Working as a team means providing integrated care across services - acute, primary, residential aged care and specialist palliative 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).”3(p36)
What is a Multidisciplinary Team?
“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. (A discipline is a branch of knowledge within the health system).”3(p36)
Who is a 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 general practitioners, community nurses, 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.”3(p37)
What is a Specialist Palliative Care Service?
“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.”3(p37)
Access to specialist palliative care services differs across Australia. For information about accessing a specialist palliative care service, you can use the Palliative Care Australia Service Directory.
PalliAGED has a webpage with resources on care coordination to provide the best palliative care and forward planning and downloadable Practice Tips on Talking within the Aged Care Team for Nurses (pdf 314kb) and Careworkers (pdf 416kb) and Continuity of Care for Nurses (pdf 368kb) and Careworkers (pdf 437kb).
The ELDAC Working Together Toolkit is a resource that contains useful information on forming or maintaining partnerships with external organisations. The ELDAC Primary Care Toolkit has resources to assist primary care providers and their staff and may assist in how to better engage with them.
Having all health professionals, the client, and the family ‘all on the same page’ regarding care goals is important. For people receiving care at home, normally the GP provides medical oversight of the person. In some instances, Nurse Practitioners may also be involved in a client’s care.
Convening a family meeting/palliative care case conference when a person is at end of life will include input from medical, nursing, allied health, chaplaincy, and the client where possible. The Albury Wodonga Regional GP Network has a resource guide (196kb pdf) that assists GPs who wish to organise or participate in family meetings/case conferences for patients with complex needs. This resource guide also includes a case conference template.
CareSearch has factsheets and other resources available on working with families and communicating well.
Family are considered an essential part of the working team and it is important for them to understand that the care of their loved one requires a team effort of several professionals in order to provide optimum care.
At least one family member should be asked to attend the client’s palliative care family meeting/case conference to assist in the care plan process. Carers NSW has a factsheet on how and why to hold a family meeting/case conference (56kb pdf).