Palliative care case conferences in the community are a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet the older person’s individual health needs.
Role of the Case Manager
A case manager or coordinator often provides a single point of contact for the older person living in the community. There may be different coordinators depending on how the current care services are arranged. Case managers coordinate the health care team and services involved in the care and support of the older person and their family.
Complex care requiring a range of providers can also be supported. This means that a multidisciplinary team is generally needed to provide holistic care to older adults.
Understand and incorporate the needs and preferences of the older person and their family by:
- Consulting with the older person, family members, significant others and care workers to identify and share information regarding changing needs and preferences.
- Respecting the lifestyle, social context, cultural and spiritual needs of the older person.
- Applying the principles and aims of a palliative approach in development of a care plan for the older person.
- Providing emotional support using effective communication skills.
- Understanding and supporting the advance care planning process.
- Identifying and reflecting upon the potential impact of delivering a palliative approach to self, care workers and family carers.
Be able to access all relevant local health, social and volunteering services by:
- Establishing and maintaining relevant networks to ensure appropriate referral of older persons to services from within and outside your organisation.
- Advocating for the older person regarding service delivery.
- Effectively communicating the purpose and availability of services to the older person and family.
- Developing and implementing routine procedures to ensure that allocated service delivery continues to match the older person’s and their family’s requirements.
- Maintaining effective communication with all services involved in delivering a palliative approach and care to the older person.
- Regularly reviewing the changing needs of the older person to ensure they are met.
Apply the principles and aims of a palliative approach in caring for the older person by:
- Encouraging the older person and their family to share information about the person’s needs and preferences.
- Respecting the older person’s lifestyle, social context, cultural and spiritual needs.
- Regularly checking and following the care interventions as documented in the care plan.
- Identifying and reflecting upon own emotional responses to delivery of a palliative approach.
- Seeking support when needed.
Observe, monitor and report the older person’s and family’s needs to the case manager by:
- Referring needs and issues expressed by the older person and family to the appropriate healthcare or allied health member of the team.
- Recognising and reporting any signs of the older person’s deterioration and increased needs.
- Recognising and reporting any increased emotional needs of the older person and their family.
- Monitoring the effectiveness of interventions received and reporting this back to the case management team.
A palliative care case conference in the home may take a few weeks to organise.
Planning is essential.
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Palliative care case conference planning checklist (402kb pdf) will help you ensure you have the information you need to commence the case conference.
Having one person with the overall responsibility for this ensures nothing is forgotten.
Make sure someone takes responsibility for planning and organising the conference.
- Who to invite to a palliative care case conference
Generally, participants at a palliative care case conference will be the:
- Older person (if able)
- Substitute decision maker(s) or ‘person responsible’
- Family members or significant others
- GP
- Members of the community aged care team
- Any of the other people who are involved in the person’s care
- How to begin organising a palliative home care case conference
- Contact the general practitioner in the first instance. They are likely to have the most limited availability.
- Notify the general practice manager to book the case conference into the general practitioner’s patient appointment schedule.
- Find out which setting works best for the GP - should the meeting be held in their rooms, by teleconference, or in the client’s home?
- Contact all of the other participants for their availability and provide details for the meeting.
- Have an alternative plan if the meeting needs to be cancelled suddenly.
- Discuss how to distribute the outcomes from the meeting to the people involved.
- Participating in a case conference
Make sure you have the appropriate information to be able to share with the other healthcare providers to begin the process of making an individual care plan for the older palliative person that will meet their requirements for the last six months of their life.
The information you need might include:
- Clinical records.
- Medication charts.
- Advance care planning documentation.
- Family information.
- Feedback or questions from other health workers who are not able to attend the case conference.
- Cultural Perspectives
If your patient is involved with a palliative care service, they may already have structures and processes to support palliative care case conferences. Contact the service provider to find out how they organise case conferences for patients.
Home Care Packages Programs provide support for the ongoing symptoms of aging. They are not specifically designed to provide palliative care associated with medical conditions or diseases that cause a life-limiting illness. If the older person is not involved with specialist palliative care, referral to a specialist service may be considered if they have care needs that cannot be provided through a palliative approach and primary care support.
The Specialist Palliative Care Service may provide an initial assessment and consultancy role for the client whose care needs will extend over a long period of time and a more intensive role in palliative and end-of-life care in the last days or weeks of care provision.
Palliative Care Case Conference Processes
More detailed information on the following aspects of palliative care case conferences is available:
Page updated 04 December 2023