Everyone ages differently. Many older adults remain independent while others experience more health issues. It is difficult to identify “at risk” residents that could benefit from advanced care planning programs. The purpose of this project is to determine the most effective way to identify high risk older adults receiving home care or living in long-term care (LTC) so their care partners can provide individualized care according to a personal plan.

The need for effective advance care planning and end-of-life care for residents living in long-term care homes is clear. As residents go through their end-of-life journey, their health and the symptoms they experience will change. It is the responsibility of LTC team members to make sure that their end-of-life wishes are honoured. Several studies have demonstrated that older adults’ advance care plans value better quality of life and eliminating risk over survival.

Team members and family members should be well informed about, and engaged in, advanced care planning. The goal of the long-term care portion of this project is to apply proven approaches to Advance Care Planning (ACP) and demonstrate that they can be carried out successfully.