Advance Care Plan

The Advance Care Plan (ACP) module is designed to:

• alert the user to patients who should have an ACP but don't
• patients that do have an ACP.

The existence of an ACP can be through Read codes or via the "ACP" screening term.

The Read codes used by default are any that start "9X" i.e:

• 9X0: Advanced Directive Discussed with Patient
• 9X1: Advanced Directive Discussed with Relative
• 9X2: Advanced Directive Signed

Alternatively the "ACP" screening term can be used where the outcome indicates whether:

• Patient excluded
• In Progress
• Completed
• Declined.

If no information can be identified indcating that an ACP exists, there are a variety of "rules" that can be used to identify patients where an ACP is recommended:

• The Care Plus tab of the patient manager indicates that the patient has a terminal illness
• The patient has been diagnosed with any of the following:
  • Chronic Renal Failure
  • Dementia
  • COPD
  • Heart Failure
  • Motor Neuron Disease
  • Parkinson's Disease
  • Multiple Sclerosis
  • (Other conditions can be added e.g. some PHOs include Diabetes)
• The patient has reached a certain age (which can be based on the patient's ethnicity).