Make a Plan, Share a Plan

In late 2017, Upper Peninsula Health Care Solutions, Inc. was awarded a grant from the Michigan Health Endowment Fund to expand the evidence-based advance care planning program, Make a Plan, Share Plan. The project improved access to advance care planning services for all adults in the Upper Peninsula by expanding the local work workforce and creating local access points throughout the region. The project’s goal was to reduce healthcare costs by reducing unwanted care, while creating a culture that reduces the moral distress of physicians and better aligns care with what patients truly desire from their healthcare system.

Advance care planning is making informed decisions about the care that you want to receive if you should ever become unable to speak for yourself.  The process involves discussions with loved ones, family and caregivers, but the decisions are yours; based on your personal values and preferences.  Planning ahead ensures that your wishes are carried out and relieves the people you care about of the burden of making difficult healthcare decisions on your behalf without the benefit of your input.

The establishment of an advance care plan involves contact with a trained and certified advance care planning facilitator who will help you to identify what is important to you and reflect on your decisions about your healthcare priorities.  Your ACP facilitator will also help you choose and appoint a patient advocate and assist in the development of an advance directive.

  • patient advocateis a person that you trust and who will accept the responsibility of ensuring that your wishes are carried out if you are unable to express them.
  • An advance directiveis a document that codifies your goals, values, and intentions in a way that helps providers to understand and follow your directions for care.

Studies indicate that there is a significant gap between individuals believing that advance care and end-of-life planning is important and those that have documented goals.  The Make a Plan, Share a Plan advance care planning model, developed in partnership with Upper Peninsula Health Plan (UPHP) and Honoring Healthcare Choices – Michigan, is centered on honoring the dynamic and individualized needs of patients and addressing the shortfall identified by both patients and providers.

The project systematically improved access to advance care planning services by expanding educational opportunities to increase the number of certified advance care planning facilitators in the region.

At the conclusion of the project in late 2019, 27 certifications for First Steps and Advanced Steps Advance Care Planning facilitation were awarded and the Upper Peninsula Health Plan continues to provide ACP facilitation trainings to cohorts of students on an annual basis. Over 240 facilitated ACP conversations were held throughout the UP by participating partners and volunteers. These conversations resulted in over 100 advance directive documents being filed with physicians and attorneys. In addition, 15 Community Health Workers, representing six organizations were certified to promote and facilitate ACP conversations.