Blog Post

Published April 23, 2019

Why Advance Care Planning is a Crucial Part of Population Health Strategy


Fueled by pressure to improve both clinical and financial outcomes, population health management has become a burgeoning field in healthcare

Achieving the goal of improving the quality and effectiveness of healthcare while controlling costs for defined groups of patients is an immense challenge.  

Populations take many forms and can be defined by region, employee pool, disease cohort, demographics, socioeconomics, etc. To complicate matters, population health not only refers to the overall health of a population, but also the distribution of health and access to care. Plus, there are individual factors that affect population health outcomes, such as genetics, behavior, social environment, and physical environment.  

The consensus among healthcare leaders is that the key to optimal population health management is to provide care that is integrated across healthcare teams and communities with all the stakeholders aligned in their approach and incentives. 

That’s one tall order. 

With a growing focus on risk-based care, organizations are prioritizing care and access for those patients who are considered “high-risk” and “high-cost.” In general, these populations are groups of patients whose health status puts them at increased risk of higher health care utilization, such as those with certain chronic diseases and life-limiting diseases. 

This is Where Advance Care Planning Comes In

A lack of advance care planning (ACP) puts vulnerable populations at risk. It’s been shown that high-risk, high-cost populations are less likely to discuss or carry out ACP, which may result in these individuals receiving end-of-life care that is unwanted or not aligned with their values.  

When advance care planning is included in the continuum of care, individuals within populations receive care that is less fragmented and meets their care goals. Those who are most vulnerable are at less risk of falling through the cracks. Overtreatment is minimized. 

It Increases Patient Engagement


ACP involves shared decision making between patients, families and their healthcare providers to help patients make informed decisions about what care is best for them when facing serious illness. This process naturally expands patients’ engagement in their care, which has been shown to improve clinical outcomes. Patients living with chronic illness who are highly engaged also experience better outcomes. As for costs, increased patient engagement is associated with reduced spending, a crucial goal in population health management.  

It Leads to Better Utilization of Care

When ACP is part of the care continuum, it promotes the appropriate use of services. It helps patients facing serious illness learn they have choices, which include palliative care and hospice. By preventing unwanted procedures and hospitalizations at end-of-life, ACP contributes to lower costs of care and helps relieve undue suffering among patients and families.

It Promotes Coordinated Care

Effective population health strategies focus on coordinating care across the continuum. ACP fills a critical gap for high-risk, high-cost patients, who are the most vulnerable to falling through the cracks. Successful ACP initiatives ensure that these vital conversations are documented and readily available for patients as they move across healthcare settings, improving communication and ensuring better transitions of care throughout the course of illness.  

It is a Patient-Centered Intervention

One of the core components of successful population health strategy is the implementation of patient-centered interventions. Although it sounds counter-intuitive to the broader focus of population health, quality healthcare delivery should not be a one-size-fits-all approach. Numerous studies have shown that goal-concordant care is associated with improved health of populations.  At its essence, ACP is patient-centered care that entails care delivery that aligns with individual values, preferences, and goals.  

Ultimately, healthcare organizations that make ACP a part of their population health strategies will improve quality of care delivered to patients and enhance the patient experience while better managing and allocating healthcare resources.   

ACP Decisions creates evidence-based video decision support tools that promote effective advance care planning and are easily accessible on a user-friendly technology platform. Find more resources and information by visiting our blog. If you’d like to learn more about implementing an advance care planning initiative in your organization, contact us today

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