This project is South Australians approach to the Commonwealth Greater Choice for At Home Palliative Care Project (GCfAHPC).

Two quality improvement facilitators employed by Adelaide Primary Health Network (APHN) are working with eight residential aged care organisations and thirty aged care facilities. The focus of this work is to improve the process of advance care planning from admission to the end of life in order to provide the right care for the resident in the right place.

The achievement to date resonates in the engagement and partnership between APHN and the aged care sector. This partnership is enabling and supporting a range of quality improvement measures.

Vital Talk training facilitated by a palliative care specialist will support registered nurses to plan and carry out formal advance care planning conversations with residents and families from admission to the end of life. A new document called My Life Decisions will capture the resident’s wishes, concerns and goals of care. The purpose of this is to support people who are unable to make a legal document but want to have their goals and wishes written down for future reference. This document is being trialled as part of the project and its key principle is the support of all residents to make decisions about what is most important to them.

My Life Decisions will contribute to the completion of the South Australia Health 7 step pathway, to enable the information exchange between the aged care facility, ambulance and hospital. The project will also support the introduction of a formal assessment tool (SPICT) for deterioration, an after-death audit, information sessions for residents and families and training for personal care staff.

A lead nurse working in each of the thirty facilities is working closely with the quality improvement coordinators to implement the quality improvement measures. The intended project outcomes are the introduction in all facilities of a robust advance care planning pathway and nurses skilled and confident to facilitate advance care planning conversations with residents and their families. This work supports the new aged care standards and the right of a person to be supported to make decisions about their health and care arrangement.