Comprehensive Care - Frequently Asked Questions

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.

Comprehensive care means that the patient receives care that is planned and coordinated around their physical, mental and cognitive health needs. Patients should also continue to receive comprehensive and compassionate care at the end of their life.

This new standard was developed to address the cross-cutting issues underlying many adverse events in health care. It recognises the need for care to be centred on patient goals and wellbeing.  It also addresses important issues not included in the first edition of the NSQHS Standards, such as mental health, cognitive impairment, health literacy, end-of-life care, and Aboriginal and Torres Strait Islander health. These have the potential for significant improvements in care.

The new standard aims to ensure that a patient’s goals and risks of harm are identified so that comprehensive care plans can be developed and delivered to meet their needs. It also recognises the importance of teamwork and collaboration to provide comprehensive care. Along with new actions, the new standard includes actions from the Preventing and Managing Pressure Injuries Standard and the Preventing Falls and Harm from Falls Standard from the first edition.

To ensure that the organisation’s safety and quality systems, policies and processes are integrated, it is important to consider how all the NSQHS Standards are linked.  This will reduce the risk of duplicating efforts that may arise from attempts to implement the eight standards separately.

For the Comprehensive Care Standard, meaningful implementation requires attention to the processes for partnering with patients in their own care, and for safely managing transitions between episodes of care. Therefore, there are strong links with the Clinical Governance, Partnering with Consumers, Communicating for Safety and Recognising and Responding to Acute Deterioration Standards.

Table 1 provides a summary of the six essential elements of comprehensive care delivery, outlining the purpose of each element and where this might relate to actions in the NSQHS Standards.

Table 1: Essential elements of comprehensive care delivery

To share your story or experience of comprehensive care you may like contact us via email or submit a story through the share your comprehensive care story process.

Measurement and evaluation of comprehensive care should occur within a wider framework for improvement, and many different and well-established approaches for safety and quality improvement exist.

Health service organisations should ensure comprehensive care policies, procedures and protocols align with state and territory requirements and reflect best practice and current evidence. Review the use and effectiveness of these policies, procedures and protocols through a schedule of clinical audit or performance reviews. Actively engage clinicians in the audit processes, analysis of results and plans for proposed actions for improvement.

In addition to having organisational systems in place, health service organisations can evaluate comprehensive care delivery through the periodic review of:

• Credentialing and defining scope of clinical practice
• Clinical education and training, including whole of organisation clinical, and safety and quality education and training
• Performance monitoring and management
• Patient stories and feedback, patient reported outcome measures, and patient and family surveys
• Feedback from members of the workforce.

For more information, refer to the following Commission resources and web pages:

• Element 6: Review and improve comprehensive care delivery

Leaders of health service organisations are required to support clinicians to deliver comprehensive care. The clinical workforce plans and delivers comprehensive care aligning to the Comprehensive Care Standard. It is every clinician's responsibility to participate in teamwork to contribute and coordinate person-centred comprehensive care. Comprehensive care is not delegated to any specific healthcare profession. Clinicians work collaboratively to plan and deliver comprehensive care.

The Commission defines a multidisciplinary team as - a team that includes clinicians from multiple disciplines who work together to deliver comprehensive care, and deals with as many of the patient’s health and other needs as possible.

The team may operate under one organisational umbrella or may be from several organisations brought together as a unique team. As a patient’s condition changes, the composition of the team may change to reflect the changing clinical and psychosocial needs of the patients.

Multidisciplinary care includes interdisciplinary care, where a discipline is a branch of knowledge within the health system.

It will be important to assess the training needs of your workforce in relation to delivering comprehensive care, identify any gaps, and determine if additional training or education resources are required. The governing body needs to define the mandatory education and training requirements to support the provision of comprehensive care and evaluate the effectiveness of such training. 

The health service organisation needs to provide orientation to the workforce that includes the roles and responsibilities for safety and quality and cultural awareness and cultural competence.

Further information can be found in relation to training systems on the NSQHS Standards website:

• Action 1.20
• Action 5.1c

Teams that are high-performing are found to share a common vision, have a strong sense of trust and confidence, optimise collaboration, communication and coordination and understand one another’s roles and responsibilities.

Ensuring governance, infrastructure, resources, availability and quality of workforce training and quality improvement processes will improve multidisciplinary collaboration and teamwork. The extent to which these factors impact on the quality of collaboration between team members will vary from setting to setting and over time.

Specific actions in the Comprehensive Care Standard recognise the importance of teamwork and collaboration. Suggested strategies to strengthen teamwork processes to implement the NSQHS Standards  include³³:

• Training to increase individual competence of team members and offer the opportunity to practise skills (further discussed below under Workforce development);
• Structured communication protocols to increase reliability of communication
• Clear articulation of the roles, responsibilities and accountabilities of different team members
• Work and process redesign to provide structured opportunities for effective team communication.

More information can be found at the Communicating for safety resource portal.

The Commission uses the following terminology:

• Risk screening: a short process to identify patients who may be at risk of, or already have a disease or injury. It is not a diagnostic exercise; rather a trigger for further assessment or action.
• Risk assessment: a more complex and in-depth measurement process designed to be completed when required after screening to quantify risks of harm and identify potential mitigation strategies.

The way in which risk screening and assessment processes for are used varies within health service organisations, 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, and the particular specialty they may be under.

See also: Element 3 Risk screening and assessment

A valid screening tool is one that has been tested and found to accurately identify individuals at-risk within a targeted population and setting. Risk screening is important to identify and mitigate potential risks for the patient.

Despite there being many risk and assessment tools available, many are of questionable quality and few have been validated. Health service organisations can create improved consistency of approach, and potentially a reduction in duplication, if an agreed organisation-wide approach to screening is put in place.

The specific processes a health service organisation develops for risk screening and assessment will depend on the hospital’s size, location, type, the patient population and the available clinical workforce. Individual patient characteristics such as presenting condition, comorbidities and the ward or department to which they are admitted are also relevant. 

Implementing the Comprehensive Care Standard - Approaches to person-centered screening

2018

Publication, report or update

Identifying patients who may be at risk of harm, and mitigating the risks for those patients is a core part of comprehensive care planning and treatment.

How comprehensive care is delivered in practice will depend on the context of care delivery (organisational size, location and the type of service delivered), and the patient receiving care. Systems to delivery comprehensive care will therefore vary, even within the same health service organisation. A flexible approach to standardisation will support local implementation and innovation.

While systems to deliver comprehensive care delivery may differ, the outcome for patients should be the same. That is, care is delivered based on the comprehensive care plan and in partnership with patients, carers and families. The comprehensive care plan is integrated, individualised and identifies goals of care that 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. This involves effective communication, coordination of care across teams, and ensuring diversity and equity are respected and supported.

• Information to help support healthcare organisations deliver comprehensive care

Work undertaken on the key attributes of high-performing person-centred organisations may also be helpful.

Access resources

Health service organisations have a wealth of administrative and clinical data about their patient population. This data can be analysed and used to identify common risks or complications experience by patients at the organisational and ward level. Some of the common risks nationally are those identified in the hospital-acquired complications (HAC) list, which includes 16 serious complications that clinicians can respond to, and put in place clinical mitigation strategies to reduce their occurrence.  

The information gleaned from such data can be used to inform decisions about the types of assessment processes that would be more frequently required within the organisation, and the types of strategies that would be needed to minimise commonly experienced risks.

For example, if a health service organisation identifies that their patient profile includes a high proportion of frail elderly patients, then the organisation could strengthen the types of screening approaches, assessment tools and baseline interventions needed to mitigate risks of harm from falls, pressure injuries, cognitive impairment and malnutrition.

Goals of care are clinical and personal goals for a your episode of care and are determined in the context of a shared decision making process. They include the specific treatments, the intensity and types of interventions and care, articulating what you hope to achieve through your health care.

The purpose of identifying and agreeing to goals of care is to develop a shared understanding between you, family, carers, other support people and the clinicians in the multidisciplinary team about your clinical expectations, personal needs and preferences  and the likely steps required to attain the agreed goals.

Identifying goals of care helps to organise and prioritise care activities and contributes to improved satisfaction, quality of life and self-efficacy. At a minimum, your health care provider should ask what is important to you in relation to your health care, and use this information to identify goals of care with you.

More information can be found by accessing the following resources and pages:

• Element 2: Identifying goals of care

Comprehensive Care - Element 2: Identifying goals of care - Tips for clinicians

2019

Fact sheet or brochure

These eight tips about setting goals can be used when assisting patients and family, carers and other support people to identify and develop goals of care.

Goals of care are clinical and personal goals for a patient’s episode of care that are determined in the context of a shared decision making process. They include the specific treatments, the intensity and types of interventions and care, articulating what a person hopes to achieve through their health care.

The purpose of identifying and agreeing to goals of care is to develop a shared understanding between patients, family, carers, other support people and the clinicians in the multidisciplinary team about the clinical expectations, personal needs and preferences of the patient and the likely steps required to attain the agreed goals.

Identifying goals of care helps to organise and prioritise care activities and contributes to improved satisfaction, quality of life and self-efficacy for patients. The approach taken by an organisation to identify patient’s goals of care may include use of tools, frameworks, models or adoption of more generalised person-centred communication methods. As a minimum, clinicians should ask patients what is important to them in relation their health care, and use this information to identify goals of care.

More information can be found by accessing the following resources and pages:

• Element 2: Identifying goals of care
• Communicating for safety resource portal

Comprehensive Care - Element 2: Identifying goals of care - Tips for clinicians

2019

Fact sheet or brochure

These eight tips about setting goals can be used when assisting patients and family, carers and other support people to identify and develop goals of care.

Videos about shared decision making:

Overview

Myth busting

Decision aids

No, you do not need to develop a different care plan for each identified risk.

For more information about comprehensive care planning see: Element 4: Develop a single comprehensive care plan

A comprehensive care plan provides an organising structure for information about treatments for individual patients’ diagnoses and their risks and issues with performing activities of daily living. A documented plan that is up-to-date, accurate, reliable, relevant and legible aids continuity of care and supports communication of key health information. The comprehensive care plan should follow the principles of good documentation.

There are a number of components that should be included as a minimum in a comprehensive care plan and the detail of those components will differ depending on the individual circumstances of the patient. Ensuring information in the comprehensive care plan is correct and individualised to the patient supports clinicians to:

• Provide continuity of care
• Make safe clinical decisions in alignment with the comprehensive care plan
• Effectively communicate across transitions with other healthcare providers and across multidisciplinary teams about the current and planned interventions and care
• Effectively communicate and support partnerships with patients
• Reduce suboptimal management of patients’ conditions, inadequate assessment of functional state and inadequate detection of preventable complications.

For more information about developing a comprehensive care plan see Element 4: Develop a single comprehensive care plan

The Partnering with Consumers and Comprehensive Care Standards require health service organisations to have systems that are based on partnering with patients in their own care to the extent that they choose. Strategies that support involving patients, families and carers in care planning could include:

• Informing patients and the workforce about the Australian Charter of Healthcare Rights
• Patient-centred policies, procedures and protocols to support clinicians to partner with patients, informed consent, patient preferences and document consent
• Processes to ensure the workforce are skilled and knowledgeable in seeking consent, particularly from at-risk populations, such as culturally and linguistically diverse people, Aboriginal and Torres Strait Islander people, and children
• Processes to identify the capacity of a patient to make decisions about their care
• Processes to identify substitute decision-makers where necessary
• Education and training programs to support the workforce to form partnerships with patients
• Communication methods to address the diversity of the patient population and local community.

For more information on shared decision making visit the Shared decision making page. Other useful information can be found on the person centred care page. 

Specialty services often have a protocol or care pathway that serves the needs of a comprehensive care plan.  Variations to standardised pathways can sometimes be managed within the specialty service, however clear referral guidelines should be specified.

Health service organisations should consider how they support clinicians to identify goals of care including documenting, communicating and using goals to inform comprehensive care planning and delivery.  The approach taken by an organisation may include use of tools, frameworks, models or adoption of more generalised person-centred communication methods. As a minimum, clinicians should ask patients what is important to them in relation to their health care, and use this information to identify goals of care.

When patients are admitted to a day procedure unit, they should be asked by a clinician if there have been any changes to their condition or circumstances since their preadmission screening. If changes have occurred and the patient no longer meets the acceptable risk profile for the organisation, they should be referred to the most suitable service. Also see the Commission fact sheet for Day procedure Services.

Risk screening and assessment - Information for Day Procedure Services

2020

Fact sheet or brochure

It is important to understand why a patient does not want to participate in care planning – don’t assume.

Shared decision making is not about leaving patients to make decisions unsupported. It's about the clinician and patient working together to determine the best course of action for that person. Studies show that most patients want to be involved, or at least they want to be offered the opportunity to participate in care planning.

Shared decision making is more than a discussion. It's more than having great communication skills and rapport with patients; shared decision making involves extra steps, such as explaining: each option; the quantitative evidence of the risks and benefits of each option; and then exploring with the patient their preferences and what matters to them.

A comprehensive care plan is a document or digital view describing agreed goals of care, and outlining planned medical, nursing and allied health activities for a patient. Comprehensive care plans reflect shared decisions made with patients, carers and families about the tests, interventions, treatments and other activities needed to achieve the goals of care. The content of comprehensive care plans will depend on the setting and the service that is being provided, and may be titled differently in various health service organisations.

More information is available from Element 4: Develop a single comprehensive care plan

The commission has developed a number of fact sheets on advance care planning.

Advance Care Planning - Information for health service organisations

2020

Fact sheet or brochure

Advance Care Planning - Information for clinicians

2020

Fact sheet or brochure

My Health Record - Rapid Reference Tool - Advance Care Planning Information

2019

Poster or graphic

Other sites that may be helpful include:

• Advance Care Planning Australia
• End of life directions for aged care
• RACGP advance care planning
• Add an advance care plan to My Health Record
• Cognitive Decline Partnership Centre: Advance care planning
• Dementia Australia – planning ahead
• Supporting decision-making: A guide for people living with dementia, family members and carers

The electronic medical record (eMR) contains a very detailed and often lengthy documentation about a person's health care. A comprehensive care plan is a document or digital view within the eMR describing agreed goals of care, and outlining planned medical, nursing, midwifery and allied health activities for a patient. A single comprehensive care plan should be prepared for a patient so that core information can be easily shared, accessed and acted on by all members of the multidisciplinary team. Use of an  eMR within a health service organisation is not sufficient demonstration of the development of a comprehensive care plan for each patient.

A comprehensive care plan is not limited to one page. Comprehensive care plans will be different depending on the clinical needs, and care preferences of the patient, care  delivery models or service types. Each organisation should assess needs and implement a planning and documentation process that meets the needs of the population served. What is important is that the comprehensive care plan is contained within a document or digital view and includes the agreed goals of care, and outlining planned medical, nursing, midwifery and allied health activities for a patient. 

How comprehensive care is delivered in practice will depend on the context of care delivery (organisational size, location and the type of service delivered), and the patient receiving care. Systems to delivery comprehensive care will therefore vary, even within the same health service organisation. A flexible approach to standardisation will support local implementation and innovation.

While systems to deliver comprehensive care delivery may differ, the outcome for patients should be the same. That is, care is delivered based on the comprehensive care plan and in partnership with patients, carers and families. The comprehensive care plan is integrated, individualised and identifies goals of care that 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. This involves effective communication, coordination of care across teams, and ensuring diversity and equity are respected and supported.

Information to help support healthcare organisations deliver comprehensive care is at: Comprehensive care

There is also useful information in the key attributes of high-performing person-centred organisations resource. 

Review of key attributes of high-performing person-centred healthcare organisations

2018

Publication, report or update

Seven attributes of high-performing person-centred healthcare organisations were identified during this review.

Communication is a core clinical skill that can be developed and improved with practice, experience, continuous learning, mentorship and support. Clinicians need to develop expert communication skills, especially when discussing risks or delivering bad news to patients, families, carers and support people. Patients and families differ in their needs for information, interpretation of information delivered to them, and how they respond.

You may find the following resources helpful:

• Communication risk elearning module 
• End-of-life essentials e-learning modules
• Communication for safety resource portal

End-of-life Care - Audit

2018

Audit, monitoring or reporting tool

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Health service organisations need to develop their own systems to deliver safe, timely and high-quality comprehensive end-of-life care. These systems will need to be tailored to the setting, the needs of the population, and the available resources and workforce, while aligning with the NSQHS Standards, the National Consensus Statement: essential elements for safe and high-quality end-of-life care and the National Consensus Statement: essential elements for recognising and responding to clinical deterioration.

More information is at:

National Consensus Statement: Essential elements for safe and high quality paediatric end-of-life care

2016

Publication, report or update

The end-of-life care actions in the Comprehensive Care Standard are intended for the provision of end-of-life care in settings where acute care is provided. It may be appropriate for patients who are in the last years or months of life to undergo a clinical procedure in a day procedure unit, however it is important that risk screening is undertaken to ensure patient safety.

The health service organisation needs to have policies and procedures that outline the care of patients whose care may vary from a standardised clinical pathway and patients that do not meet the acceptable risk profile for the organisation should be referred to the most suitable service. Day procedure services should have processes in place in the event that a patient dies.

The specific harms included in the Comprehensive Care Standard have been identified as high-prevalence, preventable adverse events in hospitals, where clinical risk mitigation strategies may reduce, but not necessarily eliminate, the risk of harm.

You need to consider a number of factors to determine the risks applicable to your organisation. You should access appropriate information to gain an understanding of:

• The risk profile of the patient population served
• Profile of the clinical workforce including skill mix of the service
• Available resources including human, equipment and the physical environment.

Each patient may be at risk of harm during health care that may not have been considered. These patients need to be identified by clinicians to ensure that they receive comprehensive care.

You need to consider a number of factors to determine the risks applicable to your organisation. You should access appropriate information to gain an understanding of:

• The risk profile of the patient population served
• Profile of the clinical workforce including skill mix of the service
• Available resources including human, equipment and the physical environment.

Each patient may be at risk of harm during health care that may not have been considered. These patients need to be identified by clinicians to ensure that they receive comprehensive care.

The Minimising patient harm criterion of the Comprehensive Care Standard now encompasses the actions from the individual pressure injury and falls standards.

The Minimising harm criterion also includes nutrition and hydration, preventing delirium and managing cognitive impairment, predicting, preventing and managing self-harm and suicide, predicting, preventing, and managing aggression and violence, and minimising the restrictive practices of restraint and seclusion.