Conversations that matter: Making advance care planning standard care

Advance care planning (ACP) is a critical way to align patients' goals and values with their medical care. These conversations can feel difficult for individuals and families - for example, when weighing whether to pursue life-prolonging treatment that may extend time but limit comfort or independence - as they consider future health care decisions.

Yet when these conversations do take place, they often become a meaningful gift - providing clarity, easing the burden of decision-making and ensuring that care aligns with what matters most to the patient.

Despite its importance, studies consistently show that the number of people who complete ACP documentation remains low. Common barriers include gaps in care between settings, inconsistent documentation, difficulty accessing ACP information in electronic health records (EHRs) and insufficient clinician education.

"For advance care planning to be truly effective, it must be an ongoing, iterative process," explained Nathan Fairman, a health sciences clinical professor in the Department of Psychiatry and Behavioral Sciences at UC Davis Health. "A system-wide approach is essential - one that consistently identifies patients who need support with ACP and ensures resources are accessible and available across every care setting where patients are seen."

To better support patients with ACP, UC Davis Health made a substantial, system-wide commitment to improving how patients and providers engage in these conversations.

As part of this effort, the team developed a simple screening method to help the doctors responsible for admitting patients to quickly identify those with serious illnesses. Such patients were offered an opportunity to discuss advance care planning during their hospitalization with specially trained social workers.

This novel pathway led to higher ACP completion rates, increased palliative care involvement and greater inpatient hospice enrollment.

For example, there was a reduction in unwanted or non-beneficial medical care, which also helped to ensure that patients receive care aligned with their preferences and values.

As a result, UC Davis Health increased advance care planning conversations among adults age 65 and older receiving primary care from just over 10% to more than 70%. In a separate initiative, equity gaps among non-English-speaking patients were reduced by half.

These comprehensive efforts were recognized by the Quality Leaders Awards (QLA) from the California Health Care Safety Net Institute for excellence in advancing advance care planning across both inpatient and ambulatory settings.

A team-based approach

A cornerstone of UC Davis Health's advance care planning success has been its intentional, multidisciplinary design - bringing together physicians, nurses, social workers, population health experts, IT specialists and operations leaders around a shared purpose of delivering goal-concordant care. Central to this effort are dedicated ACP social workers, whose specialized training and protected time allow for deeper, more meaningful conversations with patients and families.

"These conversations take time," said Fairman. "Patients need space to think through what matters most to them, how their health may change and who they trust to speak on their behalf if they're unable to."

Social workers are uniquely positioned to guide patients and loved ones through this reflective process, helping them clarify values, identify surrogate decisionmakers and document preferences in a way that is accessible across care settings.

UC Davis Health now supports three inpatient and two ambulatory social workers dedicated exclusively to ACP - ensuring continuity from the hospital to outpatient care.

Beyond direct patient care, social workers have played a critical role in shaping the program itself. They helped design UC Davis Health's branded advance directive, informed updates to systemwide ACP policy, contributed to clinician training and provided expertise on how to make tools more patient-centered and usable.

"Their involvement has helped ensure that this work is patient-centered, and embedded more deeply into everyday clinical practice, rather than treating it as a one-time task," added Fairman.

Advancing equity in ACP

While ACP rates have improved dramatically overall, program leaders were intentional about ensuring that progress was equitable.

Early data revealed a persistent gap in ACP completion among patients whose preferred language was not English. Addressing this disparity became an institutional priority.

In response, UC Davis Health expanded access to linguistically and culturally appropriate ACP resources. The health system's advance directive materials were translated into five additional languages (Spanish, Russian, Vietnamese, Chinese and Korean). In addition, a new ACP website was launched to better support patients and families before clinical visits.

"Our clinicians and social workers are focused on proactively identifying patients who might benefit from extra support, rather than relying solely on patient-initiated discussions," shared Connor Reilly, project manager for quality and safety at UC Davis Health. "These targeted efforts have paid off, and we have been able to reduce the ACP completion gap among non-English-speaking patients by more than half."

Advance care planning is now part of the organization's broader health equity and disparity-reduction work, recognizing that everyone deserves the opportunity to have their values heard and honored, regardless of language or background.

What's next?

With a strong foundation in place, program leaders are now focused on deepening patient engagement and broadening the program's reach. A key priority is helping patients prepare for ACP conversations before they ever sit down with a clinician.

New digital tools within the MyUCDavisHealth (or MyChart®) portal walk patients through reflective questions, while targeted outreach through text messages and patient campaigns provides education at key moments in care.

The team is also investing in additional clinician training to improve comfort and skill with conversations about serious illness. In addition, they are exploring new partnerships across the University of California Health System to share best practices and evaluate impact at a broader scale.

"Advance care planning should not be episodic or siloed, but integrated, continuous and deeply human," explained Fairman. "When done well, ACP supports patients, unburdens families and helps health systems deliver care that is truly aligned with what people want. That's the work we're committed to continuing."