This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11S0W-GPQIN-ND-C3-53/0416

Advance Care Planning (ACP) Goal Setting and ACP Facilitator Need Determination

Organization Date

1. Target Patient Population

Note: A targeted patient population could be the patients of a certain provider, the patients of a specific clinic/care setting, patients of a certain age or patients experiencing the end-stages of their disease. Consider a combination of any or all the above.

Our target patient population:

2. Number of Patients in Our Targeted Population a.

3. Advance Care Planning (ACP) Goal

% of patients in targeted population with documented HCD* b.

# of patients in targeted population with documented HCD c.

Target date # of months # of years d.

4. Current ACP Status

# of patients in targeted population who currently have HCD e.

# of patients in targeted population who will need facilitated ACP ( c-e) f.

5. ACP Facilitator Need Determination—Indicate monthly or yearly calculation

# of ACP conversations needed: _____ per month _____ per year g.

# of ACP hours needed: ____ per month ____ per year (g x 2) to achieve goal h.

Note: Plan 1 ½- 2 hours for each facilitated ACP conversation or 2 conversations in 4 hours.

FTEs needed for ACP facilitated conversations (h/2080) i.

# of ACP facilitators needed j.

Notes:

*HCD – health care directive