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Pinnacle MHN launches Advance Care Plan (Waikato)

An advance care plan (ACP) is an articulation of a patient's wishes, preferences, values and goals relevant to all current and future care, including end of life care.

The journey of completing an ACP connects the patient, family/ wh?nau and clinicians in an ongoing conversation about how the patient wishes to live their life, including lifestyle and treatment options.Documenting an ACP ideally starts well before end of life and is responsive to changes in a person's life and wishes.

We have partnered with Waikato DHB, and other PHOs to support practices to embed this, as this is a much better fit than secondary care environments and makes sense to create a 'business as usual' approach to this person-centred opportunity within general practice.

Project target group

Although anyone can complete an ACP, for the purpose of this project, the target (and funded) population group are those patients identified through the Waikato DHB interRAI assessment process, and/or living in a resthome.

Lists of eligible patients identified as the target group for funded consultations will be given to each practice. Any other patient outside the target group wishing to complete an ACP will not be funded through this programme.


This is a Ministry of Health initiative and funding has been allocated to DHBs. Waikato DHB sees ACP as fitting better in primary care and therefore practices are being offered the opportunity through PHOs, to support patients in completing an ACP through a funded consultation for those target groups, but promoting and supporting any patient who wishes to document their health and life choices.

What is the funded amount, length of consultation and who can complete the consultation?

The consultation can be with a general practitioner/nurse practitioner or practice nurse with a duration time of up to 90 minutes. For each consultation completed between 1 January 2019 and 30 June 2019 with a patient from the target group $112.50 can be claimed via an advanced form (Medtech) or manual form (non-Medtech).

How does the clinician qualify to claim for the funded consultation?

Completion of the 4-page clinician document is signed and held in the patient records.

ACP completion

What does the clinician have to complete?

During the consultation the clinician will complete the four-page clinician ACP document. This is signed by both the clinician and patient. The two pages in the patient's ACP booklet reflect the same information and also needs to be completed and signed off by both parties.

What does the patient and wh?nau have to complete themselves?

The ACP booklet is theirs in which to document as much or little as they want. Only the advance directive section need clinician input (during the longer consultation).


Training is encouraged and available, although not compulsory. Online training (level 1) can be accessed via the Health, Quality and Safety Commission website. Pinnacle MHN and Hauraki PHO are combining to provide workshops in November and again in early 2019 (TBA) for those wanting more support.

Upcoming training

  • Monday 19 November, 6-8pm in Pohutakawa Room, Te Kuiti Community House, 28 Taupiri Street, Te Kuiti.

  • Tuesday 20 November: 6-8pm in Conference Room, Level 1, Thames Hospital.

  • Wednesday 21 November: 9.30-11.45am in Hauraki PHO Hamilton office at 16 Von Tempsky Street, Hamilton.

To register for any of these workshops please contact Dot Brown on the details listed below.

ACP support

Having an in-practice ACP champion will help engage clinicians, create a streamlined process and ensure a sustainable approach to engaging patients who want to plan for current and future health decisions.

Dot Brown, Pinnacle MHN ACP project manager is available to support one-on-one or group meetings. To find out more or arrange a visit contact Dot on the details below.

Read more about ACP on the Health Quality and Safety Commission website.

Do practices have to participate?

No, but each practice will be offered a provider agreement. ACPs enable a very patient-empowering, patient-centred discussion and can make a positive difference to the patient-clinician relationship. Having a funding stream available may help to embed ACP into general practice and ensure the ACP process is sustainable regardless of future funding.

For more information

Contact Dot Brown, Pinnacle MHN ACP project manager on or 027 274 5401.

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