Comprehensive care is health care that is based on identified goals for care, which may be a discrete episode of care (for example, a hearing check) or as part of a comprehensive care plan (for example, services provided under a mental health care plan or chronic disease management plan). These goals are aligned with a patient’s expressed preferences and healthcare needs, consider the impact of the patient’s health issues on their life and wellbeing and are clinically appropriate.
Implementing comprehensive care requires effective processes to partner with patients in their own care, and to safely manage transitions between episodes of care and care providers. Achieving this action also relies on implementing the Partnering with Consumers Standard and Communicating for Safety Standard actions.
Planning and delivering comprehensive care involves several essential elements. The way in which these elements are implemented in practice varies between healthcare services, depending on a range of factors, such as the service context, size, location and patient population; the characteristics of the patient and their presenting problem, for example age, comorbidities and social circumstances.
Planning and delivering comprehensive care involves the following activities.
Risk screening and assessment – risk screening and assessment are a core part of healthcare delivery and comprehensive care. As well as identifying clinical issues, they also identify the likelihood of harm, and support decision-making about treatment and risk mitigation.
Clinical assessment and diagnosis – using report of symptoms from patients, carers and families where appropriate, information about course of illness or condition as well as other relevant patient history, healthcare providers evaluate clinical information to make a clinical assessment and diagnosis within their scope of practice and commence development of an appropriate and effective comprehensive care plan.
Identifying goals of care – identifying and settings goals of care in collaboration with the patient, rather than focusing on clinical goals alone, ensures care is individualised. Understanding a patient’s values and their expectations and aspirations for their health and wellbeing, as well as clinical issues and risks of harm are all essential to the establishing shared goals of care.
Agreeing a plan for care – developing and agreeing a plan for care provides an opportunity to document a single, clear and holistic plan that addresses diagnoses, goals of care, identified risks, action taken and proposed and the key treatment information for the episode of care. It can also serve as a tool to support multidisciplinary collaboration where appropriate.
Delivering comprehensive care – align the delivery of comprehensive care with the comprehensive care plan and address the identified clinical and personal goals of care, diagnoses and risks.
Recall to follow-up – establish processes to contact and recall patients for subsequent health. This can be done by the healthcare service or through referral to another healthcare service. An example of patient recall is required is when follow-up care is required after diagnostic imaging or pathology results are received.
Review and improvement of care delivery – reviewing and improving care are iterative processes and can occur because of changes in a patient’s condition, their diagnosis, their location, their goals or any other clinical and personal reason. These changes often require reassessment and adjustments in the care plan.
Advance care plans – an advance care plan documents the stated preferences about a person’s health and personal care, and preferred health outcomes. An advance care plan ensures that patient’s preferences are known if they are no longer able to speak for themselves. They can reduce the likelihood of unwanted or inappropriate treatment. Not all patients will have an advance care plan. Where they are in place, healthcare providers need to be able to accept and action as appropriate.
Links to Actions 1.04 Risk management; 1.11 Healthcare records; 2.04 and 2.05 Shared decisions and planning care
