Care coordination

Managing care across different providers and sites of care

What it is

People with a life-limiting illness can have complex needs and may receive care from different health professionals and services. Managing and attending appointments in different settings of care and with different care providers may be difficult for the person, their family and carers, and care may seem disjointed.

Having clear care processes is helpful. This can include who has responsibility for:

• maintaining prescriptions for palliative medications
• regularly reviewing the person’s symptoms and assessing their care arrangements
• being contacted in the case of an emergency
• home visits for a person who is cared for at home and no longer able to attend a GP clinic
• writing a death certificate for an at-home death.

Why it matters

When palliative care patients are treated in an emergency, they may be at risk of receiving inappropriate or unwanted treatment. This risk may be reduced through planning.

The ACSQHC comprehensive care standard for end-of-life care (1.87MB pdf) includes teamwork and coordination of care as essential elements. Care coordination in support of this requires:

• multidisciplinary collaboration and teamwork
• clearly defined roles and responsibilities of each clinician working in a team
• use of communication tools e.g. ISBAR, My Health Record,
• use and documentation of referral criteria and processes.

In practice

The following documents can help with coordination to improve the quality and safety of care, and reduce unnecessary interventions:

• My Health Record
• Patient-held paper records e.g. health summaries, symptom diaries, and medication lists (838kb pdf) or contact information (604kb pdf)
• Written advance care plans,
• Case conferencing face-to-face or via teleconference, are useful to plan and document shared care, and negotiate care arrangements
  
• Palliative care protocols for ambulance services e.g. SA and NSW. Where such arrangements do not exist, a written plan of care for the ambulance can relieve paramedics of the obligation to perform CPR on a palliative care patient who is actively dying, or to transport them to an emergency department.