised care from day one. This proactive approach leads to higher satisfaction rates among residents and families, as clinical decisions reflect the person’s own choices rather than assumptions or crisis-driven decisions.

Facilitates Smoother Family Communication and Reduces Decision-Making Conflicts

ACP provides a structured opportunity for residents and families to discuss future care openly, often for the first time. By offering resources and time during the admission process, families can participate in these conversations without the pressure of a medical emergency. This clarity reduces the risk of conflict and confusion during critical moments, supporting family unity and easing the emotional burden of decision-making.

Supports Palliative and Anticipatory Care Planning with Timely Interventions

Integrating ACP early allows for timely identification of palliative care needs and anticipatory planning. This means that care teams can implement appropriate interventions, such as symptom management or comfort measures, before crises occur. The result is a smoother care journey for frail elders, with fewer emergency events and a greater focus on quality of life.

Enhances Staff Confidence in Respecting ACP Documentation

When ACP is embedded into the admission workflow, staff are better equipped to honour residents’ wishes during critical situations. The use of structured tools, such as the Evaheld Legacy Vault app, provides a simple and private digital workbook for residents, while the facility’s partner dashboard allows admissions teams to track completion as part of onboarding. This ensures that ACP documentation is accessible and up to date, giving staff confidence to act in accordance with the resident’s preferences.

Links to Quality Accreditation and Regulatory Compliance Benefits

Proactive ACP not only improves clinical outcomes but also supports compliance with legal and ethical standards. Facilities that integrate ACP into their admission process demonstrate alignment with quality accreditation requirements and regulatory expectations for person-centred care. This commitment is increasingly scrutinised by oversight bodies and is a marker of excellence in residential aged care.

• Key Data: Residents with ACP are significantly less likely to receive inconsistent treatments near end of life.
• ACP documentation is associated with fewer hospitalisations and emergency events.
• Resident-centred care improves both clinical outcomes and overall quality of life.

By making Advance Care Planning a natural, supportive part of the admission journey, residential aged care facilities can deliver real-world benefits for frail elders, their families, and the broader care team—proving the value of proactive, person-centred planning from day one.

Empowering Staff: Training and Embedding ACP into Routine Practice

Advance Care Planning (ACP) is most effective when it is woven seamlessly into the daily operations of aged care facilities. Staff training is the cornerstone of this integration, equipping teams with the confidence and skills needed to initiate and sustain meaningful ACP conversations. When ACP becomes a routine part of the admission process, it not only supports operational efficiency but also demonstrates a facility’s commitment to person-centred care from the very first day.

Comprehensive Staff Training: Building Confidence and Competence

Research consistently shows that comprehensive education in Advance Care Planning increases staff confidence and improves the quality of ACP conversations. Staff who are well-trained feel more comfortable discussing sensitive topics, leading to higher rates of ACP documentation and greater family awareness.

• Initial Induction: All admissions coordinators, nurses, and allied health staff should receive ACP training as part of their onboarding. This includes role-playing scenarios, understanding legal requirements, and learning how to use structured ACP tools.
• Ongoing Education: Regular refresher sessions and workshops ensure that staff remain up-to-date with best practices and policy changes.

Embedding ACP into Admission Policy and Procedure

The admission period is a key “teachable moment” for new residents and their families. By embedding ACP into the admission workflow, facilities can normalise these conversations and reduce the stress often associated with planning for future care.

1. Introduce ACP Early: Frame ACP as part of “settling in and ensuring we know your preferences.” This approach reassures residents that their wishes are valued from the outset.
2. Provide Resources and Time: Offer clear, accessible information and allow residents and families time to consider their options without pressure.
3. Structured Documentation: Use standardised forms and prompts to guide the conversation and ensure all relevant topics are covered.
4. Secure and Accessible Filing: Completed ACP documents should be filed securely and made easily accessible to all relevant staff.

Leveraging Technology: The Evaheld Ecosystem

The Evaheld ecosystem offers an ideal toolkit for embedding ACP into routine practice. The Legacy Vault app provides a simple, private digital workbook for residents to record their wishes. Meanwhile, the facility’s partner dashboard allows admissions teams to track ACP completion as part of the onboarding workflow, ensuring no one falls through the cracks. This digital approach enhances operational efficiency and supports consistent follow-up.

Quality Assurance: Regular Refreshers and Audits

To maintain high standards, regular audits and refresher training are essential. These processes help identify gaps, reinforce best practice, and ensure ACP documentation remains current and relevant. Facilities that schedule periodic reviews of ACP records see improved care continuity and greater satisfaction among residents and families.

Collaborative Team Approach

Embedding ACP into routine practice is most successful when it involves a multidisciplinary team. Nurses, social workers, and allied health professionals all play a vital role in supporting residents and families through the ACP process. Collaborative approaches foster a culture of shared responsibility and ensure that ACP is not seen as a one-off task, but as an ongoing conversation.

Examples of Successful Staff-Led ACP Initiatives

• Peer Mentoring: Experienced staff mentor new team members in conducting ACP discussions, building a supportive learning environment.
• ACP Champions: Designated staff members act as ACP champions, driving awareness and supporting colleagues in routine documentation.
• Integrated Checklists: Facilities implement ACP checklists within electronic admission systems, prompting staff at key stages and ensuring consistency.

In summary, systematic staff training and embedding ACP into routine practice are proven strategies for increasing documentation, enhancing family engagement, and delivering truly individualised care in aged care facilities.

Looking Ahead: Future Innovations and Policy Directions in ACP for Residential Aged Care

As residential aged care continues to evolve, the future of Advance Care Planning (ACP) is set to be shaped by technology, policy reform, and a deeper commitment to cultural competence. The admission period remains a pivotal opportunity—a “teachable moment”—to introduce ACP as a natural and supportive part of settling into an aged care facility. By embedding ACP into the onboarding process, facilities can ensure that residents’ preferences are understood, respected, and documented from the very start, reducing stress for families and staff alike.

Emerging digital platforms are transforming how ACP is delivered and managed. Interactive tools, such as the Evaheld Legacy Vault app, enable residents to privately and securely record their wishes in a digital workbook, making the process less daunting and more accessible. For admissions coordinators and directors of nursing, the facility’s partner dashboard offers a streamlined way to track ACP completion as part of the onboarding workflow. This ensures that no resident’s voice is overlooked and that substitute decision making is supported by clear, up-to-date information.

Looking forward, the integration of AI-supported decision aids holds significant promise. These tools can guide residents and their families through complex choices, offering tailored information and prompts that help clarify values and preferences. For substitute decision makers, AI can provide real-time support, reducing uncertainty and enhancing confidence in making decisions that align with the resident’s wishes.

Policy trends are increasingly favouring a system-wide approach to ACP in aged care facilities. National and state-level reforms are moving towards standardised processes, ensuring that ACP is not an isolated activity but a core component of care planning across the sector. This alignment across jurisdictions will be crucial for broader adoption, enabling seamless sharing of ACP data between healthcare providers, hospitals, and aged care facilities. Such collaboration ensures that a resident’s documented preferences follow them throughout the care continuum, reducing the risk of unwanted interventions and supporting truly person-centred care.

Cultural sensitivity is also emerging as a key pillar of effective ACP. As Australia’s aged care population becomes increasingly diverse, facilities must ensure that ACP conversations and documentation are accessible and respectful of different cultural values, languages, and beliefs. Interactive digital platforms can be adapted to support multiple languages and culturally relevant resources, empowering all residents to engage meaningfully in planning their future care.

The next decade will likely see further research into the long-term outcomes of early ACP adoption. Evidence suggests that proactive, structured ACP at admission leads to higher satisfaction for residents and families, fewer unwanted hospitalisations, and greater alignment between care delivered and personal wishes. By tracking outcomes through digital platforms, aged care providers can continually refine their ACP processes, demonstrating quality improvement and compliance with evolving standards.

In conclusion, the future of Advance Care Planning in residential aged care is bright, driven by innovation, policy alignment, and a commitment to cultural competence. By embracing digital platforms like Evaheld and embedding ACP into the admission journey, aged care facilities can ensure that every resident’s voice is heard from day one. This proactive, system-wide approach not only supports substitute decision making but also sets a new benchmark for individualised, compassionate care in Australia’s aged care sector.

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TL;DR: Embedding Advance Care Planning in residential admission ensures residents' wishes guide their future care. Using tools like Evaheld's Legacy Vault app makes this process smooth, less daunting, and personalised.