Objective: The objective of this improvement initiative is to effectively increase community and the health care system’s awareness of advance health care planning (AHP) with the outcome goal of increasing the number of Advance Health Directives (AHD) and POLSTs on file in the hospital’s electronic medical record (EMR.)

Background: An outreach model was created by taking elements from existing initiatives and customizing them to meet the needs of the local area through encouraging conversations by using the AHD. Baselines measurements in 2016 included a community needs assessment showing 42% of the population in the service area state they have completed an AHD, with Hispanics at a rate of 14.7% and low income at 25%. Palliative abstracted data, representing 12% of hospital admissions showed 24.8% of patients admitted with AHD and 20.5% with POLSTS. The hospital uploaded 1,821 documents into the EMR in 2016. Financial support is from the hospital and through philanthropy for a service area population of about 115,000.

Case Description: An evolving system-wide approach started in 2016 with the flagship offering of two-hour hands-on community workshops offered once to twice a month by a trained RN with all documents provided at no cost. The workshop focuses on goal setting to complete the AHD, clear instructions on bringing it to the hospital and provider offices as well as follow-up phone discussions when needed. Proven advertisement methods of these workshops keep attendance robust for the four years. AHP presentations with larger audiences happen at retirement communities, organizations, and other events. Similar workshops are made available to health care system staff, with formal training in key areas that have great opportunity to assist with awareness and completion of AHD’s and POLST’s.

The initiative also included selecting a single version of the AHD for the health care system and then partnering with a local EOL Foundation to adopt the AHD and spread it through the County to reduce variation.


Christine Payne, BSN, RN, NE-BC
Director, Nursing Support Services
Community Hospital of the Monterey Peninsula
23625 Holman Highway
Monterey, CA 93940
(831) 625-4711