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