Barriers to Advanced Care Planning & Implementation

Barriers to Advanced Care Planning & Implementation

Advanced Care Plans (ACP) assist in bridging the gap between patients and physicians to discuss their future treatment preferences. It is an in-length discussion between the individual, care providers, and family to decide their future care solutions.

However, various barriers hinder its proper plan implementation ranging from limited patient participation to emotional obstacles and lack of awareness. This article discusses the many challenges in advanced care planning and its implementation.

Care Plan Fundamentals

A care plan ensures better care and treatment for elderly citizens. Herein, nursing diagnosis forms the core of setting goals to resolve issues faced by patients. Additionally, patients cannot often make decisions surrounding their medical condition.

It highlights the need to begin discussing the core questions for the care plan, which include: 

  • What are the primary components to fit in a care plan?
  • What is meant by a nursing care plan?
  • Why do you require a care plan?

Advanced care planning enables patients in better decision making by getting an in-depth understanding of their health and illnesses, diagnosing illness, preferences, and appropriate treatments. With a care plan, patients can better communicate their fears and like to design health decisions. It includes connecting with patients and promoting an engaging discussion across different clinical settings.

Care Plans Must be Easy to Share With the Relevant Stakeholders

As per studies, physicians do not use EHR or Electronic Health Records to their total capacity. Therefore, there is a growing need to integrate digital care planning with EHR to improve patient care. Apart from allowing clinicians to communicate effectively with the patients, it also enables better transmission of information, data safety, patient knowledge, and increasing effectiveness.

Additionally, integrating EHR with a digital care planning system makes it easy to update the information by reducing inefficiency.

Barriers Related to Advanced Care Plans

Let us read through some of the barriers related to ACP, which are:

  • Limited Structured Data

Unstructured data is a primary challenge in utilizing the data from EHRs to measure the quality of advanced care and structuring data into specific types for strategizing plans. For instance, the fields include weight, BP, BMI, sugar level, etc. It helps to locate the information without any hassle and ease.

  • Lack of Consensus

Lack of consensus is a major drawback in defining if the patient must follow the conversations or the written directives.

As per research, the nurses often develop the inpatient setting, which the medical practitioners do not usually employ. Additionally, it is also not provided to patients during discharge. Therefore, it is a significant challenge to incorporate ACP, a nursing task. Herein, it is necessary to reframe the process by bringing the physicians into the picture to coordinate the care plan.

  • Limited Patient Participation

Often patients depend on their families and doctors to make decisions. For example, a chemotherapy patient spoke about letting his daughter make the decision. Another patient said about trusting doctors and believing them in making the best decision for their treatment. Unfortunately, that poses a challenge wherein patients are unaware of their condition, thereby hindering ACP.

  • Unprepared Healthcare System and Experts

The physicians find it tough to understand the complications in case of terminal illness that pose a barrier in meeting the advanced patient care discussion. In addition, the lack of competence in coping with emotional challenges, including advance care planning and counseling.

  • Many Data Elements Are Not Recorded in a Standard Way

Improper record maintenance was highlighted as a principal barrier to integrating care plans into EHRs. It is often noted that the information is not recorded in a standard way. For instance, EHR data is not added discreetly. It may be located within other records. Additionally, not all information may be compiled in one location.

There is a requirement to develop a care plan for each issue faced by the patient and integrate them in a standard way of inputting and documenting all care plans in one location within the EHR to ensure accurate coordination.

  • The Learning Curve: Implementing Care Coordination Software for Wellness Programs Will Require Training

There is a growing need for training to implement care coordination software. It includes providing individual training through video and written tutorials. In addition, the tech support assistance helps understand the nuances of using the resources and implementing plans for advanced care for the elderly.

  • Insufficient Time To Have Advance Care Planning Discussions

A shortage of data to perform the advance care planning discussions. As per studies, advanced care planning is conducted across different settings such as by nurses, care homes, hospitals, and primary care. Studies highlighted that over 75% of advance care planning discussion was initiated by nurses while 70% by home caretakers. However, these did not progress beyond documenting the individual’s wishes.

Additionally, most planning discussions, approximating 43%, happened with patients who are either chronically ill or terminally ill. Therefore, it throws light on insufficient time as a barrier to building a care plan concerning lack of knowledge. Besides, the patient and families’ desire makes it challenging to discuss the condition.

How Equipo Assists in Overcoming the barriers to Advanced Care Planning

One of the aspects of eliminating the hindrance to advance care planning is replacing written documents with digital versions. It is easy and safe to update data and provides the opportunity to improvise accuracy and accessibility. Equipo’s care coordination software offers a faster and well-researched system to devise operational efficiencies.

Some of the distinct features include:

  • Up-to-date Care Record visibility

Preloaded library to edit patient care plans to view on the web and mobile platforms. Additionally, update all documents directly to the user records.

  • Record Care Plans and Notes to Share With the Entire Care Team

Document all interactions, notes, and records, allowing secure access across different levels of user groups such as caretakers, managers, coordinators, family, etc.

  • Delivering Customized Patient-Centric Care

Access all the parameters and discussions with patients to understand requirements and deliver a customized advanced care plan suitable for the individual.


There is a growing need to improvise care coordination through a systematic tool helping caretakers, patients, and physicians illustrate the various options to initiate a discussion with patients. An organized ACP will assist patients in making appropriate decisions to receive advanced care for a better quality of life. Schedule a demo of Equipo’s Care Coordination Software here.