Work Together
Working as a team means providing integrated care for the older person and their family and carers across settings of care. This will require sound relationships and cooperation across services, including home care, acute care, primary care and specialist palliative care. Working together is vital as it supports the quality and continuity of care for older people with end-of-life needs. Continuity of care means that:
- Relevant information is appropriately exchanged between involved providers of care.
- The preferences, values, and care needs of the older person are known, respected, and inform care.
- Care is coordinated smoothly and collaboratively.
Enabling palliative and end-of-life care at home depends on effective communication and relationships between formal providers, such as health professionals and care workers, as well as family and carers supports. [1]
Which people and services are essential to working together in home care?
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Family
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Home Care Providers, care workers
and clinicians
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Support at Home Care Partners
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Primary Care Providers
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Multidisciplinary Care
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Specialist Palliative Care Services
People identified by the person as family. This may include people who are biologically related, however it may not. Other people that may be identified as family include:
- those who joined the family through marriage or other relationships, such as kinship
- chosen family
- street family for those experiencing homelessness
- friends
- pets. [2]
Home care providers are organisations that provide Commonwealth-funded aged care services in the home. [3] These services are delivered by care workers and clinicians who provide different forms of support in the person’s home including personal care, domestic assistance, and clinical care. [3] Home care providers may be responsible for the overall case management of end-of-life care in the home.
Care management activities are delivered by a Support at Home provider through staff members known as care partners. [4] Care partners are critical to the delivery of quality care and services and monitoring changing care needs. It is important the care partner establishes a trusting relationship with the older person, their registered supporter, their family and carers to gain a full understanding of the supports required. [4]
Primary care providers include health services, health professionals and workers, such as GPS, community nurses, allied health and paramedics. They generally are the first service an older person with a life limiting illness may go to for health care, outside of a hospital or specialist. [2, p32]
Comprehensive care that is planned and delivered by health professionals across a range of disciplines. These professionals may be from the same or different organisations. They work together to address as many of the older person’s needs as possible. [5]
Multidisciplinary health care services with a focus on ongoing care and consultation for people with a life-limiting illness. This also includes supporting their family and carers. These services may provide care in inpatient settings, as well as through specialist community teams.
In general, specialist palliative care services are not directly involved in the care of people with uncomplicated needs related to their life-limiting illness. [2, p32] Access to specialist palliative care differs across Australia. The National Palliative Care Services Directory has information on accessing a specialist palliative care service.
The following strategies provide guidance about how to work effectively with older people, their families and carers, and across services and sectors of care.
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Improve clinical communication
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Coordinate care effectively
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Facilitate case conferences
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Resources for case conferences
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Develop partnerships
Clinical conversations and handovers should be clear, focused, and include the relevant information. Involve the older person when practical.
The ISBAR (52kb pdf) is a tool to improve clinical communication and can be customised to specific clinical contexts. The ISBAR is a mnemonic standing for:
- Identify/Introduction: Who you are and what is your role?
- Situation: What is going on with the older person?
- Background: What is the clinical background/context?
- Assessment: What do you think the problem is?
- Recommendation/Risks: What actions would you recommend and what are the risks?
Assign and accept responsibility for actions to be taken in a specific timeframe. End-of-life decision-making can be challenging for everyone involved in a person’s care, and sometimes disagreements can arise. The ELDAC End of Life Law Toolkit has information on managing disputes about medical treatment decision-making.
Coordination of quality care at the end of life is driven by:
- Clear, accurate, timely and respectful communication between all care workers and clinicians involved in the care of the older person, and with the person’s family, carers and other community supports. This includes reviewing care plans regularly and monitoring changing needs.
- Appropriate use of verbal and documented or written forms of communication, such as case conferences and electronic care records.
- Facilitating transitions between care settings.
- Clinicians and care workers with clear knowledge about who they can share information with, and what information should be recorded and reported.
Primary care professionals play an important role in home care. The ELDAC Primary Care Toolkit has resources for supporting Primary Care practitioners including information on funding options.
palliAGED offers more information on care coordination and downloadable Practice Tips on Talking within the Aged Care Team for Nurses (221kb pdf) and Careworkers (288kb pdf), and Continuity of Care for Nurses (225kb pdf) and Careworkers (337kb pdf).
Case conferences are one way to share information among involved clinicians and providers of home care. Having all workers and health professionals, the older person, and their family and carers ‘on the same page’ regarding care goals is important.
When an older person is receiving palliative or end-of-life care at home the GP often provides medical oversight. Convening a palliative care case conference when a person is nearing the end of life may include input from medical, nursing, allied health, and the older person where possible. Family and carers can assist with clarifying goals of care and care planning. Palliative care case conferences may also be repeated on an ‘as needs’ basis.
The following resources offer further guidance about how to facilitate and contribute to case conferences:
palliAGED has fillable forms and templates to assist in planning and holding Palliative Care Case Conferences with older people, their families and other clinicians or providers involved in the care. This flowsheet explains the process of using these forms, which are listed below.
Planning and Preparing for a Case Conference:
Information for GPs:
Information on how to Conduct a Case Conference:
- The ELDAC Linkages Toolkit 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 team members and may assist in how to better engage with them.
- Watch the ELDAC Work Together educational video to identify the components of multidisciplinary teamwork. The video assists in the understanding of using case conferences to plan care, regularly reassess needs and offer proactive palliative and end-of-life care.
- Listen to the ELDAC Podcast Episode 5: When to refer to specialist palliative care.
- Increase your skills and confidence by seeking advice more experienced colleagues or closely observing them as they facilitate a case conference or communicate with others involved in the care of older people at home.
- Review the ELDAC Case Study on Ravi to explore how members of the multidisciplinary team address the older person’s physical, social and occupational, psychological and spiritual needs, and work together to deliver high‑quality care.
Setting up the Health Care Team
CarerHelp
This webpage is downloadable as a factsheet and describes the main services that may be involved in managing the care of someone at the end of life.
Asking questions can help
Palliative Care Australia
This conversation checklist provides guidance about the kind of questions that may be useful to explore when seeing a palliative care team.
Support at Home program factsheets
Department of Health, Disability and Ageing
These factsheets cover in-home aged care services that are available through the Support at Home program including the End-of-Life Pathway.