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Further information on comprehensive care

Health professionals and organisations each play an important role in delivering comprehensive care. We have guidance and resources to support effective, comprehensive care planning. The implementation strategies outlined in these resources are recommended rather than mandatory, and health services are encouraged to adopt approaches that are appropriate to their local context.

What is comprehensive care?

Comprehensive care is health care that is based on identified goals for the episode of care. These goals are aligned with the 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.
 

How do health professionals deliver comprehensive care? 

Comprehensive care involves teams of health professionals working together and communicating effectively to plan, manage and coordinate care. It requires collaborative decision‑making with the patient and, where appropriate, their support people. This is enabled by organisational systems and processes that foster a collaborative, person‑centred culture.

Comprehensive care is delivered in line with a comprehensive plan for care. A comprehensive plan for care includes documents that describe the patient’s goals of care, and list the medical, nursing, and allied health actions that will be taken to help them reach those goals.

It is created together with the patient, and where appropriate, their support people, to outline treatments, interventions and other care activities.  

To support health professionals and organisations, we have developed an implementation guide that describes a conceptual model for delivering comprehensive care and essential elements that integrate the conceptual model with the clinical processes required to care for individual patients.
 

Essential elements for comprehensive care delivery

There are six elements for successful comprehensive care delivery.

The first step in delivering comprehensive care is undertaking a clinical assessment. Clinical assessment should be based on the patient’s subjective report of the symptoms and course of the illness or condition. Accurate clinical assessment and diagnosis are crucial to developing a comprehensive plan for care that is appropriate, effective and aligned with a patient’s lifestyle and wellbeing.

Goals of care are determined through a shared decision-making process. They describe a patient’s clinical and personal goals within the context of their clinical situation. 

The purpose of identifying and agreeing to goals of care is to develop a shared understanding between patients, their support people, and the healthcare professionals in the multidisciplinary team. The goal setting process clarifies the clinical expectations, personal needs and preferences of the patient and the likely steps required to attain the agreed goals.

Risk screening guides the healthcare team’s immediate actions to mitigate and monitor risks. This includes conducting a risk assessment, implementing risk‑mitigation strategies, escalating care when required, and informing the patient’s plan for care.

Risk screening is a brief, systematic process used to identify whether a patient may be at risk of harm. Its purpose is to determine whether further assessment or early intervention is required. It is commonly completed on admission, transfer of care, or when a patient’s condition changes. 

Risk assessment is a clinical process used to explore, understand, and evaluate identified risks to inform clinical decision‑making, prioritise care needs, and reduce the likelihood of harm. It integrates clinical assessment, clinical judgement, patient input, and relevant history. Risk assessment is detailed, person-centred and action focused, and should enable prioritisation of interventions.

Risk screening and assessment can look differently depending on a range of factors, including: 

  • The hospital context, such as the size, location, type of hospital and patient population
  • The available clinical workforce
  • The way in which an individual patient has presented, such as through the emergency department, as an elective admission, or as a referral from outpatients, or a doctor’s rooms
  • The characteristics of the patient, such as their presenting problem, age, comorbidities and social circumstances
  • Where they are admitted to, and their treatment pathway, including whether they are a surgical, medical or subacute patient.

Risk screening and assessment should be completed to inform decision‑making, prompt action, and plan care that is safe, appropriate, and proactive to the patient’s individual needs.

A documented, comprehensive plan for care reflects shared decision‑making with patients and, where appropriate, their support people, outlining the interventions, treatments, and activities required to achieve agreed goals of care.

The content of a comprehensive plan for care varies according to the type of service being provided and the care setting. Health organisations may use different terms to describe this plan, and it may be recorded either in paper form or within digital systems. A comprehensive plan for care does not need to be a single document; it may consist of multiple related records that guide care delivery. For further guidance on what constitutes a comprehensive plan for care, review actions 5.7 through 5.13 in the National Safety and Quality Health Service Standards.

Advanced Care Planning 

Advance care planning is a structured process that supports individuals to reflect on, discuss and document their values, goals and preferences for future health care, should they lose decision‑making capacity. The outcomes of this process may include an advance care directive and/or the appointment of a substitute decision‑maker, both of which guide health professionals and support people in providing care that aligns with the person’s wishes. Advance care planning forms part of the comprehensive plan for care. 

External resources 

There is no one way to deliver comprehensive care as each person has different needs.

Comprehensive care should aim to address the clinical needs of the patient, their individual goals and preferences, and any risks of harm.

All members of the patient’s clinical team should be included in the comprehensive plan for care and work together to achieve the agreed outcomes.

Support people are vital to the delivery of comprehensive care, and clear strategies are needed to involve them when the patient consents to their participation.

Comprehensive care should be dynamic and respond to changes in the person’s condition, expectations, needs, diagnoses or prognosis.

Reviewing the delivery of comprehensive care helps ensure the patient’s personal and clinical needs continue to be met and supports timely updates to their care plan as those needs change.

How the elements relate to NSQHS Standards actions 

The six elements of comprehensive care delivery relate to specific actions in the National Safety and Quality Health Service Standards. Health professionals can use this table to review how their delivery of comprehensive care contributes to meeting actions in the standards. 

ElementPurpose of the elementRelated NSQHS actions
Element 1:
Clinical assessment and diagnosis
  • To evaluate the clinical information and make a provisional, and possible differential diagnoses
  • To determine appropriate investigations and actions required by the healthcare team
  • To prioritise and delegate interventions, timeframes and appropriate escalation processes
  • To commence the development of an appropriate and effective comprehensive care plan with the patient, families, carers and other support people and the multidisciplinary team
1.1, 1.6, 1.23, 1.24, 1.27 
2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.10 
5.3, 5.4, 5.5, 5.11, 5.12, 5.13, 6.9, 6.10, 6.11 
8.6–8.9
Element 2:
Identify goals of care

Develop a shared understanding of: 

  • The patient’s goals for their health care in the short, medium and long term
  • The clinical situation, including diagnoses, treatment options and clinical goals
  • The patient’s values, needs and preferences about their health and care
  • The patient’s expectations about the care episode and treatment outcomes
1.16 
2.6, 2.7, 2.8, 2.10 
5.3, 5.9, 5.13 
6.1, 6.3, 6.11
Element 3:
Risk screening and assessment
  • To gain an understanding of the degree to which a patient might be at risk of harm, or poorer outcomes
  • To inform decisions about action the healthcare team needs to take immediately to address identified risks such as specific assessment processes, implementation of risk mitigation strategies, and escalation of care where needed
  • To inform the development of a comprehensive care plan with the patient
1.15, 1.16 
2.2, 2.7 
3.6 
5.7, 5.10–5.12, 5.21–5.34 6.3, 6.4, 6.7, 6.9–6.11 
8.9, 8.10, 8.13
Element 4:
Develop a comprehensive plan for care
  • To develop a clear and holistic plan that includes the goals of care, identified risks, action taken and key treatment information for the episode of care
  • Provide an accessible resource that can be shared, used and updated by the multidisciplinary team
1.16 
2.6, 2.10, 2.7 
4.3 
5.3–5.6, 5.12, 5.13 
6.3, 6.4, 6.7–6.11
Element 5:
Deliver comprehensive care
  • To ensure patients receive coordinated delivery of the total health care required or requested
  • To ensure the care provided meets the agreed clinical and personal goals of care as described in the care plan
1.16 
2.7 
5.6, 5.14 
6.3–6.11
Element 6:
Review and improve comprehensive care delivery
  • To confirm the care delivered aligns with the comprehensive care plan
  • To allow for the revision or modification of the comprehensive care plan and delivery, in response to changes in patient health and circumstances
  • To review the delivery of comprehensive care and support ongoing quality improvement
1.16, 1.28 
2.10 
3.6 
4.3, 4.10 
5.14, 5.19 
6.3, 6.7–6.11

 

Additional resources

Last updated: 29 April 2026