Customizing medical decision-making discussions for healthcare organizations

ACP Consulting, a program of the Coalition for Compassionate Care of California (CCCC), works in partnership with healthcare organizations and communities to design effective, cost-efficient advanced care planning solutions tailored to the population of each organization. The result is a targeted, quality experience for patients, their families, healthcare professionals and the organization.

The service is responsive and customized for demographically and geographically diverse populations, as well as each organization’s unique culture. We take a top-down as well as bottom-up approach, building from, and dovetailing with, whatever practices a client already has in place. We start with what’s working and incorporate additional best practices to establish a high-quality, sustainable program.

What is Advance Care Planning (ACP)?

Advance care planning is the process by which people think about their preferences for medical care should they become unable to speak for themselves.

The goal of ACP Consulting is to help organizations align medical care and treatment with a person’s goals for life, goals for care and treatment preferences. In this way, healthcare organizations not only create a community where patients are supported in having these wishes honored but the organization sees more effective and efficient use of resources.

The Need for Advance Care Planning (ACP)

In the current healthcare world, there is substantial misalignment between the medical care people want during serious illness and the medical care they actually receive. Unfortunately, people are often not empowered to speak up for the kind of care they want, and clinicians are often not trained to talk with patients about their treatment options and preferences. When it does happen, the process sometimes consists of checkbox forms and jargon-laden hypotheticals, rather than meaningful conversations about preferences, values and goals over time. Short-circuited conversations can too easily lead to the provision of aggressive care, which in many instances is not in line with a patient’s best interests or values.

Identified by the American Academy of Physicians as one of the top high-quality, low-cost interventions for healthcare systems and providers for increasing patient satisfaction, advance care planning can lead to:

  • Improved patient and family satisfaction
  • More efficient allocation of resources
  • Reduced readmissions
  • Improved facilitation of skilled nursing facility transfers
  • Reduced provider stress
  • Proper use of POLST
Our ACP Consulting team provides expertise in the following areas:

  • Strategic planning support
  • Coalition building
  • Leadership engagement
  • Curriculum and materials
  • Training, with follow-up support, feedback and mentoring
  • Metrics and electronic records
  • Grant-writing support
  • Public awareness campaigns
  • Education of advance care planning facilitators and advocates

Our experts will help you evaluate existing strengths, weaknesses and opportunities, and educate community leaders and key stakeholders about advance care planning. Our services will help you to train staff regarding advance care planning best practices in order to establish systems and integrate them into ongoing care, identifying metrics to evaluate program effectiveness, and creating a common vision that supports advance care planning conversations, including attention to public policy and reimbursement issues.

Our team becomes your partner in implementation. We guide our clients in each step of the process, from the earliest pilot projects and leadership support, to customized curriculum development, and through to the full sustainability of a program integrated into your organizational culture.

The CCCC Advantage
While today’s healthcare organizations recognize the value of understanding the wishes of seriously ill patients, the challenge is how to integrate advance care planning into existing operations smoothly and efficiently.

As a coalition with partners across the healthcare spectrum, CCCC has amassed a broad range of experience and expertise, making us uniquely qualified to tailor specific solutions to the individual needs of our institutional clients, whether large or small, urban or rural, for-profit or non-profit.

The inter-professional consultation team of CCCC brings a wealth of knowledge to each project, and works in partnership with our clients to bring communities together, co-create meaningful change and achieve deeper and more sustainable results. Our focus on enhancing the effectiveness of communities, professionals, and systems is what sets the services of CCCC apart.

Coalition for Compassionate Care of California has a proven track record of leading successful, large-scale, multi-organization initiatives in complex, culturally diverse communities, such as implementation of the Physician Orders for Life-Sustaining Treatment (POLST) across California. Within five years of its introduction, 95% of California nursing homes had completed POLST forms with residents, 65% of hospitals had a formal POLST policy, and 75% of assisted living facilities had implemented POLST education for staff.

Our team brings the same dedication to finding advance care planning solutions tailored to the individual needs of each of its clients. We help our clients with strategic planning, program development, clinician education and training, development of informational material, quality assurance, and metrics.

How We Work

Program Design and Implementation

CCCC understands that advance care planning is an ongoing process. We will help our clients assess workflow and create a plan to integrate advance care planning into their daily operations so that they can engage patients and their families at critical points of care.

For systems that already have an advance care planning program in place, we can provide evaluation and assessment and make recommendations for improvement.

For those that don’t already have an advance care planning program in place, we work with you to implement the right advance care planning solution for your organization and population. We can provide mentoring, additional education or training, as well as ongoing evaluation and assessment to capture feedback and help make your program more effective.

Tools and Training

Advance care planning programs require training, materials and resources to teach, guide and document conversations about advance care planning and goals of care. CCCC has the tools and resources to meet your needs. Our proven materials are ready to use, vetted for literacy levels, and have been demonstrated to be effective. We also offer a variety of translation options.

If you prefer, customized materials can be created to address the specific needs of your organization, staff composition or patient population.


ACP Consulting provides expert level training in either direct-to-staff or train-the-trainer format. Following training, your clinicians will be able to provide high-quality advance care planning. Having trainers within your organization will make your program self-sustaining.

If advance care planning training is already operational in your organization, our team can help you evaluate your current processes and refine and improve your training with fresh tools and new curriculum.


Judy Thomas, JDJudy Thomas, JD
Judy Thomas, JD, is CEO of the Coalition for Compassionate Care of California (CCCC). Directing CCCC since 2000, Ms. Thomas has helped improve the illness and end of life experiences of hundreds of thousands of Californians and their loved ones. Today CCCC includes a staff of 12, a highly active board of 13 accomplished professionals, and an effective statewide network with a wide range of individuals, organizations, and foundations dedicated to advancing care for those with serious illness.

Under Ms. Thomas’ leadership, beginning in 2007, CCCC led a successful statewide effort to implement Physician Orders for Life Sustaining Treatment (POLST), a standardized medical order form to indicate specific types of life-sustaining treatments a seriously ill patient chooses. By discussing and documenting a person’s choices, the POLST form helps patients and caregivers provide wanted care and avoid unwanted, potentially intrusive services. Through advocacy and legislation, community coalitions, and provider education Ms. Thomas and CCCC have changed the way we plan for and provide care for seriously-ill Californians.

Lael C. Duncan, MDLael C. Duncan, MD
Dr. Lael C. Duncan is the Medical Director of Consulting Services for the Coalition for Compassionate Care of California. She is an expert educator on Physician Orders for Life-Sustaining Treatment (POLST), end-of-life communication between patients and providers, advance care planning, and legislation that impacts end-of-life care in California. Dr. Duncan consults with health care organizations, medical providers and communities to improve access to care that honors patient values.

Dr. Duncan is a licensed California physician with more than 15 years of clinical practice in internal medicine, infectious disease, and long term acute care for patients with multi-system disease. After graduating with honors from the University of Washington Medical School in 1991, Dr. Duncan did her residency training at Dartmouth Hitchcock Medical Center. She is board certified in both Internal Medicine and Infectious Diseases. Dr. Duncan has practice experience with in-patient and out-patient care, hospital epidemiology and infection control, long term care, and rehabilitation following critical illness.

Shirley Otis-Green, MSW, ACSW, LCSW, OSW-CShirley Otis-Green, MSW, MA, ACSW, LCSW, OSW-C
Shirley Otis-Green is the Clinical Director of Consulting Services with the Coalition for Compassionate Care of California, a Research Consultant for the Psychosocial Oncology Specialization Program at the University of Louisville, Kent School of Social Work, and the founder of Collaborative Caring.

Shirley’s education, research and consultation efforts focus on quality-of-life, palliative care, leadership development and the creation of meaningful organizational change. Her work is dedicated to enhancing excellence in the delivery of culturally-congruent, person-centered and family-focused inter-professional care through the implementation of effective learning principles.

Learn More

Contact us and learn more about how ACP Consulting will help your organization and your patients. Call (916) 489-2222 or email us.