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Care Coordination

What we know

Continuity, coordination and transition of care are key domains for providing quality care to older adults at the end of life. Continuity refers to the exchange of knowledge between carers, the person and health professionals while care coordination is the alignment of care across providers and settings. Continuity of care and care coordination have significant impact on satisfaction and quality of life as well as reducing the number of acute care re-admissions. Both require that people and services have the capacity to adequately forward planning.

What can I do?

If a person’s health changes or deteriorates, you can signal that the documented goals of care may need to be reviewed.

When decisions need to be made about care, refer to the documented advance care plans, including advance care directives; it’s an advantage to all to have these documents easily accessible.

Clarify your role in the palliative care team and how you will stay ‘in the loop’ with care planning.

Identify the substitute decision-maker and the key family member; establish regular communication with them and notify them of important changes in health or to care.

Establish a list of relevant contact information so that the family and the members of the health team know how to contact the correct people.

If a person is moved to or from your care, ensure that letters and/or summaries are forwarded or received and that these are filed correctly.

When transfer does occur, ensure that beneficial treatments aren’t discontinued.

Suggest a comprehensive medication review which can be funded through Residential Medication Management Review (RMMR)  or Home Medicines Review (HMR).

Consider whether a case conference or a family meeting would be useful.
 

 

What can I learn?

Read Every Moment Counts: A new vision for coordinated care for people near the end of life calls for brave conversations (National Council for Palliative Care (UK)) which discusses what ‘good care’ looks like from the consumer perspective.

Watch How to Use the Residential Aged Care End of Life Care Pathway (RAC EoLCP) from the PA Toolkit.

Phillips J, Mandile M, Dover V, Dever M, Nelson C, Pirie H. Toolkit: Creating a Multidisciplinary Team Approach to Care Planning In Residential Aged Care Facilities (300kb pdf). Coffs Harbour: Mid North Coast Division of General Practice; 2006.

Check out the online learning modules:

from PCC4U from End-of-Life Essentials

 

What can my organisation do?

Use the suite of resources from The Palliative Care Outcomes Collaboration (PCOC) to support integration of palliative care into practice.

To define the palliative care team and roles within the team, the suggestions in the National Standards Assessment Program (NSAP) fact sheet (218kb) can be used.

Support regular meetings of the palliative care team to maintain a good level of communication between team members and with the family; helpful resources are:

Provide the capacity for advance care planning documents to be easily accessed and used in care planning and care coordination

 

Page updated 24 May 2017