Action 5.13

This action requires clinicians to use the processes described in the Partnering with Consumers Standard to work with patients or substitute decision-makers to reach shared decisions about the comprehensive care plan. It also requires clinicians to use the processes described in the Communicating for Safety Standard to document the comprehensive care plan and communicate its content to relevant members of the workforce.

The level of detail in a comprehensive care plan should reflect the significance and complexity of a patient’s clinical situation. For example, the comprehensive care plan for an older frail person with multiple comorbidities, an existing pressure injury and no family, who is admitted through the emergency department for severe pneumonia, will require a much greater level of detail than that required for an otherwise well young person admitted for an elective procedure. The Victorian Department of Health and Human Services website has more information about comprehensive care for older people.

Ensure that comprehensive care plans include:

• Agreed goals of care and actions required to achieve them
• Actions required to manage identified risks of harm
• Actions required to ensure safe discharge from the health service organisation
• Indications for review of the comprehensive care plan.

The comprehensive care plan may also identify the individuals who are accountable for the actions required to achieve the goals of care, manage clinical risks and ensure safe discharge from the health service organisation.

Identify goals of care

Ensure that goals of care reflect the input of doctors, nurses, allied health clinicians, consumer liaison officers (for example, Aboriginal liaison officers), the patient, carers and family. Goals of care may include:

• Condition- or disease-specific goals such as ‘give maximum three days of antibiotics and fluids; seek specialist palliative care advice regarding symptom control; likely palliation if significant deterioration occurs or if there is no improvement within 72 hours’
• Functional goals such as ‘maintain ability to independently perform activities of daily living’
• Personal goals such as ‘attend daughter’s wedding in four weeks’.

Ensure that goals of care also identify the overall intent of an episode of care, including whether there are any agreed limitations on medical treatment. For example, the Tasmanian Department of Health and Human Services’ Medical Goals of Care Plan indicates whether the overall goal of medical care is intended to be:

• Curative or restorative without limitations on treatment
• Curative or restorative with limitations on treatment
• Palliative symptom management
• Terminal care.

Clinicians who deliver care to people who experience mental illness can work collaboratively to ensure that clinical goals are balanced with the person’s own values. The National Framework for Recovery-Oriented Mental Health Services: Guide for practitioners and providers describes how this can be implemented.

Identify support people

A person-centred healthcare system is one that supports patients to make informed decisions, and successfully manage their own health and care. This includes giving patients choice about when to let support people, such as family or carers, be involved in their decision-making or make decisions on their behalf.¹ Family or carers know the patient best, and their presence can help to reassure patients in times of uncertainty, anxiety or vulnerability.

To identify support people a patient wants involved in their care, develop effective processes that include:

• Asking the patient during initial conversations or admission processes to identify any support people they wish to be involved in communications and decision-making about their care
• Allowing the patient to nominate or change their nominated support people at any time throughout their care
• Documenting the contact details for a patient’s support people in their healthcare record and treatment notes
• Communicating about a patient’s support people, including any changes in support people, to all members of the patient’s healthcare team.

In some cases, a patient may need the organisation to put them in contact with someone who can provide support for communication and decision-making. Provide:

• Contact details for local, state or territory consumer health advocates or organisations that can provide support for healthcare decision-making
• Access to interpreters or interpreting services that can be involved in discussions about health and healthcare options
• Access to cultural support service or cultural liaison officers, such as Aboriginal health workers.

Support people cannot be part of a patient’s healthcare decision-making if they are not present. Review the organisation’s visiting policies to identify opportunities to allow a patient’s support people to be present throughout care. One strategy to support this is patient-directed visiting, which removes restrictions on visiting times, allowing carers and family to decide on the visiting times that best suit them.

Where a support person is not nominated by a patient and a substitute decision-maker is required to make a decision on the patient’s behalf, ensure that processes are in place to identify appropriate substitute decision-makers.

Plan for discharge

Part of the comprehensive care planning process is planning for discharge from the health service organisation. This includes identifying any services, equipment and follow-up that may be needed to safely discharge the patient. Develop processes to ensure that follow-up arrangements are made before the patient leaves the health service, and that any required referrals are dealt with promptly. The person, and their family and carers, should be engaged in discharge planning from the beginning of the healthcare episode.

Review the comprehensive care plan

The comprehensive care plan may include general indicators that are applicable to all patients, as well as specific indicators relating to individual patients. Some examples of general indicators are:

• Regularly scheduled review based on length of stay (for example, routine weekly review, or routine review when expected length of stay for a particular intervention or procedure is exceeded)
• Review after critical events such as medical emergency calls
• Review after handover to a new specialty or service (for example, after discharge from intensive care to the ward)
• Review if the patient, substitute decision-maker or family requests it or expresses concerns.

Some examples of individual indicators are:

• Failure to reach a planned goal within a predetermined time (for example, failure to clinically improve after a period of treatment)
• Whether potential complications of a condition or treatment occur
• Review after particular procedures or interventions have been performed, or when the results of diagnostic tests are available
• A patient at the end of life is readmitted.

This action requires clinicians to use the processes described in the Partnering with Consumers Standard to work with patients or substitute decision-makers to reach shared decisions about the comprehensive care plan. It also requires clinicians to use the processes described in the Communicating for Safety Standard to document the comprehensive care plan and communicate its content to relevant members of the workforce.

The level of detail in a comprehensive care plan should reflect the significance and complexity of a patient’s clinical situation, and the type of intervention provided. In day procedure services, a generic pathway is likely to be appropriate for most patients, with exceptions or individual clinical requirements noted.

Regardless of the type of process the service uses to document the comprehensive care plan, it should include the capacity to document:

• Agreed goals of care and actions required to achieve them
• Actions required to manage identified risks of harm
• Actions required to ensure safe discharge from the day procedure service.

Identify support people

A person-centred healthcare system is one that supports patients to make informed decisions, and successfully manage their own health and care. This includes giving patients choice about when to let support people, such as family or carers, be involved in their decision-making or to make decisions on their behalf.¹ Family or carers know the patient best, and their presence can help to reassure patients in times of uncertainty, anxiety or vulnerability.

To identify support people a patient wants involved in their care, develop effective processes that include:

• Asking the patient during initial conversations or admission processes to identify any support people they wish to be involved in communications and decision-making about their care
• Allowing the patient to nominate or change their nominated support people at any time throughout their care
• Documenting the contact details for a patient’s support people in their healthcare record and treatment notes.

In some cases, a patient may need the organisation to put them in contact with someone who can provide support for communication and decision-making. Provide:

• Access to interpreters or interpreting services that can be involved in discussions about health and healthcare options
• Access to cultural support service or cultural liaison officers, such as Aboriginal health workers.

Support people cannot be part of a patient’s healthcare decision-making if they are not present. Review the organisation’s visiting policies to identify opportunities to allow a patient’s support people to be present throughout care.

Plan for discharge

Part of the comprehensive care planning process is planning for discharge from the day procedure service. This includes identifying any services, equipment and follow-up that may be needed to safely discharge the patient.

Examples of evidence

Select only examples currently in use:

• Training documents about
  • shared decision making
  • comprehensive care
• Audit results of comprehensive care plans for documenting
  • goals for the patient’s treatment and care
  • details of the patient’s nominated substitute decision-maker, carers and other support people to be involved in care decisions
  • actions to achieve goals
  • review date for goals
  • discharge plan
• Observation of clinicians’ practice that shows use of the health service organisation’s processes for shared decision making
• Records of interviews with clinicians that show that they understand the health service organisation’s processes for shared decision making
• Observation of patients and carers participating in making decisions about their care
• Observation of accessibility of communication resources for clinicians to provide contact details for support services, such as local consumer health advocates, interpreters, or cultural support or liaison services
• Feedback from patients on the extent to which decisions were shared, goals were developed, support people were involved in discussions, and discharge planning was undertaken.

This action requires clinicians to use the processes described in the Partnering with Consumers Standard to work with patients or substitute decision-makers to reach shared decisions about the comprehensive care plan. It also requires clinicians to use the processes described in the Communicating for Safety Standard to document the comprehensive care plan and communicate its content to relevant members of the workforce.

The level of detail in a comprehensive care plan should reflect the significance and complexity of a patient’s clinical situation. For example, the comprehensive care plan for an older frail person with multiple comorbidities, an existing pressure injury and no family, who is admitted through the emergency department for severe pneumonia, will require much greater detail than that required for an otherwise well young person treated for a fracture. The Victorian Department of Health and Human Services website has more information about comprehensive care for older people.

Ensure that comprehensive care plans cover:

• Agreed goals of care and actions required to achieve them
• Actions required to manage identified risks of harm
• Actions required to ensure safe discharge from the health service organisation, if relevant
• Indications for review of the comprehensive care plan.

The comprehensive care plan may also identify the individuals who are accountable for the actions required to achieve the goals of care, manage clinical risks and ensure safe discharge from the health service organisation.

Identify goals of care

Ensure that goals of care reflect the input of doctors, nurses, allied health clinicians, consumer liaison officers (for example, Aboriginal liaison officers), the patient, carers and family. Goals of care may include:

• Condition- or disease-specific goals such as ‘give maximum three days of antibiotics and fluids; seek specialist palliative care advice regarding symptom control; likely palliation if substantial deterioration occurs or if there is no improvement within 72 hours’
• Functional goals such as ‘maintain ability to independently perform activities of daily living’
• Personal goals such as ‘attend daughter’s wedding in four weeks’.

Ensure that goals of care also identify the overall intent of an episode of care, including whether there are any agreed limitations on medical treatment. For example, the Tasmanian Department of Health and Human Services’ Medical Goals of Care Plan indicates whether the overall goal of medical care is intended to be:

• Curative or restorative without limitations on treatment
• Curative or restorative with limitations on treatment
• Palliative symptom management
• Terminal care.

Clinicians who deliver care to people who experience mental illness can work collaboratively to ensure that clinical goals are balanced with the person’s own values. The National Framework for Recovery-Oriented Mental Health Services: Guide for practitioners and providers describes how this can be implemented.

Identify support people

A person-centred healthcare system is one that supports patients to make informed decisions, and successfully manage their own health and care. This includes giving patients choice about when to let support people, such as family or carers, be involved in their decision-making or make decisions on their behalf.¹ Family or carers know the patient best, and their presence can help to reassure patients in times of uncertainty, anxiety or vulnerability.

To identify support people a patient wants involved in their care, develop effective processes that include:

• Asking the patient during initial conversations or admission processes to identify any support people they wish to be involved in communications and decision-making about their care
• Allowing the patient to nominate or change their nominated support people at any time throughout their care
• Documenting the contact details for a patient’s support people in their healthcare record and treatment notes
• Communicating about a patient’s support people, including any changes in support people, to all members of the patient’s healthcare team.

In some cases, a patient may need the organisation to put them in contact with someone who can provide support for communication and decision-making. Provide:

• Contact details for local, state or territory consumer health advocates or organisations that can provide support for healthcare decision-making
• Access to interpreters or interpreting services that can be involved in discussions about health and healthcare options
• Access to cultural support service or cultural liaison officers, such as Aboriginal health workers.

Support people cannot be part of a patient’s healthcare decision-making if they are not present. Review the organisation’s visiting policies to identify opportunities to allow a patient’s support people to be present throughout care. One strategy to support this is patient-directed visiting, which removes restrictions on visiting times, allowing carers and family to decide on the visiting times that best suit them.

If a support person is not nominated by a patient and a substitute decision-maker is required to make a decision on the patient’s behalf, ensure that processes are in place to identify appropriate substitute decision-makers.

Plan for discharge

Part of the comprehensive care planning process is planning for discharge from the health service organisation. This includes identifying any services, equipment and follow-up that may be needed to safely discharge the patient. Develop processes to ensure that follow-up arrangements are made before the patient leaves the health service, and that any required referrals are dealt with promptly. The person, and their family and carers, should be engaged in discharge planning from the beginning of the healthcare episode. In an MPS, discharge may be a process of transition of care for a resident within the facility.

Review the comprehensive care plan

The comprehensive care plan may include general indicators that are applicable to all patients, as well as specific indicators relating to individual patients. Some examples of general indicators are:

• Regularly scheduled review based on length of stay (for example, routine weekly review, or routine review when expected length of stay for a particular intervention or procedure is exceeded)
• Review after critical events such as medical emergency calls
• Review after handover to a new specialty or service (for example, after discharge from intensive care to the ward)
• Review if the patient, substitute decision-maker or family requests it or expresses concerns.

Some examples of individual indicators are:

• Failure to reach a planned goal within a predetermined time (for example, failure to clinically improve after a period of treatment)
• Whether potential complications of a condition or treatment occur
• Review after particular procedures or interventions have been performed, or when the results of diagnostic tests are available
• A patient at the end of life is readmitted.