Work Together

Working as a team means providing integrated care across services - acute, primary, home care, residential aged care, and specialist palliative care.

The person receiving care and their family are considered an essential part of the working team. It is important for the family to understand that the care of their loved one requires a team effort of several professionals in order to provide optimum care.

Who is family?

“The family is defined as those who are closest to the person receiving care in knowledge, care and affection. The family may include the biological family, the family of acquisition (related by marriage/contract), and the family of choice and friends, including pets.” ¹⁴

Care Settings

A person with dementia may receive care across a variety of settings. However, 70% of people with dementia live in the community, although few of these people have severe dementia. ¹⁵ The Australian Government has services across the care spectrum from support at home currently through the Commonwealth Home Support Program and the Home Care Packages Program.

The Dementia and Cognition Supplement provides additional funding for people with moderate to severe cognitive impairment. Most people who receive this supplement are receiving Level 3 or 4 Home Care Packages designed for those with intermediate or high care needs. ¹⁶

Respite programs are available and important for family carers to access for people with dementia who are being cared for at home and require end of life care. Details on how to access respite are provided in the Family Resources section below. For people with dementia who can no longer be cared for at home, residential aged care can provide 24/7 care. More than half of people living in residential aged care have dementia. ¹⁷

Younger Onset Dementia

For people with younger onset dementia support is available through the National Disability Insurance Scheme (NDIS). Dementia Australia has specific information for people with younger onset dementia, as does healthdirect.

Specialist Palliative Care

Providing end of life care for people with dementia requires knowledge of the person’s dementia, as well as other conditions that may cause symptoms of distress. Specialist palliative care services may provide support for people living with dementia in the community or residential aged care.

The Advance Project^® provides triage tools for clinicians to use to identify if the person with dementia requires referrals to specialist palliative care services. There are specific referral triage tools for primary, home residential aged. Registration is free to access the tools.

Contact your local specialist palliative care service to identify what support is available in your local area. Palliative Care Australia provides a National Service Directory.

Complex Care Needs

People living with dementia in the community have an average of 5 long term health conditions, including dementia. Most common conditions are hypertension (high blood pressure), arthritis, hearing loss or deafness, high cholesterol, back problems and diabetes. For those living with dementia in residential aged care on average these individuals have 6 conditions. The most common are arthritis, depression/mood affective disorders, hypertension and anxiety and phobic disorders. ¹⁸

Due to the complex care needs of someone with dementia a multidisciplinary approach to care is required. This will involve generalist care providers, as well as experts in dementia and specialist palliative care.

palliAGED has a webpage with resources on care coordination to provide the best palliative care and be forward planning.

CarerHelp offers further support to health professionals with factsheets available on:

• Working with someone who is seriously ill and may be dying
• Working with Culturally and Linguistically diverse families
• Working with Aboriginal and Torres Strait Islander families
• Working with people who are LGBTIQ+
• Having death and dying discussions with culturally diverse families
• Developing inclusive practice.

Dementia-Specific Support Services

The Australian government funds multiple dementia related services, which includes:

• Dementia Behaviour Management Advisory Service: A mobile workforce provided by Dementia Support Australia (DSA) to support people with mild to moderate behaviours and psychological symptoms of dementia, and their carers, with client/resident focused information, assessment, and advice.
• Severe Behaviour Response Teams: A mobile workforce provided by DSA to support people with severe behaviours and psychological symptoms of dementia, and their carers, with client/resident focused information, assessment and advice.
• Specialist Dementia Care Program: A tailored program offering temporary, transitional care to people who are experiencing severe behavioural and psychological symptoms of dementia and who can no longer be cared for in mainstream residential aged care. Eligibility for the Specialist Dementia Care Program is determined by the Needs Based Assessment program of DSA.

Other ELDAC Resources

The ELDAC toolkits for Residential Aged Care, Home Care and Primary Care have information on working together in those specific care settings, including information about case conferences.

For tips on getting your organisation ready to provide palliative care and advance care planning the Residential Aged Care and Home Care Toolkits have organisational support sections, which provide resources on the standards and quality improvement activities, including organisational and after death audits.

The Primary Care Toolkit has links to HealthPathways, which provide clinicians working in primary care with a single website to access clinical and referral pathways and resources.