Primary healthcare news, information & resources

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 healthcare, including end of life care.

The journey of completing an ACP connects the patient, family/ whānau 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.

This is a national Ministry of Health contract and we have partnered with Waikato DHB, and other PHOs to support practices to embed this as it makes sense to create a 'business as usual' approach to this person-centred opportunity within general practice.

Target groups

Although anyone can complete an ACP, for the purpose of this project, the target (and funded) population groups are those patients:

  • identified through the Waikato DHB interRAI assessment process

  • in their last 1,000 days where ACP is considered suitable by the patient or clinician.

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


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

Consultation, funding, contract timeframe

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

Qualifying for the funded consultation

Completion of the advance directive section of the ACP by a clinician (signed if hard copy or electronically authorised if via the e-version) and uploaded into the patient's records.

ACP completion

Patient and whānau

The ACP booklet is theirs in which to document as much or little as they want. Only the advance directive section (section 6) needs clinician input (during the longer consultation).


During the consultation the clinician will complete the advance directive section (electronically or hard copy). This can be electronically verified by the clinician, or in the case of a hard copy, signed by both parties. Specific READ codes will need to be installed in your PMS.

  • Medtech practices: the read codes will need to run once within the practice to install these via the eACP (see OPL).

  • Non-Medtech: read codes need to be installed within your PMS. Please see the list of read codes and discuss with your PMS vendor to install or if you are able, install these yourself.

  • Indici practices - to be advised.


Training is encouraged and available, although not compulsory. Pinnacle MHN encourage the practice champion to complete training. Level 1 online ACP training can be accessed via the Health, Quality and Safety Commission website. A contribution of $30 per person excluding GST, towards costs for completion of the online level 1 training (four modules) by any practice staff member, will be available and can be invoiced per your contract.

Pinnacle MHN and Hauraki PHO are combining to provide face-to-face workshops again in early 2019 for those wanting more support. The project manager is available to complete practice-based training if required. Note that any face-to-face or VC training does not qualify for a contribution towards costs.

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 practices and can arrange one-on-one or group meetings. To find out more or to arrange a visit, contact Dot on the details below. Read more about ACP on the Health Quality and Safety Commission website.

Practice contracts

Each practice will be offered a provider agreement. ACPs enable a very patient-empowering, patient-centred discussion and can contribute positively to the patient-clinician relationship. This sits well with nursing and could be developed as a primarily nurse-led activity. 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: or 027 274 5407. 

Latest Clinical Resources