||Input into clinical care is provided through regular scheduled communication between team members from a range of disciplines and services delivering palliative care and aged care.
- Improved symptom control
- Increased number of scheduled multidisciplinary interactions
- Improved communication between providers
- Sharing of information
- Increased number of shared care plans
- Increased confidence in partner organisations and their staff.
|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, agreed assessment tools, and Advance Care Plans.
- Improved continuity of care
- Increased possibility of meeting patient choices
- Established contact with local services
- Increased meetings arranged to create and maintain linkages
- Developed shared documentation
- Increased use of shared care plans
- Increased continuity of care
- Increased case conferencing and communication about care
- Increased use of technologies (i.e. telehealth and ehealth records)
- Provided consumer information
- Improved understanding by consumers.
|Formalised Agreements and Plans
||Formalising linkages through written agreements and governance arrangements can ensure discussion of and commitment to resource allocation, mutual responsibilities, agreed outcomes, and communication processes.
- Evidence of formal linkage partnerships established, including formal agreements (e.g. MOUs) and shared service plans
- Adequate allocation of resources to sustain linkage activity plan
- Evaluation service data to provide information for continuous improvement.
|Designated Linkage Worker
||Appointment of a key worker whose responsibility it is to act as a care and linkage coordinator across settings is seen to improve access to services, improve cooperation between services, improve continuity of care and promote shared understanding of the Linkage worker role.
- Improved communication across settings
- Shared understanding of the linkage worker role
- Increased confidence among linkage partners
- Improved continuity of care.
||Clarity of roles and responsibilities for each practitioner involved in the linkage partnership leads to improved continuity of care particularly when transitioning between settings of care.
- Improved understanding of roles and responsibilities of each partner service provider
- Improved communication about care
- Improved continuity of care.
|Knowledge Exchange and Upskilling
||Shared learning opportunities, both formal and informal, increase knowledge and develop capabilities in providing palliative care for older Australians.
- Improved knowledge, skills and confidence of service providers in providing palliative care to older Australians.
||Processes for continual review of linkage strategies and their outcomes enable identification of their effectiveness and efficiency.
- Evidence of strategy embedded into organisational quality processes (e.g. PCOC)
- Minimum data requirements collected and reported.