Building a Strong Advance Care Planning Program

August 14, 2026

Advance Care Planning (ACP) is one of the most meaningful and complex responsibilities in post-acute and long-term care. When done well, ACP ensures that residents’ values and preferences guide care decisions throughout their journey. When done inconsistently, it can lead to confusion, conflict, and care that does not align with what residents want most.

Strong ACP programs require intentional leadership, clear processes, interdisciplinary collaboration, and ongoing education. Organizations that approach ACP as a structured, integrated program are better positioned to deliver truly person-centered care.

Intentional Design as the Foundation of ACP


A successful ACP program begins with thoughtful implementation. ACP cannot simply be layered onto someone’s role without clarity around responsibilities, workflows, and tools. Leaders must determine who will initiate conversations, how clinical teams will support discussions, how documentation will be completed, and when conversations should occur throughout the resident’s stay. Without this level of planning, ACP efforts often become inconsistent or dependent on individual staff comfort rather than organizational standards.

Leadership and Accountability Matter


While social services frequently take the lead in ACP discussions, no single department can own the entire process. Nursing, medical providers, and administrators all play essential roles in ensuring ACP conversations are accurate, meaningful, and actionable. Physicians and nurse practitioners are critical for addressing prognosis-related questions and completing medical orders, while administrators set expectations and support integration into care planning and operations. Leadership involvement signals that ACP is a priority and reinforces its importance across the organization.

Routine, Proactive, and Responsive Process


Strong ACP programs are both routine and responsive. ACP should be introduced early and revisited at key trigger points, such as hospital transfers, significant changes in condition, or care plan meetings. Routine review ensures preferences remain current and aligned with the resident’s health status.

Equally important is ensuring ACP documentation is accessible when it matters most. Preferences must travel with residents during transitions of care and be easy for all team members to locate during emergencies.

Education Builds Confidence and Consistency


ACP conversations can feel uncomfortable without training, and staff turnover can quickly erode consistency. Ongoing education, whether comprehensive training or brief refresher sessions, helps ensure that all team members understand ACP principles, their role in the process, and how to support residents and families with empathy and clarity.

Additionally, ACP education should extend beyond clinical leaders to include frontline staff, who often have close relationships with residents and families.

Leadership Considerations

Successful ACP should be interdisciplinary and team-focused. Leaders should consider the following:

  • Advance Care Planning must be intentionally designed, not informally assigned.
  • Clear leadership accountability supports consistency and follow-through.
  • ACP should be routine, proactive, and revisited during changes in condition.
  • Documentation is only effective when it is accessible, current, and well understood.
  • Education is essential to building confidence, especially in organizations experiencing turnover.
  • Administrator engagement is critical to embedding ACP into culture and workflows.

A Sustainable Path Forward

Advance Care Planning requires leadership, structure, and commitment. Organizations that invest in intentional ACP processes create clarity for care teams, confidence for families, and care experiences that truly honor resident wishes. Strong ACP programs reflect compassionate, effective leadership.

Pathway Health Resources

Tune In! New PATHTalks Episode

In our latest PATHTalks episode, Pathway Health’s COO Lisa Thomson connects with Dr. Kathleen Unroe and Dr. Susan Hickman to explore why structured, integrated Advance Care Planning programs are better positioned to deliver truly person-centered care. Tune in:

For deeper insights into the health care continuum and more, explore our other PATHTalks episodes today.

 

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