Linkages - Do – Implementing

Do - Implementing

The “Do” module focuses on the implementation of your palliative care and advance care planning goals, utilising appropriate strategies and resources, and broadening engagement activities.

After working through this module, you will be able to:

  • Mobilise partners to provide better palliative care and advance care planning for older people in your care
  • Implement selected linkage strategies between aged and palliative care services
  • Utilise ELDAC Toolkits to enable better palliative care and advance care planning for older people in your care
  • Motivate staff to participate in the change process to improve palliative care and advance care planning

Partners now need to deliver the resources and services they committed in the earlier planning phase. Refer to your resource map and action plan.

“The most successful partnerships are those that are clearly task-focused – where all partners are actively engaged in delivering tangible and practical results.”
The Partnering Toolbook

Bring internal staff “on-board” with the palliative care and advance care planning improvements. Changes in the workplace can be threatening to some staff and can become a barrier to your implementation plans. Application of motivational strategies and activities can help to deepen staff engagement.

Common reasons for resistance include:

  • Reason for change is unclear;
  • Belief that there are “more pressing issues” to address;
  • Belief that change is unnecessary or being dealt with the wrong way;
  • Feeling personally criticised;
  • Wariness created from previous “improvement strategies” that failure to take off; and
  • Concern about extra work implications 9.

These strategies can increase staff motivation to change and help get everyone on board with your palliative care and advance care planning improvements:

  • Communicate the benefits to your staff and allow them time to reflect on, and ask questions about, the proposed improvements;
  • Promote staff ownership in the change by asking for their ideas and suggestions;
  • Endorsement and support from organisation leaders;
  • Develop staff communication and team work skills;
  • Capacity-building to ensure staff have the knowledge and skills to implement the improvements;
  • Adequate staffing and resources;
  • Back up your arguments for change with evidence ;
  • Communication and celebration of wins;
  • Reward top performers; and
  • Identify and address negative attitudes and beliefs 9 11.


“What’s in it for me?” This activity will help you identify mutual benefits. Information about this process is available online. The recommended activity can be found on page 14 of the linked document. 12

“Mad, sad, glad.” Meet with your team to discuss their experiences of the partnership in an environment that is ‘safe’. Information about this process is available online. The recommended activity can be found on page 45 of the linked document. 12

Create a storyboard – A storyboard is a wonderful visual tool to both generate curiosity and enable local teams to view the change ideas before they actually need to implement the new protocols. 13

Implement your action and communication plans:

  • Utilise your action and communication plans to guide your implementation of activities to improve palliative care and advance care planning for older people in your care.
  • Follow your plans carefully, monitor related outcomes, and modify as necessary.

TIP: Consider appointing a coordinator to manage the action plan. A coordinator can ensure partners are fulfilling their responsibilities well and in a timely manner 7.

A service will partner to provide high quality integrated and multidisciplinary care. Working together can facilitate internal and cross-institutional capacity building.

Integrated care

“Integrated palliative care aims at improving coordination of palliative care services around patients’ anticipated needs (p.1091)” 25 Seamless and efficient referrals and care transfers improve care outcomes. Additionally, it serves to reduce service delivery gaps, delays, and duplication. 26 Aged care providers often partner with other health care services to ensure out-of-hours or specialist coverage for their clients or residents.

Integrated care done successfully ensures the right person receives the right care at the right time from the right health care professional.

Success in integrated care requires appropriate and timely referrals. The appropriateness of the referral ensures service resources are used effectively, efficiently, and economically. A timely referral ensures specialist palliative care providers secure time to develop relationships with the resident or client, and can proactively detect and address their problems and needs.25 Appropriate, timely referrals depend on the referring health care professional’s knowledge of palliative care and available palliative care services. 25

Education, communication, and organisation are key issues. Service mapping is a critical first task. Referrals and transfer processes benefit from standardised criteria, protocols and pathways. Standardised information exchange processes should be utilised and agreed upon by all partners. You may wish to consider utilising an established clinical communication tool such as ISBAR. More information on ISBAR, and resources including a fact sheet, lanyard card, and telephone sticker, poster and telephone pad on this link.

Get to know, and feel comfortable with, your partners and their services. Health care professionals are more likely to refer to a service they have experience with, trust and respect.

Recommended activities and resources:

  • Audit your current referral pathways  (Both formal and informal)
  • Service mapping in your local area  (For more information on service mapping visit Identify Potential Partners)
  • Health Pathways(More information on Health Pathways)
  • Referral pathway/flowchart
  • Pathway for escalation
  • Reportable signs of deterioration  (For more information on recognising deterioration see the Primary Care Toolkit, the Home Care Toolkit, or the Residential Aged Care Toolkit as relevant.)
  • Referral guidelines/criteria
  • Referral forms
  • Transfer forms
  • Return from hospital/following a specialist consultation – what to ask?

Case Study: Integrated Care

There are many components of a successful integrated care approach.

A primary partnership activity for the Peninsula Health project was the development of a regional palliative care referral pathway for residential aged care facilities (RACFs) and general practitioners (GPs).  This required utilising the communication pathway and role clarification linkage strategies.

Staff commented – that through an integrated care approach - they “learned so much more about each other’s organisations – we are using each other’s services better”.

Listen to how this referral pathway was achieved.

Multidisciplinary care activities

To meet your client or residents’ multidimensional care needs you may decide to develop a multidisciplinary team across services. Regular meetings and joint documentation will increase the efficiency of your team. The Role Clarification linkage strategy <see “Utilise Linkage Strategies”> is particularly useful to clearly define roles and responsibilities for each member. The key palliative care processes (advance care planning, palliative care case conferences, and end of life care pathways/plans) particularly benefit from a multidisciplinary approach.

Recommended activities and resources:

  • Document roles (clear role descriptions), responsibilities and expectations regarding service delivery; clarity on role and service activities from each partner
  • Shared calendar
  • Shared care plan
  • Shared advance care planning documentation (referral form and record of discussion)
  • Shared end of life care documentation (See Metro South’s Residential Aged Care End of Life Care Pathway, Section 4: Multidisciplinary Communication Sheet as an example)
  • Conduct regular multidisciplinary meetings; implement a triage process
  • Is there a process in place that allows documents of ACP and care plans to be uploaded, stored (and easily accessed), carried forward and shared as appropriate?

Capacity building

Another major reason for partnering is to increase your organisation’s capacity in providing palliative care and advance care planning. Working with other service providers is an opportunity to increase your service’s knowledge, skills and professional linkages. For example, you may decide your staff could successfully utilise a syringe driver in your palliative care delivery with training from a specialist palliative care service. Or you may enlist the support of a social worker to train your staff in conducting difficult conversation in advance care planning.

Capacity building is often a two-way process between partner services. Partners can share successful internal processes and systems with each other and provide insights into their own services.

Recommended activities and resources:

  • Conduct an education needs survey, determine which educational needs are best met by an external provider, and develop an palliative care and advance care planning education plan (See the Personal Development Survey in the Home Care Toolkit or Residential Aged Care Toolkit  as relevant")
  • Invite Specialist Palliative Care Services or other external service provider to conduct education sessions for your service
  • Develop train the trainers’ workshops to develop local expertise
  • Investigate options for remote education (e.g., webinars)
  • Investigate a PEPA placement – PEPA provides an opportunity for primary health care providers to develop skills in the palliative approach by undertaking a supervised clinical placement of up to four days within a palliative care specialist service
  • Participate or observe multidisciplinary team meetings e.g. palliative care case conference, patient/client/resident review. 27
  • Mentoring and reflective practice. 27

Case Study: Capacity Building

Developing partnerships and connections with a Specialist Palliative Care Service can increase capacity for an organisation. mecwacare developed a strong effective partnership with Cabrini Palliative Care creating new systems and practices. Shared education and mentoring opportunities increased staff capacity. Capacity building activities included: upskilling of staff with shared education, shared communication tools and protocols, and clarification around each services’ role. Education sessions were held at each service and local GPs were provided with palliative care information folders. Cabrini consulted on clinical issues and provided mentoring to mecwacare staff.

Here the strong connection between the two services are discussed by Lisa Reynoldson.


Utilising the following evidence-based linkage strategies to facilitate your service partnering activities.

Role Clarification

This is about getting to know each other and understanding the roles and responsibilities of each member of the service partners.  Who does what, when and where?

Clarifying roles and responsibilities increases effectiveness, and leads to improved continuity of care, particularly when transitioning between settings 28. Role clarification will also assist to identify gaps and overlaps in care provision. 

Ask yourself...

1. Are roles and responsibilities of all palliative care service partners understood and clearly defined?
2. Are boundaries, limitations or duplications of care provision of service partners clearly identified? (e.g. geographical and service delivery)

Written and Verbal Communication Pathways

Shared and standardised documentation and communication processes support care delivery, and may include usage of common language, standardised referral forms, End of Life pathways, agreed assessment tools, and Advance Care Plans 28.  Effective communication assists service partners to work well together.

Ask yourself...

1. Do you have an agreed referral process for your residents/clients to be referred to a specialist palliative care service or related services?
2. Do you have all the information you need on your current referral tool for triage? If not, what is missing?
3. Is there up to date information to follow including who, how, and when a palliative care service should be contacted?

Case Study: Written and Verbal Communication Pathways

Clearly articulating a communication plan between services is essential to optimise collaboration.

Communication systems can be put in place to ensure services are working together effectively.

Here the Project Manager discusses the frustrations both partners experienced with unannounced visits from the Specialist Palliative Care team. Recognising and addressing the communication-based issues in this situation produced an immediate change for the better.

Listen to the project Manager, Maddy Cosgrove, RN, describe the solution they came up with to improve their verbal and written communication.

Multidisciplinary Team (MDT) Structures and Processes

Multidisciplinary care occurs when service providers from a range of disciplines work together and utilise the practices of collaboration and communication to deliver comprehensive care. This can be delivered under one organisational umbrella or by bringing together service providers from a range of organisations to constitute a unique team 29, as in the case of service partnerships.

Scheduling regular communication opportunities between ranges of disciplines across the service partners, facilitates multidisciplinary team input into care planning and delivery. 28

Ask yourself...

1. Is there already an MDT that includes a range of disciplines from all of the service partners?
2. Do the members of the MDT have collective input into care planning and delivery?

Formalised Agreements and Plans

Formalising service partnerships, through written agreements and governance arrangements, can ensure discussion of and commitment to resource allocation, mutual responsibilities, agreed outcomes, and communication processes 28.

Ask yourself...

1. Does your organisation have a formalised agreement in place with our service partners?
2. Has consideration been given to governance and leadership structures, and resource sharing in the formalised agreement statement?

Designated Linkage Workers

Appointing a staff member to act as a care and linkage coordinator across service partner settings improves access, cooperation between services, communication and continuity of care 28

Ask yourself...

1. Are resources available to support a designated linkage worker for the service partnership?
2. Do we have mechanisms in place to ensure a clear understanding of the role?
3. If there is already a linkage worker, do they currently contribute to the service partnership?

Case Study: Designated Linkage worker

A Linkage Nurse role was established at St Anne’s RACF in Broken Hill with the aim of increasing palliative care capacity across their partnership. This role provided a point of connection between organisations. The role involved informal and formal education, mentoring of staff, and increasing care worker confidence. The Linkage Nurse also assisted in improving their clinical documentation system with the support of the Specialist Palliative care team input.

The Linkage Nurse was a change champion, who helped to embed a new culture within her facility. In this way there was a gradual and purposeful building of the organisation’s capacity to provide quality palliative care and advance care planning. 

Here the Linkage Nurse and her Manager discuss the contribution that the Linkage Nurse role made and how her role was undertaken. 

Knowledge Exchange and Upskilling

Service partners learn from sharing their knowledge and experiences.  Shared learning opportunities increase knowledge and develop confidence and capabilities 28.

Ask yourself...

1. Do you have an education plan for advance care planning and palliative care within your organisation?
2. Can you create learning and knowledge exchange opportunities across the service partnership? (e.g. begin a journal club, special interest group, joint education sessions, mentoring activities, 1:1 clinical learning)

Continuous Quality Improvement

Processes for continual review of service partnerships and their outcomes enable identification of their effectiveness and efficiency 28.

Ask yourself...

1. Does your continuous improvement system have built-in review?
2. Are all your activities tied into the plan-do-check-act cycle for continuous improvement?


Further information on the Linkage Strategies is available in the Decision Assist Palliative and Aged Care Linkages Manual.

These are located on this website. Go to the ELDAC Toolkits.

Page updated 12 March 2024