Do - Implementing

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

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}.

Activities:

“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.

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.

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.

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?

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

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. 

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.

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

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.

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. 

Knowledge Exchange and Upskilling

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

Continuous Quality Improvement

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

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.