Goals of Care Management

Advance Care Planning (ACP) is a way to help patients, families and decision-makers to think and talk about their wishes for health care. A Goals of Care Designation (GCD) is a medical order used to communicate the patient's general aim for health care, including any preferred location for and limits to that care.

The Connect Care clinical information system has tools that facilitate recording patient's wishes, attaching advanced care planning documents to the chart, documenting evolving wishes, capturing a specific GCD status and sharing this information across the continuum of care. Quick info:

Goals of Care Status

Summary goals of care information is prominent in the Patient Storyboard, which appears as the leftmost column of all opened patient charts. At the top of Storyboard, just underneath the patient identifiers, is a "ACP/GCD" line. Hovering over this brings up a summary of the current patient's goals of care information, including:

  • Current GCD Status

  • GCD Status History (past designations and changes)

  • Details of most current status

  • List of attached ACP documents

Goals of Care History and Documentation

Selecting (clicking on) the ACP/GCD line in Storyboard opens an "Advanced Care Planning and Goals of Care Designations" navigator within the patient's chart. The navigator has links for activities that relate to capacity assessment, designating alternate decision-makers and jumping to the Orders activity to enter a GCD order.

There is also a link to a "Tracking Record" (see below) where documentation about additional details or changes in patient wishes should be recorded. Ideally, a GCD Tracking Record note is added each time there is a change in GCD designation.

Goals of Care Orders

A Goals of Care Designation (GCD) is required for all patients in all contexts (emergency, outpatient, inpatient, long-term care, continuing care, etc.). A first registration of a patient's GCD level is entered into Connect Care as a prescriber order, as are any subsequent changes to the GCD level.

A GCD order becomes active upon signing and remains active until changed or replaced. It pertains wherever Connect Care is the record of care, spanning all encounters. It is automatically printed or faxed when transitions of care involve facilities that do not use Connect Care as the record of care.

It is important to ensure that all patients have an active GCD, to enter changed orders with care, and to periodically review GCD orders in compliance with advanced care planning policies. All GCD orders include details about the location and authorization for the order, as well as a space for any clarifying comments. More details, as well as evolving considerations, are documented in the GCD "Tracking Record". Common GCD order tasks for prescribers include:

  • Add GCD Order (patient currently without GCD Status)

    • Use "GCD" or "goal" as an order search term in the Orders activity.

    • Select an appropriate GCD order, reflecting the intended GCD Status (R1, R2, R3, M1, M2, C1, C2).

    • The order composer provides a quick reminder about the definition of the requested GCD level (e.g., R1), followed by three questions and a field for optional clarifying comments.

      • Indicate the GCD order location (home or facility), authorization (patient and/or alternate decision-maker) and validation (awaiting a dispute resolution status or not). Supplemental clarifying comments can be attached to the order and resulting GCD status.

      • Note that a "tracking documentation" link is provided within the order. This can be used to generate a GCD tracking note to accompany the order and GCD.

    • Sign the order.

  • Modify GCD Order (change in existing GCD order details)

    • If new information about an existing GCD status (e.g., change in decision-maker or no longer under dispute resolution) emerges, the current GCD order can be modified by using the "Modify" button (attached to existing order) in the Orders activity.

    • Any significant change in GCD instructions should be recorded using the "Tracking Record" documentation link.

    • Sign the modified order.

  • Replace GCD Order (change in GCD status)

    • If the patient's GCD level changes (e.g., M2 to C1), a new GCD order should be entered. This will automatically replace and update the old GCD order. It is not necessary to delete the old order first.

  • Remove GCD Order (patient status has become indeterminate)

    • The "Remove" order button within the Orders activity should only be used for a GCD order if the responsible clinician(s) determines that an existing order is outdated and there is compelling reason to not indicate a GCD status. Usually, uncertainty (e.g., no designated decision-maker and significant change in clinical status and patient unable to self-advocate) is handled by defaulting to R1 or the last-recorded GCD status.

GCD Tracking Record

The Goals of Care Tracking Record helps document the content of Advance Care Planning (ACP) and Goals of Care Designation (GCD) conversations or decisions. Notes can be added as needed and should be added whenever there is a change in GCD status.

Tracking notes can help other health care providers (shared across the continuum of care) to be aware of previous conversations, to understand the reasons for a particular GCD order and to heed any specific limits to care. Tracking record notes are printed and included with a patient's "Green Sleeve".

Tracking record notes can address any of the following questions, usefully included in discussions about advance care planning:

  • Have you completed a Personal Directive?

  • Have you selected an alternative decision maker? Do they know your wishes?

  • What is your understanding of where you are with your illness?

  • If your health situation worsens, what are your important goals?

Missing GCD Orders

All patients should have a GCD status, achieved through entry or re-entry of a GCD order. There are a few places in the chart where clinicians are reminded about GCD orders requiring attention.

  • Inpatient Charts

    • A "Sidebar Summary" appears by default in the rightmost panel/column of opened patient charts. The summary presented to prescribers is consistent.

    • Look for a section (usually third down) entitled "Admission Checklist".

    • If a current inpatient does not have a valid GCD status, a "Has Active and Reviewed Goals of Care Designation Order" item will appear in the "Overdue" section of the checklist.

    • Clicking on this opens the Orders activity, where a GCD order can be entered.

  • Patient Lists

    • The Patient Lists activity is the usual gateway to inpatient encounters for currently admitted patients. Any list can be used to rapidly access a physician checklist that includes information about missing GCD status.

      • When a patient (list row) is selected, a "report" appears in the bottom half of the list screen (can be configured to be side-by-side).

      • A search box appears at the top right of the report viewing area, allowing alternative reports to be selected for display.

      • The "IP Physician Checklist" report includes the "Admission Checklist", where any missing GCD orders are highlighted.

    • All Provider Team lists (found via "System Lists" >> "Facility" >> "Provider Teams") have a column showing GCD status.

    • It is also possible to edit a personalized Patient List to include "GCD" as one of the columns. This allows very fast discovery of patients within a list who need attention to GCD orders.

  • Outpatient Charts

    • The easiest way to discover a missing GCD status during an outpatient encounter is to see if the ACP/GCD section of the Patient Storyboard says "Not on file".

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