Background Home Nursing Foundation (HNF) is a non-profit home care provider established since 1976, traditionally providing chronic disease management and procedural nursing care for home bound patients. In recent years, patients’ needs have evolved to more complex, requiring a multidisciplinary approach. Including Advance Care Planning (ACP) in patient care became clear as many of our patients are approaching End-of-Life (EOL). However, the journey from training to successfully performing ACP has been challenging. Efforts have been made to train our clinical staff in ACP over the last four years, yet the execution and filing of ACP has remained dismal.

Methods A root cause analysis (RCA) was done to identify the different factors for failure to execute ACP conversations. Factors identified were lack of readiness from patients and their health proxy in discussing general ACP, lack of mentors for newly trained staff, logistical challenges in the home setting, mismatch in capabilities, staff turnover, lack of guidelines and suitable care models to identify and manage patients who would benefit from ACP and ultimately EOL care.

We addressed the factors identified by the RCA, re-examined staff training and recruitment, developed an EOL care path to identify, assess and manage patients who might benefit from palliative care and targeted these patients to start Preferred Plan of Care* (PPC).

Results The team subsequently performed three successful PPC conversations with signed documentation within a month of piloting the EOL care path.

Conclusion For home bound and frail elders, PPC might be the format of choice. Staff training and recruitment should be accompanied by redesigning the care process and models. With the care path, there was a clear trigger and assurance of follow up which ensured the PPC was formalised.

* PPC is a format of ACP designed for people in the last twelve months of life.