Agency for Integrated Care and GERI team up to foster the full potential of Advance Care Planning implementation in Singapore

Image: AIC

ACP is the process of planning for one's current and future healthcare guided by one's values and preferences, which are communicated to people who are important to the individual and healthcare professionals. ACP has been implemented in Singapore for more than a decade.

However, local studies have highlighted the lack of a national framework on quality implementation of ACP, which have resulted in inconsistencies and varying standards of ACP practices across care settings.

To address this, the Agency for Integrated Care (AIC) and GERI have collaborated via a knowledge exchange platform to engage relevant knowledge users which included ACP leaders, facilitators, administrators and healthcare professionals. This platform was used to shape and discuss organisational, ethical and procedural aspects of ACP implementation, resulting in the development of a set of practice guidelines titled "Guidelines for Quality Implementation of Advance Care Planning".

Launched in May 2025 at AIC's Community Care Workplan Seminar, the Guidelines represent a significant milestone in standardising and improving quality ACP practices across Singapore. It is available to users in various settings, including Regional Health Systems, polyclinics, community hospitals, nursing homes, and community networks for scaling up and widespread implementation.

Click here to access the guidelines.

Overcoming barriers to ACP implementation in real-world settings

Commenting on the significance of the guidelines, the project's platform lead, Dr Raymond Ng, said: "Adoption of the practice guidelines at the national policy level and by various organisations can help to raise awareness of the importance of the ACP process as well as improve the quality of its implementation." Dr Ng is the Co-chair of the National Advance Care Planning Steering Committee and Chief, Palliative & Supportive Care, Department of Integrated Care, Woodlands Health. He is also a Visiting Consultant at GERI.

"The ACP process is a complex and multi-dimensional endeavour that must be adapted to each culture and context. Application of implementation science principles can help foster the full potential of ACP implementation in real world settings," Dr Ng added.

Dr Tan Woan Shin, GERI's Director of Research and co-lead of the project platform, said: "Through the guidelines, we hope to reduce variations in ACP implementation across providers and settings, and to better provide guidance on how to organise ACP implementation to circumvent barriers identified in earlier evaluations."

"The guidelines also include a list of recommended quality indicators, which could support policymakers and providers to monitor the progress of ACP to meet the contextual needs of individual organisations," said Dr Tan, who is also a Scientist at GERI.

Harnessing knowledge translation and implementation science principles

Knowledge translation science bridges the gap between evidence and practice. The Knowledge-to-Action (KTA) model guided the GERI team through multi-level stakeholder engagement to derive a set of practice guidelines for quality ACP implementation, which took an evidence-based, practitioner-informed and participatory approach that sought to encourage greater acceptance, adoption and implementation of the guidelines.

GERI applied knowledge translation and implementation science principles by identifying and prioritising evidence-based barriers utilising the Theoretical Domains Framework. The Select Tool, which was based on the Behaviour Change Wheel model, was then used to develop the implementation strategies which formed the framework of the Guidelines.

GERI supported the national workgroup in developing and testing strategies to overcome barriers to ACP implementation. For more on this process, read our interview with study team member and GERI researcher Penny Lun here.