A Sample Engagement: Robert’s Journey


April 15

Prospective participants are identified and reconciled with Health Plan’s current case management efforts.

May 27

Specialist makes initial contact to confirm candidate’s eligibility and interest. After establishing relationship, the specialist elicits Robert’s specific reason, his “why” an Advance Care Plan (ACP) is important to him and his willingness to continue to discuss and focus on ACP. Engagement criteria is met. A session is scheduled for the following week.


June 4

Specialist begins by understanding Robert’s health condition and what he values. Robert expresses deep concern for his family. Specialist explores how being a protector and caregiver influences his thinking about health and medical decisions. His preferences and priorities center around caring for the family. The specialist begins to connect Robert’s “why” to a plan for future care, to his goal, care for his family. Specialist schedules call to focus on specifics that influence his decision making.


June 17

Robert and specialist focus on Robert’s goals. He shares his desire to manage pain better and help care for his son who is also sick. Robert’s wife joins call and shares her difficulty in accepting Robert’s diagnosis. Specialist focuses on what she is wanting for Robert, and Robert’s wishes. Specialist sends support materials and link to Living Voice to help them think about Robert’s goals, acceptable and unacceptable situations, and specific care decisions they may want to consider ahead of time.

July 1

After talking with his wife and thinking more specifically about care goals, Robert shares he has completed proxy/ACP using the Living Voice tool. Specialist reviews with Robert his plan to share his wishes. Robert mentions his wife reviewed ACP and agreed to share with physicians and son. Specialist helps Robert plan for these conversations and identify barriers that could arise when sharing with son/physician.


July 22

In follow up session, Specialist confirms proxy/ACP have been shared and reviews Robert’s process to continue sharing and discussing with physicians and family as his medical situation changes. Specialist sends small glass hearts to Robert/wife acknowledging their courage, and agrees to be available in coming months if needed.