Standard 5: Comprehensive Care

Using the comprehensive care plan

Action 5.14

The workforce, patients, carers and families work in partnership to:

a. Use the comprehensive care plan to deliver care

b. Monitor the effectiveness of the comprehensive care plan in meeting the goals of care

c. Review and update the comprehensive care plan if it is not effective

d. Reassess the patient’s needs if changes in diagnosis, behaviour, cognition, or mental or physical condition occur

Intent

The comprehensive care plan is used to direct the delivery of safe and effective care that aligns with the patient’s needs and preferences.

Reflective questions

What processes are in place to ensure that the care delivered is consistent with the patient’s comprehensive care plan?

What processes are in place to ensure that the workforce monitors the effectiveness of a patient’s care plan, including reviewing and updating the plan when necessary, in collaboration with the patient, carer and family?

Key tasks

  • Develop processes to ensure that clinicians and other members of the workforce are aware of their obligation to provide care in accordance with the comprehensive care plan, and in collaboration with patients, carers and family members
  • Develop processes to ensure that the effectiveness and currency of the comprehensive care plan are routinely reviewed
  • Develop guidance about indications to reassess the patient’s care needs, preferences and goals, and revise the comprehensive care plan.

Strategies for improvement

Hospitals

Provide education and training

Provide orientation, education and training for clinicians and other members of the workforce so that they understand their individual roles, responsibilities and accountabilities in delivering care in accordance with the comprehensive care plan. In addition to providing training to doctors, nurses, midwives and allied health clinicians, training is also needed for auxiliary members of the workforce involved in delivering patient care. For example, members of the food service workforce may need training about their role in managing risks associated with malnutrition and dehydration, and ward clerks may need training to ensure that substitute decision-makers are identified and carers can see patients outside usual visiting hours. Ensure that training covers organisational processes and more specific processes at the ward, unit or service level.

Topics to cover in workforce education include:

  • When and how to use the comprehensive care plan
  • Roles, responsibilities and accountabilities of different team members in delivering comprehensive care
  • Assessment, documentation and communication of patient progress against the goals of care
  • Indications to repeat screening, assessment and comprehensive care planning processes
  • How to partner with patients, carers and families to optimise the delivery of comprehensive care
  • How to support the specific role of carers in delivering comprehensive care
  • How to gain access to other expertise (for example, specialist input) and equipment (for example, pressure-relieving mattresses) required for delivering comprehensive care in alignment with a patient’s needs
  • How to provide feedback about issues with processes that support the delivery of comprehensive care.

Involve patients and carers

The Partnering with Consumers Standard includes strategies to ensure that clinicians work in partnership with patients when delivering care. Extra strategies may be needed to ensure that collaboration with carers and families is effective, and in line with the preferences and consent of individual patients, carers and families.

Collaboration with carers and family is becoming increasingly important in the delivery of safe and high-quality care. Carers and family members often have intimate knowledge of what is ‘normal’ for a patient, and can detect small changes that may indicate substantial deterioration or improvement in a patient’s condition.1,2 Involving carers and families in the delivery of care may also help to reassure patients, and ensure that their needs are being met.3 For example, carer involvement in the delivery of care to patients with cognitive impairment can help to reduce patient distress and assist in planning for transitions of care.2

Carers may have an official role that goes beyond that of other family members. Accurately identify carers to ensure that they have access to support and services that help them to fulfil their role, and to ensure that any legal matters in relation to consent and decision-making are established.4,5 For example, carers for children and young people may have identification cards that establish their role as legal guardians, which need to be sighted. For Aboriginal and Torres Strait Islander people, there may be a collective approach to carer responsibilities. Confirming who is responsible for different aspects of care is important for ensuring that carer engagement is effective. More information is available in Comprehensive Care for Aboriginal and Torres Strait Islander Consumers.

Useful documents that may help to inform and support collaboration with specific groups of carers are available from Carers Australia, including:

Review processes

Involve the workforce and consumers in reviewing the effectiveness and usefulness of comprehensive care delivery processes. Develop processes for ensuring that updates and changes to comprehensive care planning tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that members of the workforce understand how to use and apply newly developed processes in their work.

The Recognising and Responding to Acute Deterioration Standard contains more information about how to reassess the patient’s needs when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported (Action 8.5).

Day Procedure Services

Provide education and training

Provide orientation, education and training for clinicians so that they understand their individual roles, responsibilities and accountabilities in delivering care in accordance with the comprehensive care plan. Training for auxiliary members of the workforce involved in delivering patient care may also be needed.

Tailor education and training according to the complexity of the day procedure service and the patient population. Considering the short contact time that most day procedure services have with patients, it is likely that the focus of education and training will be on:

  • Expectations for the care delivered by the workforce
  • When and how to access the comprehensive care plan
  • Assessment, documentation and communication of patient progress compared with the goals of care
  • How to partner with patients, carers and families to optimise the delivery of comprehensive care.

Involve carers

Carers may have an official role that goes beyond that of other family members. Accurately identify carers to ensure that any legal considerations relating to consent and decision-making are established.4,5 For example, carers for children and young people may have identification cards that establish their role as legal guardians, which need to be sighted.

For Aboriginal and Torres Strait Islander people, there may be a collective approach to carer responsibilities. Confirming who is responsible for different aspects of care is important for ensuring that carer engagement is effective. More information is available in Comprehensive Care for Aboriginal and Torres Strait Islander Consumers.

Review processes

Involve the workforce and consumers in reviewing the effectiveness and usefulness of comprehensive care delivery processes. Develop processes for ensuring that updates and changes to comprehensive care planning tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work.

The Recognising and Responding to Acute Deterioration Standard contains more information about how to reassess the patient’s needs when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported (Action 8.5).

Examples of evidence

Select only examples currently in use:

  • Policy documents that describe the requirements for routinely reviewing the effectiveness of the comprehensive care plan
  • Audit results of
    • the effectiveness of the comprehensive care plan in meeting goals of care
    • whether comprehensive care plans are being reviewed when necessary, including after significant changes in the patient’s diagnosis, behaviour, cognition, mental state or condition
    • whether information is provided to patients, carers and families about their proposed treatment
    • whether case conferences with patients, carers and families are held when necessary
  • Training documents about using the comprehensive care plan, including roles and responsibilities, and how to partner with patients, carers and families to deliver care
  • Results of patient and carer experience surveys
  • Interviews with patients and carers about participation in ongoing review and reassessment of the patient’s comprehensive care plan
  • Patient and carer information packages that provide information to enable them to participate in their care
  • Forms that patients review, sign and receive as a copy that relate to their clinical management
  • Feedback from patients, carers and families about their inclusion in delivering care
  • Observation of clinicians, carers and patients working together to deliver a comprehensive care plan, including monitoring and reviewing the plan as needed.
MPS & Small Hospitals

Provide education and training

Provide orientation, education and training for clinicians and other members of the workforce so that they understand their individual roles, responsibilities and accountabilities in delivering care in accordance with the comprehensive care plan. In addition to providing training to doctors, nurses, midwives and allied health clinicians, training is also needed for auxiliary members of the workforce involved in delivering patient care. For example, members of the food service workforce may need training about their role in managing risks associated with malnutrition and dehydration, and ward clerks may need training to ensure that substitute decision-makers are identified and carers can see patients outside usual visiting hours. Ensure that training covers organisational processes and more specific processes at the ward, unit or service level.

Topics to cover in workforce education include:

  • When and how to use the comprehensive care plan
  • Roles, responsibilities and accountabilities of different team members in delivering comprehensive care
  • Assessment, documentation and communication of patient progress against the goals of care
  • Indications to repeat screening, assessment and comprehensive care planning processes
  • How to partner with patients, carers and families to optimise the delivery of comprehensive care
  • How to support the specific role of carers in delivering comprehensive care
  • How to gain access to more expertise (for example, specialist input) and equipment (for example, pressure-relieving mattresses) required for delivering comprehensive care in alignment with a patient’s needs
  • How to provide feedback about issues with processes that support the delivery of comprehensive care.

Involve patients and carers

The Partnering with Consumers Standard includes strategies to ensure that clinicians work in partnership with patients when delivering care. Other strategies may be needed to ensure that collaboration with carers and families is effective, and in line with the preferences and consent of individual patients, carers and families.

Collaboration with carers and family is becoming increasingly important in the delivery of safe and high-quality care. Carers and family members often have intimate knowledge of what is ‘normal’ for a patient, and can detect small changes that may indicate substantial deterioration or improvement in a patient’s condition.122,156 Involving carers and families in the delivery of care may also help to reassure patients and ensure that their needs are being met.31 For example, carer involvement in the delivery of care to patients with cognitive impairment can help to reduce patient distress and assist in planning for transitions of care.156

Carers may have an official role that goes beyond that of other family members. Accurately identify carers to ensure that they have access to support and services that help them to fulfil their role, and to ensure that any legal matters regarding consent and decision-making are established.159,160 For example, carers for children and young people may have identification cards that establish their role as legal guardians, which need to be sighted. For Aboriginal and Torres Strait Islander people, there may be a collective approach to carer responsibilities. Confirming who is responsible for different aspects of care is important for ensuring that carer engagement is effective. More information is available in Comprehensive Care for Aboriginal and Torres Strait Islander Consumers.

Useful documents that may help to inform and support collaboration with specific groups of carers are available from Carers Australia, including:

Review processes

Involve the workforce and consumers in reviewing the effectiveness and usefulness of comprehensive care delivery processes. Develop processes for ensuring that updates and changes to comprehensive care planning tools and processes are effectively communicated to clinicians. This may involve developing specific, targeted implementation strategies to ensure that clinicians understand how to use and apply newly developed processes in their work.

The Recognising and Responding to Acute Deterioration Standard contains more information about how to reassess the patient’s needs when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported (Action 8.5).

Last updated 5th July, 2018 at 06:38pm
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References

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.

Redley B. Risk screening and assessment for avoiding preventable harm to older people in hospitals. Melbourne: Centre for Quality and Patient Safety Research, Deakin University; 2016.

Harding E, Wait S, Scrutton J. The state of play in person-centred care. London: The Health Policy Partnership; 2015 (accessed Sep 2017).

van Rosse F, Suurmond J, Wagner C, de Bruijne M, Essink-Bot ML. Role of relatives of ethnic minority patients in patient safety in hospital care: a qualitative study. BMJ Open 2016;6(4):e009052.

Royal Australian and New Zealand College of Psychiatrists. Position statement 76. Supporting carers in the mental health system. Melbourne: RANZCP; 2012.