Older people at the end of their life often have unique and complex health and support needs. As a result, they may receive care across many different settings and by many different health professionals. Keeping everyone on the same page about a client’s health and support needs can be difficult.
Using linkage strategies to work with other services and providers, is one way to improve the care clients receive at the end of life. Partnering with other services makes sharing information easier and can result in a host of benefits, including increased continuity of care for your clients and improved skills and confidence in providing palliative care for your staff.
When thinking about creating linkages between services, it’s important to start with evidence-based strategies. A systematic literature review previously conducted at the Queensland University of Technology (QUT) revealed seven evidence-based linkage strategies that can be used to create effective and mutually beneficial linkages between care providers.
These seven strategies were trialled across twenty sites in Australia, resulting in benefits including:
- Increased staff knowledge, skills and confidence in advance care planning and palliative care;
- 12% decrease in hospital transfers in the last week of residents’ lives;
- Early changes to personal and workplace practices and increased use of linkage strategies;
- Increased awareness and communication with local services and resources;
- Increased completion of advance care planning documentation for your residents;
- Improved continuity of care between services.
While the initial demonstration site trials have concluded, the ELDAC project has been funded by the Australian Government Department of Health to continue implementing these strategies across aged, specialist palliative and primary care services in Australia.
A team of facilitators are available to provide support, at no cost to your organisation, to implement these evidence-based strategies, which are described further in the table below.
If you are interested in improving the quality of end of life care you provide to older Australians by partnering with other services, the ELDAC team of facilitators are keen to help you. Please visit the Sector Engagement page for further information about the benefits of working with an ELDAC facilitator, or to register your interest.
Alternatively, if you would like to start implementing these strategies in your organisation without the support of a facilitator, further information and instructions are available in the ELDAC Working Together toolkit.
||Input into clinical care is provided through regular scheduled communication between team members from a range of disciplines and services delivering palliative care and aged care.
- Improved symptom control
- Increased number of scheduled multidisciplinary interactions
- Improved communication between providers
- Sharing of information
- Increased number of shared care plans
- Increased confidence in partner organisations and their staff.
|Written and Verbal Communication Pathways
||Shared and standardised documentation and communication processes support care delivery, and may include usage of common language, standardised referral forms, agreed assessment tools, and Advance Care Plans.
- Improved continuity of care
- Increased possibility of meeting patient choices
- Established contact with local services
- Increased meetings arranged to create and maintain linkages
- Developed shared documentation
- Increased use of shared care plans
- Increased continuity of care
- Increased case conferencing and communication about care
- Increased use of technologies (i.e. telehealth and ehealth records)
- Provided consumer information
- Improved understanding by consumers.
|Formalised Agreements and Plans
||Formalising linkages through written agreements and governance arrangements can ensure discussion of and commitment to resource allocation, mutual responsibilities, agreed outcomes, and communication processes.
- Evidence of formal linkage partnerships established, including formal agreements (e.g. MOUs) and shared service plans
- Adequate allocation of resources to sustain linkage activity plan
- Evaluation service data to provide information for continuous improvement.
|Designated Linkage Worker
||Appointment of a key worker whose responsibility it is to act as a care and linkage coordinator across settings is seen to improve access to services, improve cooperation between services, improve continuity of care and promote shared understanding of the Linkage worker role.
- Improved communication across settings
- Shared understanding of the linkage worker role
- Increased confidence among linkage partners
- Improved continuity of care.
||Clarity of roles and responsibilities for each practitioner involved in the linkage partnership leads to improved continuity of care particularly when transitioning between settings of care.
- Improved understanding of roles and responsibilities of each partner service provider
- Improved communication about care
- Improved continuity of care.
|Knowledge Exchange and Upskilling
||Shared learning opportunities, both formal and informal, increase knowledge and develop capabilities in providing palliative care for older Australians.
- Improved knowledge, skills and confidence of service providers in providing palliative care to older Australians.
||Processes for continual review of linkage strategies and their outcomes enable identification of their effectiveness and efficiency.
- Evidence of strategy embedded into organisational quality processes (e.g. PCOC)
- Minimum data requirements collected and reported.
Diana Harrison, ELDAC Facilitator from Queensland University of Technology
Jennifer Gavin, ELDAC Facilitator from Queensland University of Technology
Melissa Brodie, ELDAC Facilitator from Queensland University of Technology
Rebecca Moore, ELDAC Facilitator from Queensland University of Technology