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Conference Abstracts

Elevating the consumer voice by developing an integrated digital solution for advance care planning across clinical teams in five health authorities


Carla Arkless

Nelson Marlborough Health, New Zealand, NZ
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Advance care planning (ACP) in the South Island of New Zealand was happening in pockets within a disconnected health system, where ACP was either not being offered, or the documentation was inaccessible, ambiguous, or non-existent.

We aimed to use the existing South Island IT system to support the integration of ACP into routine clinical care across all settings, keeping the person at the centre of their healthcare.

The national Advance Care Plan and Guide, developed in 2016,  used a co-design method and was subsequently used in the South Island as a basis for a digital solution.  IT and clinical teams across the 5 District Health Boards (DHBs) worked in partnership to develop an integrated system which allows ACP documentation to become part of the clinical record.

Aim and theory of change

‘Best for person, best for system’:

•           to promote equity and integration

•           consistency - create solutions once rather than five times

•           elevate the person’s voice.

The system is for all competent adults who want to add ACP documentation to their health record. Stakeholders are South Island clinical teams.

Commencing in 2016, the system went live in May 2019.  Quality processes have continued to evolve.

The highlight was the development of an effective digital solution and a quality review process.  Initially there was a widespread assumption that the digital form was the solution. What transpired was the realisation that to embed ACP processes into clinical practice, dedicated local resource and regional coordination was required.  Coming together as a team across all DHBs became hugely important as we learned, developed and problem-solved together. 

Digital ACP is sustainable for clinical teams.  Wider use of ACP is demonstrated to improve the sustainability of the health system.

The system and processes are transferrable.



This has been a successful project which continues to evolve and improve. Key components include:

•           Integrated digital platform for storing and wide sharing of ACPs and other retrievable documentation about a person’s healthcare goals and preferences

•           Centralised administration and leadership

•           Quality review team comprising 2 clinicians from each DHB working collaboratively

•           Comprehensive written guidelines including standards statements to support the quality review process for all ACPs added to the system

•           Written guidelines to support the integration of ACP into clinical practice developed and shared for local adaptation


Through dedication and perseverance, we have an integrated system that captures a person’s voice as part of their healthcare record. It provides us with a strong foundation to continue to increase clinician engagement, confidence and skills with ACP.

Lessons learned

•           Having an electronic Plan that can be shared is the starting point not the solution

•           Centralised coordination has been crucial to the development and embedding of the system and quality processes

•           Quality processes are a key component to this work and have had wide-reaching impact on the integration of ACP into clinical practice, and to the embedding and refining of the system

•           This complex change process requires tenacity and leadership


How to Cite: Arkless C. Elevating the consumer voice by developing an integrated digital solution for advance care planning across clinical teams in five health authorities. International Journal of Integrated Care. 2022;22(S1):18. DOI:
Published on 08 Apr 2022.


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