Plan – Identifying and Preparing

How do you currently assess your palliative care and advance care planning processes and outcomes?

How do you identify areas for improvement in the delivery of this care?

A gap analysis will help you identify areas for improvement in your delivery of quality palliative care and advance care planning. A gap analysis asks you to compare your current level of performance with a desired level of performance. Your desired level of performance may be to meet accreditation guidelines, national palliative care standards, or an internal continuous improvement target.

Desired outcomes in delivering quality palliative care include: 1) improved quality of care for aged care recipients; 2) reduction of unnecessary hospital admissions from residential aged and home care providers; and 3) reduction in length of hospital stays for palliative care admissions from residential aged care facilities and home care providers.

ELDAC has developed a palliative care framework identifying key processes facilitating quality palliative care. These processes include:

• Discussing advance care planning
• Recognising end of life
• Assessing end of life needs
• Developing an end of life care plan
• Working together across services and professional groups
• Responding to deterioration
• Managing dying
• Supporting bereavement

Investigate your current level of performance, including palliative care outcomes and processes – as identified above. You may elect to use a simple measure or a tool to provide a baseline.

A simple measure may include:

• a count or tally (e.g. the number of palliative care educational sessions for staff in a year)
• a proportion (e.g. the percentage of residents/clients/patients with an advance care directive or plan)
• a rating (e.g. family satisfaction rated on a scale from 1-10).

Data collected from multiple individuals can be averaged (e.g. the average family satisfaction score).

You may also elect to utilise a tool. ELDAC recommends two tools to assist you to identify areas for improvement:

The ELDAC After Death Audit (Residential version) or After Death or Discharge Audit (Community version) are tools to measure the quality of care provided to an individual at the end of life. Outcomes measured in the after death audit include hospitalisations in the last week of life, place of death, and compliance with the individual’s end of life wishes. The After Death Audit can also be used to assess your use of key palliative care processes, including advance care planning and the development of end of life care plans.

The ELDAC After Death Audit has been updated and the new Version 2 is now available. The content has been streamlined and reflects the feedback received from Phase 1 of ELDAC. For access to the After Death Audit tools that can be used in either residential or community care settings, click download link below.

(This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

>> Download the updated Version 2 ELDAC After Death Audit for Residential Aged Care (653kb pdf) 

>> Download the updated Version 2 ELDAC After Death Audit for Home Care (636kb pdf)

The ELDAC Organisational Audit provides a snapshot of your organisations’ structural commitment to quality palliative care and advance care planning. It allows you to measure your organisations’ performance in the following areas: clinical care, education and workforce development, policies and procedures, information systems, and quality improvement. This analysis will help you to identify how working together with other aged, primary and palliative care services can improve palliative care and advance care planning in your service.

The ELDAC Organisational Audit has been revised to address the learnings from Phase 1 of ELDAC and to align with the Aged Care Quality Standards. Version 2 is now available. For a sample Organisational Audit template, click download link below.

(This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

>> Download the updated Version 2 ELDAC Advance Care Planning and Palliative Care Organisational Audit for Residential Aged Care (846kb pdf) 

>> Download the updated Version 2 ELDAC Advance Care Planning and Palliative Care Organisational Audit for Home Care (848kb pdf) 

The following advance care planning audit tool and supporting resources will assist with identifying current practices and areas for improvement.

Personal Learning Assessment

To assist in identifying your staff's learning and development needs and to give an indication of the priority learning areas for your organisation, please utilise the ELDAC Personal Leaning Assessment and ELDAC Personal Learning Plan.

There are two sections to the assessment:

• Section 1: Knowledge of palliative care and advance care planning
• Section 2: Skills and confidence in providing palliative care and advance care planning

It is recommended that your staff complete this process annually as their learning and development needs may change.

>>Download ELDAC Personal Learning Assessment Form (356kb pdf)

>>Download ELDAC Personal Learning Plan Form (1096kb pdf)

Comparison of your palliative care and advance care planning performance to national standards and frameworks can also inform your Gap Analysis (see below).

Identifying areas for improvement in your provision of palliative care and advance care planning will assist you to determine the advantages of potential partnerships.

What could partnerships bring to your organisation’s palliative care delivery?

Activities:

Conducting a SWOT analysis can assist you in identifying the advantages and disadvantages in partnering. It asks you to identify:

• Strengths: What does our service do well in terms of palliative care and advance care planning?
• Weaknesses: What aspects do not work so well?
• Opportunities: Would partnering with other providers help our service overcome our weaknesses and build on our strengths?
• Threats: Are there any constraints or threats we need to consider in a potential partnership?

An alternative to the SWOT is an SBAR analysis:

• Situation: What is happening at the present time, within our service, in relation to palliative care and advance care planning?

• Background: What are the circumstances leading up to this situation?
• Assessment: What do I think the problem is?
• Recommendation: What should we do to improve the provision of palliative care and advance care planning for older people under our care?

Now that you have decided to investigate partnering, it is time to give further consideration to who these partners might be. Give serious consideration to potential palliative care partners from the aged care, primary care, acute care, and specialist palliative care sectors. These steps will guide you through this decision making.

Service mapping

A Service Mapping exercise can assist you in:

• identifying all the providers, resources and treatment options in the delivery of palliative care and advance care planning to older persons in your service and local area
• identifying the contributions that various service providers make to providing palliative care and advance care planning
• increasing your knowledge of existing referral and treatment options
• identifying gaps, overlaps and barriers in accessing existing services

Potential partners could include:

• specialist palliative care services
• aged care services (residential and community)
• acute health services (hospitals)
• ambulance service
• primary care providers (General Practitioners)
• pharmacists
• allied health professionals (e.g. social workers, occupational therapists, speech pathologists, physiotherapists)
• the local Primary Health Network (PHN).

Consider connecting with service providers that can bring additional expertise to meet your client’s needs in palliative care and advance care planning.

The following service directories can assist you to complete a comprehensive service mapping exercise:

• Find a health service or health professional – including general practices, hospitals, pharmacies, allied health.
• Primary Health Networks (PHN)
• Aged care providers
• Specialist Palliative Care Services

Conduct an exploratory meeting with potential partners

Conduct preliminary discussions with potential partners about opportunities and gaps for improving palliative care and advance care planning for older people. Focus on identifying mutual benefits of working together.

An exploratory meeting with potential partners allows you to investigate opportunities for working together with a range of aged and palliative care service providers, setting the stage for a new collaborative approach to palliative care delivery.

Key aims of an exploratory meeting include:

• Defining the advance care planning and/or palliative care issues the partnership will address;
• Discuss the individual interests of each partner;
• Determining if partnerships will add value; and
• Identifying how the partnership would work in order to provide coordinated palliative care.²

Conduct a resource mapping activity

This step enables each partner to consider what they can contribute to your palliative care and advance care planning action plan.

• Think about “resources” in its broadest context (e.g., staff time, knowledge and expertise, competencies, equipment, products, networks, influence, and cash are all considered valuable commodities in a partnership).⁶
• Undertake a Resource Mapping exercise in a workshop format to generate discussion. ^{6 7}
• Document resource commitments in a written document signed by each partner.

Developing a resource plan assists in clarifying roles and potential contributions from each of the partners.

Decide whether or not to partner

At this stage, you have collected information on each potential partner, including a partner’s individual interests in palliative care and resource availability. Your goal now is to align your interests and objectives for the partnership in relation to providing palliative care. You need to identify the “why” – “why should we partner?” Consider any mutual benefits in partnering.

Activity:

Ask partners to write individual interests and objectives in separate circles. Merge the circles and look for areas of overlap.

Develop a shared vision for the partnership. Such a statement is a powerful beacon guiding the partnership team in improving palliative care and advance care planning for older people.

Utilise a Systems Mapping process to plan how you might work together.

Activity:

View an example of how to facilitate a Systems Mapping process. The activity is outlined on p.31 of the document.

For an example of a process to follow to make your decision

Build the partnership relationship

Enable participants to see the possibilities through partnership as “stronger together”.

Activity: Share examples of successful partnerships in delivering palliative care for older people, learnings and outcomes. For examples of successful partnerships between aged and palliative care service providers (1402kb pdf).

Develop a partnering agreement

A partnering agreement formalises the decisions reached in the exploratory meeting. Formalising your partnering agreement in a written document facilitates shared understanding and steps partners through a list of essential project decisions. As alternatives to a formalised partnering agreement, you may prefer utilising a letter of intent, terms of reference, or a memorandum of understanding (MOU) if these approaches are more acceptable to you.

Establish governance structures and roles

Partnerships have two arms of responsibility:

1. A strategic or governance arm; and
2. An operational arm. ⁵

The governance arm is responsible for effective decision-making, planning and management, ⁷

and:

• provides guidance and support to the operational arm ⁵
• responds to partner grievances and project obstacles
• includes service managers, senior clinical staff, and key stakeholders (such as aged care peak body representatives and service users).

From: www.goodgovernance.org.au

The operational arm is responsible for delivering project outputs and outcomes ⁵.

If your partnership team is small, members can take on both governance and operational roles.

Developing a mutually agreeable action plan, risk plan and communication plan can increase the success of your palliative care and advance care planning initiatives.

Develop an action plan

An action plan transforms your palliative care and advance care planning objectives into concrete steps or actions. It is the “who, what, how and when” document. To develop your actions:

• Undertake a brainstorming activity with your partners ⁶
• Remind the group of your shared objectives in relation to palliative care ⁹
• Break objectives into activities (What will you do to achieve the objective? e.g. conduct a palliative care case conference) ⁹
• Break activities into actions (What tasks are required to implement the activity? e.g. develop a policy document, develop a case conference template, contact GPs regarding possible involvement) ⁹
• Utilise results from your resource mapping activity to allocate resources to each activity/action. ⁹
• Consider the order of the activities and actions (In which order should activities/actions be performed? Are some activities/actions dependent on the completion of other activities/actions? Are some activities/actions quite lengthy requiring an earlier start date?)⁹

For each action, record:

• A start and end date ⁹
• Resources required (Are any capacity building initiatives required?) ⁹
• Person responsible for completing the action ⁹
• An evaluation strategy for your palliative care initiative (How will you know your work has been effective?) Earlier we discussed options to use a simple measure or tool. You may wish to revisit this section to consider your evaluation options ⁹.

Remember to obtain management approval for the plan. ⁹ Widely distribute the action plan for comment. ⁹

Develop a risk plan

Think about the possible risks or consequences associated with making your palliative care or advance care planning changes. The aged care sector has many recognised challenges (e.g. high staff turnover, lack of resources, frequently changing policies).

Also consider:

• Workplace health and safety issues ⁹
• The likelihood of the risk
• What impact it would have on the project if it does occur? Give particular attention to risks that have both a high likelihood and impact.
• What actions you can take to reduce or address the risk ¹⁰.

Develop a communication plan

Think about what information needs to be shared and with whom. Consider the best medium for communicating with a particular target group. Consider appropriate methods for internal (between the partnership team members) and external communications ⁵.