Managing in the trenches of consumer care: the challenges of understanding and initiating the advance care planning process

J Gerontol Soc Work. 2012;55(8):721-37. doi: 10.1080/01634372.2012.708389.


To better understand how community-based long-term care providers define advance care planning and their role in the process, we conducted 8 focus groups with 62 care managers (social workers and registered nurses) providing care for Ohio's Medicaid waiver program. Care managers shared that most consumers had little understanding of advance care planning. The care managers defined it broadly, including legal documentation, social aspects, medical considerations, ongoing communication, and consumer education. Care managers saw their roles as information providers, healthcare team members, and educators/coaches. Better education, resources, and coordination are needed to ensure that consumer preferences are realized.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Advance Care Planning / organization & administration*
  • Attitude of Health Personnel
  • Decision Making
  • Focus Groups
  • Health Personnel* / psychology
  • Health Personnel* / standards
  • Health Services for the Aged*
  • Humans
  • Interpersonal Relations
  • Long-Term Care* / methods
  • Long-Term Care* / organization & administration
  • Long-Term Care* / psychology
  • Needs Assessment
  • Ohio
  • Patient Care Management* / methods
  • Patient Care Management* / organization & administration
  • Patient Education as Topic
  • Qualitative Research
  • Social Work / standards*
  • Terminal Care / organization & administration
  • Terminal Care / psychology