Outcome 5.4.1

Put in place systems* for partnering with the older person, their family, carers and others in assessment and planning.

• Comprehensive clinical care* systems* are designed to make sure clinical care* assessment and planning prioritises the needs, goals and preferences* of the older person. You need to have systems* that support person-centred care* (Outcome 1.1) and assessment and planning (Outcome 3.1). You also need to put in place systems* and processes* to:
  • support older people to partner in all aspects of their care and decision-making
  • identify the older person’s preferences for involving substitute decision-makers*, family and carers* in their care
  • support workers and health professionals* to understand their roles and responsibilities* for partnering with older people. This includes supporting older people to understand the outcomes* of assessment and the role of health professionals* in their care. This helps to inform their choices and preferences for care and services (Outcome 3.1).
  • review ongoing and end-of-life documents (this may include an advance care planning document* if in place or being considered) with the older person, representatives and others to make sure they’re complete and current (Outcome 3.1). This should be done if and when the older
    person chooses.

Put in place processes* for partnering with the older person, their family, carers and others in assessment and planning.

• Partner with older people to set goals of care* through discussions about:
  • what is important to them
  • their needs and values
  • their goals for their health and wellbeing*.

These discussions need to be in line with the older person’s preferences. These should also include the older person’s family, carers and others they choose to involve in their care. If an older person lacks the capacity to make decisions, include their substitute decision-maker* .

• Document and include goals of care* in clinical assessment and the care and services plan*. Regularly* assess and evaluate progress towards achieving the person’s goals of care*.
• Support older people to access and understand information about their clinical care* and services, in line with their needs and preferences (Outcome 3.1)
• Provide workers with access to training on:
  • the principles of person-centred care*
  • supported decision-making*
  • informed consent*
  • processes* to communicate with older people in line with their preferences.

Monitor, review and improve systems* for partnering with older people.

• Analyse feedback* from older people and others involved in their care about the quality and experience of partnership* in setting goals and decision-making.
• Review clinical records to make sure goals of care* are included in clinical assessments and care and services plans*.
• Collect information about older people’s experiences, reviews of documentation or other reporting and monitoring activities. Use this information to improve the safety and quality of systems* and processes* for partnering with older people. Report the results of the work you do to improve quality to the governing body*, older people and workers.

Outcome 5.4.2

Put in place processes* for comprehensive clinical assessment.

• You need to have robust systems* for person-centred care* (Outcome 1.1), assessment and planning and reablement* (Outcome 3.1). Put in place evidenced-based* clinical assessment processes* that:
  • identify and address how complex the older person's clinical conditions, issues and risks are. The older person’s care and services plan* needs to include strategies to prevent, mitigate and escalate:
    • acute conditions
    • exacerbations of chronic conditions
    • clinical risks of harm.
  • provide opportunities for older people to maintain or regain function or skills to optimise their independence and quality of life*.
• Make sure that reassessment includes evaluating whether clinical care* is effective and optimises the older person’s quality of life*, while respecting their choices and dignity of risk*.
• Facilitate access* to the older person’s preferred GP, nurse practitioner and other appropriate health professionals* for clinical assessment and to support continuity of care. Use telehealth* where appropriate for the older person, if the provider can support a telehealth* appointment.
• Make sure health professionals* have the knowledge, training and skills to:
  • complete a comprehensive clinical assessment
  • document the outcomes* of the clinical assessment and any identified risks in the care and services plan*
  • communicate these outcomes* to those involved in the older person’s care (Outcome 3.4).
• Make sure there are processes* for workers to use assessment outcomes* to inform planning for continuity of care, including at transitions of care*.
• Make sure appropriate assessment is completed by a qualified health professional*, including allied health* professionals.
  • Which includes supporting older people who have difficulty communicating.

Monitor, review and improve assessment and care planning.

• Analyse clinical data and feedback* about comprehensive clinical assessment such as:
  • assessment quality and frequency
  • whether the older person’s preferred GP and relevant health professionals* were involved
  • how assessments are included in care planning.
• Based on the outcomes* of your monitoring, identify and put in place quality improvement* strategies for comprehensive clinical assessment.
• Evaluate and report on the outcomes* of your quality improvement* activities to the governing body*, workers, older people and other relevant organisations.

Outcome 5.4.3

Put in place processes* for referring to and facilitating access to health professionals*.

Develop robust systems* for person-centred care* (Outcome 1.1) and the assessment, planning and delivery of care (Outcomes 3.1 and 3.2), including processes* for referring to and facilitating access* to health professionals*.

• Develop referral pathways that facilitate access to a range of health professionals* and health services. These may include:
  • GPs and other primary health care professionals
  • nurse practitioners
  • registered nurses
  • pharmacists
  • specialist doctors such as a geriatrician or neurologist
  • allied health* professionals (who have distinct roles to support reablement* and maintain function).
• Make sure referral pathways include ways to access:
  • geriatricians and other specialist doctors
  • dentists and oral health* practitioners
  • specialist nursing services
  • clinical advisory services
  • dementia support services
  • multidisciplinary specialist teams, such as a palliative care* team.
• Identify and access services that provide emergency and out-of hours clinical care* such as medical and dental services when needed.
• Support the older person’s preferences about referral to health professionals* and services. Identify and document their current relationships with health professionals* and private health insurance status (if they have this) to support choice and continuity of care.
• Make sure workers and health professionals* have the knowledge and skill to identify when older people need access to specific health professionals. This is based on assessments completed:
  • at the start of care
  • during scheduled clinical reviews
  • in response to change or deterioration* in the older person’s condition or function
  • when the older person’s needs can’t be met by the provider’s workforce*.
• Based on the older person’s clinical needs and preferences, facilitate access* to relevant health professionals* and specialist services when needed.
• Have robust processes* to define the roles, responsibilities* and accountability for health professionals* involved in the clinical care* of the older person (Outcome 5.1). Document the details of the older person’s preferred health professional* who is responsible for overall care (such as the GP or nurse practitioner). Make sure up-to-date contact details are available in the provider’s system*.
• Make sure workers and health professionals* use standardised clinical communication tools such as ISBAR* to support communication with health professionals* and use standard national terminology* (Outcomes 3.4 and Outcome 5.1).

Monitor, review and improve processes* for referring and facilitating access to health professionals*.

• Collect, analyse and report data on referrals to health professionals* and health services, including barriers to access and waiting times.
• Support effective partnerships* with health professionals* and services to address any barriers to access.

Outcome 5.4.4

Put in place processes* to deliver multidisciplinary care*.

• Have robust processes* for delivering person-centred*, holistic* and comprehensive care* in partnership* with the older person. This care needs to address the older person’s goals of care* , needs and preferences (Outcome 1.1 and 3.2). Carers*, family and substitute decision-makers* are involved in line with the older person’s wishes.
• Develop robust processes* in Action 5.4.3 and Outcome 5.1 to collaborate with the multidisciplinary team to:
  • define roles and responsibilities* of members of the multidisciplinary team
  • review clinical needs and goals of care* with the multidisciplinary team
  • share relevant clinical information with the multidisciplinary team, with the older person’s consent
  • support workers to develop skills in effective multidisciplinary teamwork and communication.
• Have robust processes* for access to after-hours and urgent clinical care* when you identify clinical deterioration* and need to escalate. This needs to be in line with the older person’s goals of care*.
• Consider how your service supports virtual care arrangements.
• Have robust communication processes* and protocols for notifying relevant people about clinical incidents* or changes, including:
  • GPs and other health professionals*
  • substitute decision-makers*
  • the older person’s family and carers*.

Examples include notification of a fall* , transition of care* , changes in clinical condition and incidents* .

• Make sure effective communication is supported by documenting and sharing care and services plans* and clinical information where appropriate.

Monitor, review and improve processes* for multidisciplinary care*.

• Consider strategies for monitoring and measuring the effectiveness of your processes* to deliver comprehensive care*.
• Identify areas of improvement when communicating and working with a multidisciplinary team.
• Make sure the monitoring and measuring of the delivery of comprehensive care* includes:
  • reviews of care and service plans*
  • assessment outcomes*
  • timely* access to health professionals* that is in line with the older person’s needs and preferences.
• Consider incidents* and indicator data to identify areas of improvement for delivering comprehensive care*, such as the processes* for access to after hours and urgent care.

Outcome 5.4.5

Put in place processes* for clinical monitoring and reassessment.

• Develop robust systems* for person-centred care* (Outcome 1.1) and care planning and delivery (Outcomes 3.2 and 3.3). Do this by putting in place processes* to support timely* monitoring and reassessment of clinical conditions, including:
  • recognising and responding to signs and symptoms of clinical deterioration* in an older person’s behaviour, cognition, mental*, physical or oral health*, and at transitions of care*
  • developing and using escalation pathways for older people’s care
  • providing ways for older people, substitute decisions-makers*, carers* and family to escalate concerns about changes or deterioration* in an older person’s condition
  • reviewing and evaluating the effectiveness of comprehensive care* regularly*. You also need to review when someone is transitioning between care, experiences clinical deterioration* or changes in needs. This is done in partnership* with the older person, a multidisciplinary team and substitute decisions-makers*, carers* and family.
• Train and support workers and health professionals* to identify, monitor and respond to changes or clinical deterioration* This should be in line with their scope of practice*.

Monitor, review and improve processes* for clinical monitoring and reassessment.

• Review feedback* about how timely* and appropriately workers and health professionals* respond to change or deterioration*.
• Review and analyse clinical assessment, monitoring and documentation of the older person’s clinical condition to identify areas for improvement.
• Use outcomes* from this review to improve how you respond to clinical deterioration*.