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The issue of Advanced Care Planning (ACP) is a pressing public health concern. The most opportune environment for effective ACP is in the primary care setting, though barriers such as time limitations and provider discomfort with the subject can be difficult to overcome. We worked with a county health clinic to create a referral process for group sessions. Over an eight-week period, data on 285 encounters was collected, which revealed breakdown in the chart review and referral process. Despite this, our innovation did increase ACP and can provide insight for others seeking to implement ACP related workflow changes.


Advance directives (Medical care); Nursing--Study and teaching; Patient education; Terminal care

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Copyright for this work is retained by the authors.

NRS 597: Practice Improvement Project



Document Type

Doctoral Project

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Nursing Commons