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4 Elements to Look For in an ACP Program

Monday, November 2, 2020

The right advance care planning (ACP) program can be transformative for organizations that manage a population of people with serious illnesses. Currently, many people with serious illnesses do not receive any ACP services at all; according to Medicare billing data, only 4.2% of seriously ill individuals had an ACP encounter with their physician in 2017.

With such low ACP participation rates, health plans and other risk-bearing organizations are missing out on key benefits of ACP, including:

  • Reducing unnecessary care utilization 
  • Lowering overall healthcare costs
  • Improving the member experience

Given that the current physician-led ACP model fails to deliver widespread member participation, value-based care organizations should look to implement dedicated ACP programs for their members through either internal resources or an external partner. As you consider your options, keep an eye out for the following elements that every high-quality ACP program should have.


  1. The right support, at the right time

First and foremost, it’s crucial that individuals receive the right level of support at the right time. Rather than waiting until the end of a member’s care journey to initiate ACP, research has shown that early ACP interventions yield bigger benefits for both health plans and their members. 

For example, one study from the Journal of Palliative Medicine examining found that overall adjusted care costs were $9,500 lower for individuals who had participated in an ACP program during their last year of care compared to those who had not. 

Furthermore, the New England Journal of Medicine found that seriously ill patients who received early palliative care — of which ACP is a critical service — achieved:

  • Higher quality of life – FACT-L scores (a key indicator of quality of life for the study’s population) were 7% higher for the early intervention group compared to the control group.
  • Longer survival times – The early intervention group lived 30% longer on average, despite being 64% less likely to receive aggressive treatment.


High-quality ACP programs should employ tactics such as analyzing claims data or clinical data to identify qualified individuals for ACP early in their care journey. Using this data-driven approach, these ACP programs ensure that the right people get the right support at the right time.

  1. Ongoing Outreach

Currently, it is rare that physicians or care managers will follow up with individuals about their ACP decisions throughout their care journey. But the truth is, ACP should not be a one-and-done process. Instead, it should be an ongoing conversation that accounts for the changing variables that influence one’s goals of care, including: 

  • New diagnoses
  • Major personal events 
  • Major health events

High-quality ACP programs provide continuous outreach, proactively helping individuals revisit and revise their goals of care over time. 

  1. In-depth service

At its core, ACP is deeply human. Exploring one’s core values takes guidance, compassion, and patience, and synthesizing this information into concrete goals of care is a complex, individualized process. 

Unfortunately, online third-party ACP platforms often lack the personalized, in-depth service required to provide a robust, personalized experience. Likewise, today’s healthcare providers and plans’ existing internal resources often lack the time and training to conduct ACP thoroughly for each individual.

When evaluating ACP programs, health plans should be mindful of the level of service the solution provides. Some key questions to consider include:

  • How much time is provided to think through and discuss care options?
  • Does the solution offer professional assistance to work through complex decisions?
  • Are loved ones and caregivers involved in the process?
  • Are the program’s ACP facilitators specially trained in the emotional, medical and legal elements of ACP?

These factors directly influence how thorough and personalized the ACP process will be, making them vitally important to individuals and their families as they consider their options.

  1. Documentation and distribution

Ensuring that advance directives are completed in accordance with state and federal guidelines and distributed to the point of use can be the deciding factor in whether or not an individual’s care wishes are actually carried out.

To avoid any potential errors in the creation and distribution of ACP documentation, organizations should look for an ACP program that:

  • Is deeply familiar with the state and federal ACP documentation requirements
  • Is willing to independently verify that documents are completed free of errors 
  • Is proactive in confirming documents have been received by their various points of use
  • Is able to advise individuals and family members on how and when to leverage ACP documents during health events

Additionally, high-quality ACP programs should go above and beyond the standard documentation required at the state and federal, adding supplementary notes and documentation to describe patient wishes in more detail. 

Without meticulous attention to detail during this important step in the ACP journey, individuals and their loved ones risk all of their hard work being disregarded when it matters most — a potentially devastating consequence that should be avoided from the outset. 

Crafting the Future of ACP Programs

When done correctly, ACP can be of tremendous value to both value-based care organizations and the people they serve — and it’s worth getting it right. Given the sensitive nature of the topic, ACP should be facilitated with care, compassion and experience.

At Iris, we’re crafting the future of ACP programs. Working with health plans and other risk-bearing organizations, we analyze claims data to identify qualified candidates for ACP early in their care journey. Then, our team of trained experts works with these members and their families to deeply explore care goals on an ongoing basis. Next, we document these care goals in full compliance with state and federal regulations, leveraging our own proprietary documentation in this process to ensure members’ unique care goals are described in full. Finally, we distribute these documents to the point of use, ensuring physicians and family members are empowered with the information they need to carry out members’ wishes.

If you’d like to learn more about partnering with Iris, get in touch with us today.

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