Key Element #3: Community Engagement and Education

To educate individuals on ACP, many programs develop brochures, pamphlets, and presentations focused on the completion of ADs. Such singlemodality strategies are often ineffective at changing behaviors (Lorenz et al., 2004). The American public has been well educated in the purpose of ADs. In a 2005 Pew Research Center survey, 84% of respondents were aware of their rights to complete a document that would direct future medical care (Pew Charitable Trusts, 2012). This level of AD knowledge has not dramatically changed the incidence of completion of written plans. Education alone is rarely sufficient in changing behavior.

Respecting Choices recommends a multifaceted approach to ACP education by including engagement strategies intended to promote dialogue, create a meaningful experience, and motivate people to participate in the planning process. Suggested strategies include:

Integrating social marketing ideas, such as branding (i.e., selecting a name and logo for the ACP initiative), to improve recognition throughout a community. In La Crosse, the branding is called “Making Choices”
and includes an attractive starfish logo that is used on all written materials, educational fliers, and promotional activities.

■ Using stories of others' experiences with health care decision making in written materials and video examples to emphasize common themes and motivate people to learn more.

■ Developing focused materials to help people with different components of the ACP process, such as an information card for health care agents that describes their role and responsibilities.

■ Customizing information for targeted populations, such as for religious groups or support groups for specific illnesses (e.g., heart failure, cancer).

■ Recruiting representatives from diverse groups in the community to communicate the importance of ACP and to develop culturally sensitive messages.

In addition, community engagement involves developing effective partnerships with key stakeholders, such as religious groups, attorneys, and senior advocates who can assist in disseminating the concepts of the ACP process and make referrals as needed for quality planning assistance.

Key Element #4: Continuous Quality Improvement

All successful programs are nurtured, monitored, and improved over time. ACP programs demand the same investment. Attention to ongoing quality improvement is one of the most important elements in achieving ACP program goals. As new systems, processes, and materials are designed or revised, they are tested through small and focused pilot projects prior to widespread dissemination. There are many reasons to start small and build support incrementally:

■ The initial systems that are created will not be perfect and will need testing to make improvements before wider distribution.

■ Individuals trained as ACP facilitators will need time to integrate new skills into their roles. Starting small will help make this workload more manageable as they increase their competence.

■ Newly formed ACP teams will need to learn to work together, establish referral systems, and assess the effectiveness of the individualized implementation plans.

■ Data are needed to demonstrate the effectiveness of and satisfaction with the new program to increase engagement and speed dissemination.

Respecting Choices has developed a quality improvement framework called The Five Promises (Figure 15.2) to guide organizations or communities in developing a comprehensive ACP program. This framework can be used
FIGURE 15.2 The Five Promises.

 Promise #1: We will initiate advance care planning conversations with individuals about their preferences for future medical care.

Promise #2: We will provide appropriate ACP assistance as requested.

Promise #3: We will make sure plans created are clear and communicated to those who need to know.

Promise #4: We will store and retrieve these plans so they are available wherever needed.

Promise #5: We will follow these plans as appropriate when individuals can no longer make their own decisions.

to assess the quality of current efforts, assist in the design of specific strategies to meet each promise, and identify related outcome measures.

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