Work Together

What does Work Together mean for palliative care?

Working together as a team means providing integrated care across all the services required to meet the needs of the older person at the centre of care. As the older persons condition changes, the composition of the team may change to reflect their evolving needs.

The professionals in the team may function under one organisational umbrella, or may be from a range of organisations brought together as a unique team. This can include services from acute, primary, specialist care, community, residential aged care, and specialist palliative care settings. You can see more about Service Partnering and Care Coordination to support integrated care in the Business and Practice Management section of this Primary Care Toolkit.

ELDAC has also developed Toolkits for health professionals providing care in Residential Aged Care and Home Care settings.

You can read more about what key aspects to consider when working together in the Work Together page of the ELDAC Care Model.

What is my role as a primary care professional in working together?

Primary care professionals are often the primary or ‘first contact’ of the older person with the health system to access or provide palliative care. While you may provide direct care, as described in the Provide Palliative Care section of this toolkit, it is likely that the substantive work of the primary care professional is not with the older person receiving palliative care.

Rather, coordinating the care team and sharing information to ensure appropriate and high-quality care is delivered may comprise the majority of your work.

We want you to be equipped to:

• Understand your roles and responsibilities as a primary care professional within a multidisciplinary team.
• Coordinate care of the older person effectively, including defining roles and responsibilities within the team, mapping care arrangements, and communicating changes in a timely manner. This includes working with the older person and their families and carer as part of the care team, through mechanisms like case conferences.
• Appropriately store and share information on the older person and their care arrangements between members of the care team.
• Support the older person, their families and carer in understanding roles within the care team and how to navigate between services and providers.