Background In 2013 a project was developed for the provision of formal Advance Care Planning (ACP) processes in the Canterbury Health System.

A key component of the project was facilitating general practice to engage with and support patients to undertake ACP conversations and develop electronic advance care plans (eACPlans).

Methods Integrating ACP into the primary care system in Canterbury required a multifaceted, cross system approach, with each component supporting and enhancing the other.

Practice engagement and education including practice visits, phone support, ACP processes on the clinical website, presentations, training, one-to-one support/mentoring

Consumer engagement and education including community presentations, radio interviews, articles in local publications, a consumer website & community ACP champions. Increasing the community’s knowledge and desire to create plans, has been the impetus for many practices to engage with ACP.

Systems and processes including electronic sharing of eACPlans, a subsidy to support practice teams adopt ACP and dedicated ACP facilitators & administrators to support the process.

Quality loop plans are reviewed to ensure patient’s wishes are clinically interpretable and clinicians are confident to use plans to guide care. Plans that do not meet the quality parameters are returned for follow up providing further opportunities for the ACP team to engage with the practice.

Results 87% of general practice teams in Canterbury have supported patients to create an eACPlans.

General practice teams create 80% of the Canterbury’s eACPlans.

Increased multidisciplinary approach to plan creation.

Conclusion(s) A cross-system approach to implementation has facilitated the establishment of ACP in general practice.