Clinical Support & Management
Direct care delivery has been one aspect of the program that has seen the development of resources that can be used for clinical support, and to provide information for patients, carers and families. Work undertaken within each of the projects has been achieved in collaboration with other disciplines and organisations, as well as the wider community. Examples from within the collective experience and practice of the rural palliative care projects are included here. The relevant tools and templates developed are also included.
Some examples of the resources developed for patients, carers and families are provided here . They are intended to provide assistance to those who are seeking to develop similar information and resources applicable to their own area of practice.
Patients often have to communicate their health history and current information to new health professionals. A Patient Held Record (PHR) can help with this, facilitating communication between patients and health professionals, and between primary and secondary care. PHR’s are also available in out of hours situations. Utilising electronic records and electronic communication is also discussed here, including discharge summaries, referrals and secure messaging and Palliative Care Software.
Multidisciplinary team meetings are seen as a way to tackle fragmentation of care, ensuring the smooth transition between services, as a vehicle for education, a means to widen skills, and a way of investigating options for improved service and care delivery. Case conferencing, care planning and team care arrangements can take place within these forums, with teleconferencing opportunities if distance and time do not allow attendance in more rural areas.
In line with PCA’s (Palliative Care Australia) framework for Palliative Care Services Planning, it is important to identify pathways via their developed collaborations and communities of practice. For those divisions with specialist palliative care services collaboration and linkages are essential. For those without these services divisions will need to identify the gaps in service delivery and address how they might be filled. A key element is the palliative care link nurse. These nurses are representatives with a particular interest and a specific skill set in palliative care. They act as the link between various agencies or within their own organisation.
