Patients will require different health care depending on their individual needs, preferences and goals. It is important that care is provided continuously and collaboratively in line with the patients' diagnoses, agreed goals of care and the comprehensive care plan.
The process of delivering comprehensive care should include relevant clinical disciplines working together in a multidisciplinary team to achieve this outcome. Patients, families, carers and other support people are also essential for the delivery of comprehensive care, and strategies need to be in place to ensure they are supported to be effectively involved. The processes to deliver comprehensive care will vary depending on the type of health service organisation and the population served.
The Commission has developed resources to support understanding of the type of action clinicians and health service organisations can take to support the delivery of comprehensive care.
Meeting Action 5.14
Action 5.14 in the Comprehensive Care Standards requires health service organisations to demonstrate that clinicians use a documented comprehensive and individualised care plan for a patient that includes information about the patient’s clinical assessment, diagnoses, identified risks, goals of care and preferences.
Advisory AS18/15 Comprehensive Care Standard: Developing the comprehensive care plan addresses Action 5.13 and sets out a staged approach for health service organisations. A fact sheet has been developed to provide information about the relationship between the advisory relating to Action 5.13 and meeting Action 5.14.