Working together as a team means providing integrated care across services—acute, primary, specialist care, community services, residential aged care and specialist palliative care services.
The multidisciplinary team
In palliative care this is a team including professionals from a range of disciplines who work together to deliver comprehensive care that addresses as many of the patient’s health and other needs as possible. The professionals in the team may function under one organisational umbrella or may be from a range of organisations brought together as a unique team. As a patient’s condition changes, the composition of the team may change to reflect the changing clinical and psychosocial needs of the patient. Multidisciplinary care includes interdisciplinary care (PCA, 2018).
Primary care provider
Health services and staff that have a primary or 'first contact' relationship with the patient with a life-limiting illness. The use of the term ‘primary care provider’ in this context refers to GPs, community nurses, allied health professionals, staff of residential aged care facilities and multi-purpose centres. It also includes other specialist services. In general, the substantive work of the primary care provider would not be with people who have a life limiting illness (PCA, 2018).
Specialist palliative care services
A multidisciplinary health care service whose substantive work involves consultative and ongoing care and support for people with a life-limiting illness, their carers and family. In general, specialist palliative care services would not be directly involved in the care of people who have uncomplicated needs associated with a life-limiting illness. Specialist palliative care professionals would be expected to have recognised qualifications or accreditation in palliative care (PCA, 2018).2(p36)
Coordination of care and services is important to support the delivery of high-quality, person-centred appropriate care and services, delivered at the right place and at the right time. The ELDAC Linkages Toolkit provides useful information on engaging with other organisations and supports forming and maintaining partnerships with other organisations to improve the provision of palliative care. The ELDAC Home Care Toolkit and Residential Aged Care Toolkit provide information and resources to support healthcare workers and care providers working in these settings to deliver comprehensive palliative care and advance care planning for clients, residents and their families. Within each section of the toolkits you will find information, 'how to' guides, tools and forms, and carer resources.
Many patients receiving palliative care have complex care arrangements involving multiple providers. This may result in risks to the care that a patient receives due to:
- fragmented decision-making,
- limited, absent or delayed communication or miscommunication between clinicians,
- increased patient burden and cost associated with multiple appointments, various clinicians and settings of care, and information systems that are not integrated,
- confusion for patients and their families or carers, particularly about who to contact in an emergency, which can lead to inappropriate and unwanted treatment.
It is important that these risks are minimised through appropriate care processes and arrangements. Clarification of the care processes for each patient is therefore critical, including who has responsibility for:
- maintaining prescriptions for palliative medications,
- reviewing symptoms and assessing care needs,
- ensuring availability of home visits for patients who are no longer able to attend a primary care practice,
- writing a death certificate if the patient plans to die at home.
As patients receiving palliative care often have complex care arrangements, with various care providers, it is likely that patient information will need to be shared. It is important that the appropriate information is provided in a timely manner to reduce the risk of receiving inappropriate treatment. It is good practice to plan ahead for these situations, particularly around emergency care or when receiving care from a new provider, for example:
- in a crisis when an ambulance has been called,
- on presentation to an emergency department or hospital,
- when referring to, or accessing care from new providers or services,
- when the patient is travelling away from a local area or care facility.
Strategies can be employed to share patient information when necessary to improve the quality and safety of care, and reduce unwanted, unnecessary or inappropriate interventions, examples include using:
- My Health Record a patient-controlled secure online summary of health information. This is particularly valuable for patients who accessing care in multiple care settings or with various providers, or whose clinical situation is complex or is changing,
- patient-held paper records such as health summaries and medication lists,
- advance care documents or plans, describing who the person’s substitute decision maker is, what the patient’s wishes are for treatment and who to contact in an emergency. This information should be shared with treating health professionals, carried by the patient, and also uploaded to the patient’s My Health Record,
- case conferences / family meetings involving those in the patient’s care team, and the patient, family and carer,
- ambulance service / paramedic palliative care plans. Protocols exist in the ambulance services of several states to allow paramedics to respond in a crisis, delivering medications as per authorised treatment plans, without the requirement to transport a patient to hospital. These care plans generally require formal approval from the ambulance or paramedic service. Where such arrangements do not exist, consider providing a written plan of care. Examples may include the patient’s advance care plan around desire for CPR or transport to an emergency department.
Case conferences or family meetings are held between the patient (if appropriate), their family/carers and/or their substitute decision maker, and members of their primary care teams, and where necessary specialist clinical care teams (for example, general practitioner, practice nurse, allied health, specialist palliative care practitioner, etc). The aim of case conferences may vary, but include to discuss issues and concerns, review care needs and care plan, identify goals and plan for future care. Case conferences can assist with communication between the patient, family/carers/substitute decision-makers, primary health care team and specialist care.
CareSearch Case conference resource guide (196kb pdf)
Albury Wodonga Regional GP Network
This resource guide was developed to assist GPs who wish to organise or participate in case conferences for patients with complex needs.
Multidisciplinary case conference medicare items for GPs
Department of Health and Aged Care
This factsheet provides information on how health professionals may meet to discuss, plan, coordinate or make arrangements on behalf of a patient. It provides information about GPs using the case conference Medicare Benefit Schedule items to organise and coordinate, or to participate in, a meeting or discussion held to ensure that their patient’s multidisciplinary care needs using a planned and coordinated approach.
Working with families
This webpage provides factsheets and resources on working with families.
Coordinating palliative care
This webpage provides information and resources on care coordination in palliative care.