Action 5.4

The health service organisation has systems for comprehensive care that:

a. Support clinicians to develop, document and communicate comprehensive plans for patients’ care and treatment

b. Provide care to patients in the setting that best meets their clinical needs

c. Ensure timely referral of patients with specialist healthcare needs to relevant services

d. Identify, at all times, the clinician with overall accountability for a patient’s care

Intent

The health service organisation provides systems to enable and support the delivery of comprehensive care to patients.

Reflective questions

What systems and processes are in place to support clinicians to communicate, deliver and document comprehensive care in the setting that best meets patients’ needs?

What systems and processes are in place to ensure the timely referral of patients to relevant services?

What systems and processes are used to identify the clinician with overall responsibility for the patient? How is this communicated to the patient and the team?

Key tasks

  • Work with clinicians and consumers to design and implement systems for developing, documenting and communicating comprehensive care plans.

  • Implement systems to ensure that patients receive care in the setting that best meets their clinical needs.

  • Work with internal and external services to implement timely referral processes.

  • Develop processes for ensuring that the clinician with overall accountability for a patient’s care is identifiable at all times.

Strategies for improvement

Hospitals

Processes for delivering comprehensive care will vary, even within a health service organisation. Take a flexible approach to standardisation so that safety and quality systems can support implementation and innovation at the ward, unit or service level. This may involve developing new models of care in some services or for some patient groups. Work with clinical groups to help them to systematically review their own processes, practices and workflow, to find out how to best implement comprehensive care in their local context.

Design processes to develop, document and communicate comprehensive care plans

Comprehensive care plans are different from traditional nursing care plans or medical treatment plans because they require the expertise of each clinician group to be brought together to coordinate and progress a patient’s care and reach agreed goals. This means that clinical and consumer groups should be involved in agreements about:

  • The minimum expectations for the content of comprehensive care plans
  • Further expectations for comprehensive care planning in specific settings or services, or for specific patient populations (for example, children, older adults, elective and emergency admissions, Aboriginal and Torres Strait Islander people)
  • Triggers for review of comprehensive care plans
  • Roles and responsibilities for developing comprehensive care plans
  • Processes for supporting shared decision making with patients, carers and families (see Actions 2.6 and 2.7)
  • Templates for documenting comprehensive care plans
  • Processes for communicating the content of the plan (see Actions 6.4, and 6.7-6.10).

Comprehensive care plans should be developed in partnership with patients, carers and families, and with input from all the clinicians involved in a patient’s care (for example, doctors, nurses, pharmacists, allied health clinicians). Organisational requirements for developing comprehensive care plans should reflect the complexity of the service’s patients, and may differ between settings and services. For example, a comprehensive care plan for a patient receiving outpatient dialysis might be detailed and complex, but will be used to guide many episodes of care. In contrast, a comprehensive care plan for a patient having elective surgery might be simple and narrowly focused, but will be used for a single, brief episode of care.

Standardised templates can assist clinicians in the goal-setting and comprehensive care planning process, particularly when patients have complex needs.1,2 Work with clinical groups to agree on the content and use of documents and electronic systems for comprehensive care planning. An overall structure for comprehensive care plans may meet patient needs across the organisation, or specific comprehensive care planning documents may be developed for different services and patient groups.

One example of a standardised template for comprehensive care planning is a clinical pathway for the management of a specific intervention. Clinical pathways can be simple or complex, depending on the nature of the intervention. Care pathways can improve outcomes for patients, and improve collaboration and teamwork between different professional groups.3 However, clinical pathways alone may not meet the needs of patients with complex or multiple health problems.

Clinical pathways should include the capacity to document patients’ preferences and goals, and individualise aspects of care as required. Develop and implement alternative comprehensive care planning strategies and tools for patients who are having an intervention that is normally managed using a care pathway, but whose care needs cannot be fully addressed with usual care (for example, patients with complex or undetermined conditions, or patients who are receiving concurrent care from multiple medical teams). Some state and territory health departments have developed and endorsed clinical pathways for particular patients, which health service organisations may wish to refer to.

Develop processes to ensure that patients receive care in the setting that best meets their needs

Hospital patient flow is a complex, organisation-wide issue that affects the workforce at all levels. When patient flow processes are suboptimal, the timeliness, safety and quality of patient care can be compromised. Outlying patients can experience higher rates of medical emergency calls, increased in-hospital mortality, increased length of stay and poorer outcomes.4-7 Multiple bed moves within an admission can increase the risk of complications such as delirium, and can contribute to poor patient experiences.8-11 Although patient flow affects clinical care, clinical care also affects patient flow. Poorly coordinated, disconnected and reactive care planning can compromise patient flow through the hospital and timely hospital discharge.12,13

Develop a patient flow process that is person centred and focused on placing patients in the right bed the first time. This may involve analysing and redesigning multiple processes across the organisation (for example, admission and discharge processes, bed-cleaning processes, comprehensive care planning and delivery processes, and elective and emergency surgery activity). Use data to evaluate the performance of existing processes and to inform collaborative improvement work with professional specialties and consumer representatives.

As a minimum, develop:

  • Clear and transparent patient flow processes that enable everyone to understand their responsibilities in relation to patient flow
  • Detailed descriptions of the roles and responsibilities for nurse managers and rostered in-charge nurses, departmental heads, after-hours managers and other key participants in the patient flow process
  • Processes for flagging patients with clinical priorities or preferences that need urgent or special consideration
  • A clear structure for escalation of, and response to, patient flow issues
  • Proactive discharge planning processes (for example, criteria-led discharge) that include capacity for early recognition of potentially complex patient discharges, and allow timely planning and coordination activities
  • A clear structure for accountabilities in relation to patient flow.

The New South Wales (NSW) Ministry of Health has developed An Evidence-Based Review and Training Resource on Smooth Patient Flow13, a resource for making improvements in patient flow.

Also consider alternative models for acute care that may suit the needs of people with complex care needs, such as:

  • Hospital in the Home, which may enable people with complex care needs to leave hospital earlier and return to familiar surroundings with therapeutic support14
  • Specialist geriatric outreach services to aged care homes, which provide rapid access to acute medical and nursing care for older people experiencing rapid decline, and can reduce avoidable hospital presentations and support the person’s choice for treatment.15

Establish referral processes

Referring clinicians, and specialist clinicians and services need to work collaboratively to set clear referral criteria. Provide accessible guidance about referral processes to different services that outlines the:

  • Clinical or other criteria for referral (for example, persistent cognitive impairment caused by unresolved delirium or undiagnosed dementia)
  • Process for making the referral (for example, referring to the service or to a particular clinician, by phone or email)
  • Processes for expediting urgent referrals
  • Availability of different services (for example, after hours)
  • Expected response time
  • Follow-up and escalation process for delayed response to a referral.

Standardise aspects of the referral process (such as required documentation) as much as possible, and develop processes for routine referrals for certain patient groups (for example, physiotherapy for postoperative patients).

Work with external services to identify referral processes to support ongoing comprehensive care.

These might include processes for:

  • Safe return to rural or remote health services
  • Transfer to subacute facilities
  • Referral for ongoing care in the community
  • Referral for follow-up of specific clinical or other issues
  • Referral to services provided by credentialed clinicians in the private sector (for example, physiotherapists, occupational therapists, dietitians, counsellors).

Set up processes for identifying the clinician with overall accountability

Although all clinicians are accountable for the care they provide to patients, the clinician carrying overall accountability for an individual patient’s care should have the seniority to make time-sensitive or complex clinical decisions. The clinician who has overall accountability should also be accessible and available so that they can lead and coordinate comprehensive care planning and delivery. Confusion about which clinician has overall accountability for a patient’s care can lead to communication issues and delays in clinical decision-making.16,17

It is a requirement in the Medical Board of Australia’s Code of Conduct that doctors ensure ‘that it is clear to the patient, the family and colleagues who has ultimate responsibility for coordinating the care of the patient’.18 This can be challenging in the hospital context, and identifying which clinician has overall accountability for a patient’s care at any given time can be complex.

Overall accountability for a patient’s care may be handed over between several clinicians (including doctors, nurse practitioners, midwives and allied health clinicians) during a 24-hour period, and during the course of a patient’s admission. On-call or locum clinicians may carry overall accountability for a patient’s care at different times. Further complexity can be added when care is shared between teams (for example, in orthogeriatrics) or when multiple teams are involved in a patient’s care (for example, patients with multiple chronic organ diseases, maternity patients with pre-existing medical conditions, children with complex medical conditions).

Work with clinical teams to develop consistent and up-to-date processes for identifying the clinician with accountability for individual patients’ care at any time of the day or night. A systematic and predictable process is required so that permanent, temporary, locum and agency clinicians can identify the correct clinician, and so that inconsistencies are not driven by variation in the time of day, the day of the week or the personalities involved.

Develop guidance about:

  • The roles and responsibilities of on-call and locum clinicians
  • Processes for managing circumstances when the clinician with accountability for a patient’s care is not available
  • Orientation of new, agency or locum clinicians to the process for identifying who has overall accountability for a patient’s care
  • How unexpected absences or last-minute changes to rosters will be communicated and managed when these affect the identification of the clinician with overall accountability for a patient’s care.
Day Procedure Services

Given the short length of stay for most patients using day procedure services, the requirements for this action may be achieved through robust by-laws setting out:

  • The responsibilities of all clinicians, including referring clinicians, in relation to patient care
  • Pre-admission screening and assessment processes that identify individual care needs and clinical risks, which lead to appropriate planning.

For example, pre-admission screening and assessment processes may identify that a patient is at risk of falls and has a new diagnosis of cognitive impairment. This would require a plan to manage these issues during the episode of care, and ensure that the referring clinician refers the patient to other services (for example, general practitioner) for further investigation and management of their cognitive impairment.

Design systems to develop, document and communicate comprehensive care plans and processes to ensure that patients receive care that best meets their needs

In the day procedure setting, a comprehensive care plan is likely to be brief and focused on the care required for a specific procedure. Strategies for managing specific care needs or clinical risks should be documented as part of the pre-admission assessment process. For example, a patient with falls risk and cognitive impairment (as described above) may need to leave their shoes on to reduce the risk of falls, and have their carer present throughout the procedure to reduce anxiety.

An example of a standardised template for comprehensive care planning is a clinical pathway for management of a specific procedure. If the day procedure service uses clinical pathways, these must include the capacity to individualise aspects of care, as required.

Set up systems for identifying the clinician with overall accountability

Although all clinicians are accountable for the care they provide to patients, the clinician carrying overall accountability for an individual patient’s care must have the seniority to make time-sensitive or complex clinical decisions. Confusion about which clinician has overall accountability for a patient’s care can lead to communication issues and delays in clinical decision-making.16,17 Ensure that by-laws identify who carries overall accountability for a patient’s care when more than one specialist is involved.

Develop guidance about:

  • The roles and responsibilities of the clinician with overall accountability for a patient’s care
  • Processes for managing circumstances when the clinician with accountability for a patient’s care is not available
  • Orientation of new, agency or locum clinicians to the process for identifying who has overall accountability for a patient’s care

Examples of evidence

Select only examples currently in use:

  • Policy documents or by-laws that outline processes for
    • pre-admission screening, shared decision making and goal-setting with patients, and triggers for review of comprehensive care plans
    • managing patient flow, including flagging patients with clinical priorities that need urgent or special consideration
    • referral to other services, including clinical or other criteria for referral
    • determining and transferring accountability for a patient’s care
  • Observation of clinicians’ practice that demonstrates use of the health service organisation’s processes for comprehensive care
  • Records of interviews with clinicians that demonstrate that they understand the health service organisation’s processes for comprehensive care
  • Roles and responsibilities for the workforce and referring clinicians
  • Training documents about
    • shared decision making and goal-setting
    • screening and clinical assessment processes for comprehensive care
    • multidisciplinary teamwork and collaboration
    • delivering comprehensive care, including at the end of life
    • strategies for minimising risks of harm
  • Committee and meeting records in which the placement of populations of patients in settings appropriate to their clinical needs was discussed
  • Examples of improvement activities that have been implemented and evaluated to better match patients’ care settings to their clinical needs
  • Memorandums of understanding or other agreements with external organisations that outline services for transfer of patients
  • Communication with the workforce that provides guidance about referral processes to different services
  • Audit results of healthcare records for documented accountability for patient care
  • Standardised referral tools and processes, including documented referral criteria for specialist services within the organisation and in the community
  • Feedback from patients and carers about whether they can identify the clinician with overall responsibility for the patient.
MPS & Small Hospitals

Processes for delivering comprehensive care will vary, even within a health service organisation. To introduce and use effective comprehensive care systems, MPSs and small hospitals will need to:

  • Work with clinicians and consumers to design and implement systems for developing, documenting and communicating comprehensive care plans
  • Implement systems to ensure that patients receive care in the setting that best meets their clinical needs
  • Work with internal and external services to implement timely referral processes
  • Develop processes for ensuring that the clinician with overall accountability for a patient’s care is identifiable at all times.

Design processes to develop, document and communicate comprehensive care plans

Comprehensive care plans are different from traditional nursing care plans or medical treatment plans because they require the expertise of each clinician group to be brought together to coordinate and progress a patient’s care and reach agreed goals. This means that clinical and consumer groups should be involved in agreements about:

  • The minimum expectations for the content of comprehensive care plans
  • Further expectations for comprehensive care planning in specific settings or services, or for specific patient populations (for example, children, older adults, elective and emergency admissions, Aboriginal and Torres Strait Islander people)
  • Triggers for review of comprehensive care plans
  • Roles and responsibilities for developing comprehensive care plans
  • Processes for supporting shared decision making with patients, carers and families (see Action 2.6 and 2.7)
  • Templates for documenting comprehensive care plans
  • Processes for communicating the content of the plan (see Action 6.4, and 6.7-6.10).

Comprehensive care plans should be developed in partnership with patients, carers and families, and with input from all the clinicians involved in a patient’s care (for example, doctors, nurses, pharmacists, allied health clinicians). Organisational requirements for developing comprehensive care plans should reflect the complexity of the service’s patients, and may differ between settings and services. For example, a comprehensive care plan for a patient receiving outpatient dialysis might be detailed and complex, but will be used to guide many episodes of care. In contrast, a comprehensive care plan for a patient admitted via the emergency department with an acute illness might be more narrowly focused, and require more frequent review and updating.

Standardised templates can assist clinicians in the goal-setting and comprehensive care planning process, especially when patients have complex needs.1,2 Work with clinical groups to agree on the content and use of documents and electronic systems for comprehensive care planning. An overall structure for comprehensive care plans may meet patient needs across the organisation, or specific comprehensive care planning documents may be developed for different services and patient groups. These documents may be available from the Local Hospital Network, state or territory health department or nearby larger hospitals.

One example of a standardised template for comprehensive care planning is a clinical pathway for the management of a specific intervention. Clinical pathways can be simple or complex, depending on the nature of the intervention. Care pathways can improve outcomes for patients, and improve collaboration and teamwork between different professional groups.3 However, clinical pathways alone may not meet the needs of patients with complex or multiple health problems.

Clinical pathways should include the capacity to document patients’ preferences and goals, and individualise aspects of care as required. Develop and implement alternative comprehensive care planning strategies and tools for patients who are having an intervention that is normally managed using a care pathway, but whose care needs cannot be fully addressed with usual care (for example, patients with complex or undetermined conditions, or patients who are receiving concurrent care from multiple medical teams). Some state and territory health departments have developed and endorsed clinical pathways for particular patients, which health service organisations may wish to refer to.

Develop processes to ensure that patients receive care in the setting that best meets their needs

Develop processes to ensure that patients who have healthcare risks or needs that cannot be managed in-house are referred to an alternative setting for care. Develop a patient flow process that is person centred and focused on placing patients in the right bed the first time. This relies on developing effective working relationships with external health services such as ambulance and retrieval services, tertiary referral hospitals and local community services.

As a minimum, develop:

  • Processes for flagging patients with clinical priorities or preferences that need urgent or special consideration
  • A clear structure for escalation of, and response to, patient flow issues
  • Proactive discharge planning processes (such as criteria-led discharge) that include capacity for early recognition of potentially complex patient discharges, and allow timely planning and coordination activities
  • A clear structure for accountabilities in relation to patient flow.

In an MPS, these processes may include transition of care for a resident within the facility. The NSW Agency for Clinical Innovation’s Living Well in a MPS Collaborative has resources to support staff providing individualised care for residents of MPSs as people living in their home.

Establish referral processes

Referring clinicians, and specialist clinicians and services need to work collaboratively to set clear referral criteria. Provide accessible guidance about referral processes to different services that outlines the:

  • Clinical or other criteria for referral (for example, persistent cognitive impairment caused by unresolved delirium or undiagnosed dementia)
  • Process for making the referral (for example, referring to the service or to a particular clinician, by phone or email)
  • Processes for expediting urgent referrals
  • Availability of different services (for example, after hours)
  • Expected response time
  • Follow-up and escalation process for delayed response to a referral.

Standardise aspects of the referral process (such as required documentation) as much as possible, and develop processes for routine referrals for certain patient groups (for example, physiotherapy for postoperative patients).

Work with external services to identify referral processes to support ongoing comprehensive care. These might include processes for:

  • Safe return to rural or remote health services
  • Transfer to subacute facilities
  • Referral for ongoing care in the community
  • Referral for follow-up of specific clinical or other issues
  • Referral to services provided by credentialed clinicians in the private sector (for example, physiotherapists, occupational therapists, dietitians, counsellors).

Set up processes for identifying the clinician with overall accountability

Although all clinicians are accountable for the care they provide to patients, the clinician carrying overall accountability for an individual patient’s care should have the seniority to make time-sensitive or complex clinical decisions. The clinician who has overall accountability must also be accessible and available so that they can lead and coordinate comprehensive care planning and delivery. Confusion about which clinician has overall accountability for a patient’s care can lead to communication issues and delays in clinical decision-making.18,16

It is a requirement in the Medical Board of Australia’s Code of Conduct that doctors ensure ‘that it is clear to the patient, the family and colleagues who has ultimate responsibility for coordinating the care of the patient’.17 This can be challenging even in small hospitals and MPSs.

Overall accountability for a patient’s care may be handed over between several clinicians (including doctors, nurse practitioners, midwives and allied health professionals) during a 24-hour period, and during the course of a patient’s admission. On-call or locum clinicians may carry overall accountability for a patient’s care at different times. Further complexity can be added when care is shared between teams (for example, in orthogeriatrics) or when multiple teams are involved in a patient’s care (for example, patients with multiple chronic organ diseases, maternity patients with pre-existing medical conditions, children with complex medical conditions).

Work with clinical teams to develop consistent and up-to-date processes for identifying the clinician with accountability for individual patients’ care at any time of the day or night. A systematic and predictable process is required so that permanent, temporary, locum and agency clinicians can identify the correct clinician, and so that inconsistencies are not driven by variation in the time of day or the personalities involved.

Develop guidance about:

  • The roles and responsibilities of on-call and locum clinicians
  • Processes for managing circumstances when the clinician with accountability for a patient’s care is not available
  • Orientation of new, agency or locum clinicians to the process for identifying who has overall accountability for a patient’s care
  • How unexpected absences or last-minute changes to rosters will be communicated and managed when these affect the identification of the clinician with overall accountability for a patient’s care.
Last updated 4th July, 2018 at 11:22pm
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References

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Adams S, Cohen E, Mahant S, Friedman JN, MacCulloch R, Nicholas D. Exploring the usefulness of comprehensive care plans for children with medical complexity (CMC): a qualitative study. BMC Pediatr 2013;13:10.

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Agency for Clinical Innovation. ACI Clinical Innovation Program: specialised geriatric outreach to residential aged care. Sydney: ACI; 2014.

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Australian Commission on Safety and Quality in Health Care. A guide to support implementation of the national consensus statement: essential elements for recognising and responding to clinical deterioration. Sydney: ACSQHC; 2011.

Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. Melbourne: Medical Board of Australia; 2014.

Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for safe and high-quality end-of-life care. Sydney: ACSQHC; 2015.