Table 1

Facilitator and Referral models of advance care planning (ACP) provision

Facilitator model of ACPReferral model of ACP
Description of modelCase managers are trained to facilitate ACP with their clients. They will conduct the ACP discussions and complete advance care directives (ACDs) (where appropriate).ACP is conducted by an ACP facilitator at a specialist service located at public health services and use trained non-medical facilitators (usually nurses) to conduct ACP. Each service determines how their ACP facilitators are trained. ACP is provided free of charge.
Potential advantagesCase managers have ongoing relationships with clients.
Case managers are part of the usual care team.
ACP is conducted in the client’s home.
Clients have access to expert facilitators.
Specific time is allocated for ACP.
Potential disadvantagesCase managers need to find time within current workloads and roles.
Case managers may not be expert enough as ACP facilitators
Client needs to travel to appointments.
Clients do not have existing relationships with facilitators.
The facilitator is not part of the client’s usual care team.
Training providedThree-module learning package (ACP theory, ethics/law, doing ACP) expected to take 2 hours to complete. This is completed prior to the an 8-hour (face-to-face) experiential workshop consisting of facilitated discussion and role play. The workshop’s primary focus is ‘how to have the conversation’. During the workshop, participants were expected to complete a full ACP discussion with another participant and document the outcome in an ACD.Two-hour face-to-face training session, providing an overview of ACP, interactive training in initiation of ACP and instructions on how to refer clients and follow-up requirements for clients who attended an ACP service.
  • ACD, advance care directive.