Next Steps Tool Kit

Build on your planning discussions & add to your personal plan

Black daughter and mom hugging

1. Share Concerns & Choices

Talk with others about your care goals and treatments options as your health needs change.

Icon: 2 papers, 1 MOLST, 1 CC/DNR. Must be valid.

2. Update & Add Documents

Update your plan and add documents that communicate your personal and medical choices.


3. Get Better Care

Work in partnership with your care providers to match care to your choices.

Getting the best possible care that honors your goals and care choices is a lifelong journey. Now that you have started to make your personal plan with a Health Care Proxy and Personal Directive in the Getting Started Tool Kit, you can build on your planning discussions and revise and add planning documents as your health needs and choices change over time.

The Next Steps Tool Kit  provides information and discussion guides to help adults manage changing health needs and chronic illness, and live well with advancing serious illness or frailty.

Here is an expanded version of the tool kit with discussion guides for both consumers and care providers to have more effective discussions.

Download the Next Step Tool Kit for Consumers below.

View the Next Step Tool Kit Checklist, a step-by-step guide to get good care today and over your lifetime.

The Next Steps Tool Kit Checklist:

The Next Steps Tool Kit Checklist:

For Consumers: Here's a simple checklist to review your plan to date,  and build on your discussions over your lifetime as your health needs change and your care goals are revisited and redefined.  We use the 3 phases of health below- Promoting Everyday Wellness to Stay Healthy; Managing Health & Chronic Illness as we age; and Living Well with Serious Illness.

Promoting Everyday Wellness To Stay Healthy

  • Do you have a Heath Care Proxy and Personal Directive (living Will)?
    • If no, you can do-it-yourself using the  Getting Started Tool Kit.
    • If yes,  take a moment to review your documents. Are they up-to-date? Are they valid?
      • Learn more with Things to Know About a Health Care Proxy; Things to Know About a Personal Directive.
  • I gave a copy of my documents to my Health Care Agent. He/she knows my instructions for care.
  • I gave a copy of my documents to my primary care physician to put into my medical record.
  • I started a planning discussion about my care goals and choices with my health care providers to put my plan into action.
    • Use the 5 Things to Talk About With Your Care Providers. Bring to your next appointment.

Managing Health & Chronic Illness As We Age

  • Start to build on your planning discussions
    • Use the 5 Things to Talk About With Your Care Providers: Managing Health and Chronic Illness
      • This handy discussion guide can help you start a discussion about your current medical condition and possible treatment options to manage your illness and improve the quality of everyday living.
  •  Consider appointing a financial decision-maker in a Durable Power of Attorney, who can step in if you need help or are unable to make financial decisions yourself.
    • Learn more : Things to Know about a Durable Power of Attorney
    • Contact an attorney or view the Community Partners in your region
  • Review and Update Your Plan: Health Care Proxy, Personal Directive and Durable Power of Attorney

Living Well with Serious Illness

  • Keep the conversation going with family and health care providers. Review your care goals and priorities.
    • Use 5 Things to Talk About With your Care Providers: Living with Serious Illness
      • If you are a frail adult or diagnosed with a serious advancing illness, this discussion guide can help you focus on your current condition and treatment options to live well with serious illness, and to make choices and priorities for the care you want and the care you do not want.
  • Consider Palliative Care to manage the pain, symptoms and stress of serious illness:
    • What is Palliative Care? fact sheet
    • Palliative Care: 5 Things to Talk About With your Care Providers. Use this discussion guide when you are first diagnosed and all through your serious illness.
  • Make choices for life-sustaining treatment & end of life care. Learn about two types of medical orders you can complete with your clinicians:
    • MOLST, Medical Orders for Life-Sustaining Treatment
    • CC/DNR, Comfort Care/Do Not Resuscitate Order
  • Consider Hospice Care
    • Learn more:  Things to Know About Hospice Care.
      • Hospice helps provide compassionate care and services to adults with a serious or terminal illness with a life expectancy of six months or less.
  • Review and Update : Health Care Proxy, Personal Directive, Durable Power of Attorney, MOLST, CC/DNR. Be sure your family and care providers have your up-to-date planning documents.