Comprehensive care

A substantial proportion of potentially preventable adverse events are underpinned by failures in communication and teamwork (between members of a single healthcare service or across multiple healthcare services).

Multidisciplinary collaboration, where healthcare providers involved in a patient’s care communicate and work as a team, is an important element of comprehensive care. It includes referral to other healthcare providers, sending reports to a referring healthcare provider and discussions regarding a patient’s care to ensure that a coordinated approach to care is provided.

The healthcare service should provide accessible guidance about referral processes to different services. This should outline the:

• Clinical or other criteria for referral
• Consent from patient to refer, and the information the patient consents to sharing
• Necessary patient information (for example, co-morbidities, medical history and medications)
• Process for making the referral (for example, referring to the service or to a particular healthcare provider, by phone or email)
• Processes for expediting urgent referrals
• Availability of different services (for example, after hours)
• Expected response time
• Follow-up and escalation process for delayed response to a referral (if relevant).

While healthcare providers deliver comprehensive care within their scope of clinical practice, no single healthcare provider can deliver all aspects of the care that a patient might need. Individual healthcare provider groups bring specific expertise and together, effective collaboration relies on establishing and communicating clear and shared goals.

Collaboration with other healthcare providers can be supported by developing processes for effective communication, communicating critical information and documenting information.  

Interventions to improve multidisciplinary collaboration vary, but broadly include:

• Training and education of individuals and the team (where present)
• Identifying opportunities for better multidisciplinary communication
• Detailing what information and decision need to be documented
• Communication of information and decisions to other healthcare providers, patients, carers and families
• Using structured communication processes, and communication tools such as ISBAR, to increase the reliability of communication
• Clear understanding of the roles, responsibilities and accountabilities of different healthcare providers in the delivery of safe and good quality care.

Links to actions 3.27 Communication to support patient referral and multidisciplinary collaboration; and 3.29 Communication of critical information

Support the workforce to collaborate with other healthcare providers, when relevant, in the planning and delivery of health care by

• training (this may be part of formal qualifications or continuing professional development)
• identifying other local healthcare providers
• introducing processes for the workforce to identify and document other healthcare providers involved in a patient’s care in their healthcare record
• establishing processes for referral and/or reporting to a patient’s other healthcare providers when relevant

• Which other healthcare providers are involved in the patient’s care?
• What information is provided to another healthcare provider when a patient is referred to them?
• How does the workforce identify and record the details of other healthcare providers involved in a patient’s health care?
• What training do healthcare providers undertake regarding multidisciplinary collaboration?

• Process for referring a patient to another healthcare provider
• Evidence of training on processes to identify and document other healthcare providers involved in a patient’s care in their healthcare record
• Referral documentation that uses structured communication processes
• Feedback from patients, carers and family members on their experience when seeing different health professionals during single or multiple episodes of care
• List of local healthcare providers
• Observation of collaborative work to plan and deliver care

Burgess A, van Diggele C, Roberts C. et al. Teaching clinical handover with ISBAR. BMC Med Educ 20 (Suppl 2), Article number 459 (2020). https://doi.org/10.1186/s12909-020-02285-0

Healthcare services have an important role to play in supporting patients and consumers to stay healthy and well; almost half of all Australians have health conditions that could be prevented. ^42,43

Health promotion and prevention activities occur in almost all healthcare settings.⁴⁴ Healthcare services are encouraged to support health education and promotion, illness prevention and early intervention in their area of clinical practice, and tailor their messages to their specific patient population. For example, podiatrists working in a community with high rates of type 2 diabetes, or community health service working in an area with a large Aboriginal or Torres Strait Islander population will present prevention and promotion messages in different ways.

• Establish processes for routinely supporting health promotion and prevention in your service. This will include
  • identifying the health education and promotion priorities relevant to the service’s patient population
  • sourcing reliable and current health information, promotion material to aid discussion with patients or display in your service
  • having a process for conducting evidence-based screening and early intervention or referrals to another relevant healthcare provider, if appropriate

• Incorporate prompts into assessment processes to discuss preventative health and health promotion with patients and their carers

• What are the priority health issues for the patients and/or the community?
• What lifestyle or other factors can the service promote or provide more information on? Are there relevant health promotion events the service can promote, such as cancer awareness events
• What evidence-based screening tools and referral services exist that might benefit the community?
• What trusted websites or health information can be recommended to support patients?

• Health promotion or prevention material displayed in the service, including where patients and carers can access additional information
• Information on services available, including handouts, leaflets, QR codes directing patients to online information
• Observation of health promotion and prevention activities and discussions with patients and/or the community
• Records of workforce professional development opportunities to maintain the skills and knowledge of current evidence-based screening, care and treatment

Australian Government Department of Health: About preventive health in Australia. Working to enable healthy living through supportive environments.

Australian Government Department of Health: National Preventive Health Strategy 2021–2030. Outlines the overarching, long-term approach to prevention in Australia over the next 10 years.

Better Health Channel website. Health and medical information to improve the health and wellbeing of people and the communities they live in.

Health Translations: a free online library with translated Australian health and wellbeing information.

National Mental Health Commission: Mental Health Calendar. A calendar of mental health and wellbeing events and days for acknowledgement.

Council for Intellectual Disability: Easy Read resources for people with intellectual disability. A collection of health fact sheets in Easy Read format for people with intellectual disability, their families and carers.

Zenzano T, Davidson Allan J, Bigley MB, Bushart, RL. The Roles of Healthcare Professionals in Implementing Clinical Prevention and Population Health. American Journal of Preventive Medicine February 2011, 40(2):261-7. Available from: DOI:10.1016/j.amepre.2010.10.023

Comprehensive care is health care that is based on identified goals for care, which may be a discrete episode of care (for example, a hearing check) or as part of a comprehensive care plan (for example, services provided under a mental health care plan or chronic disease management plan). These goals are aligned with a 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.

Implementing comprehensive care requires effective processes to partner with patients in their own care, and to safely manage transitions between episodes of care and care providers. Achieving this action also relies on implementing the Partnering with Consumers Standard and Communicating for Safety actions.

Planning and delivering comprehensive care involves a number of essential elements. The way in which these elements are implemented in practice varies between healthcare services, depending on a range of factors, such as the service context, size, location and patient population; the characteristics of the patient and their presenting problem, age, comorbidities and social circumstances.

Planning and delivering comprehensive care involves:

Risk screening and assessment

Risk screening and assessment are a core part of healthcare delivery and comprehensive care. As well as identifying clinical issues, they also identify the likelihood of harm, and support decision making about treatment and risk mitigation

Clinical assessment and diagnosis

Using report of symptoms from patients, carers and families where appropriate, information about course of illness or condition as well as other relevant patient history, healthcare providers evaluate clinical information to make a clinical assessment and diagnosis within their scope of practice and commence development of an appropriate and effective comprehensive care plan

Identifying goals of care

Identifying and settings goals of care in collaboration with the patient, rather than focusing on clinical goals alone, ensures care is individualised. Understanding a patient’s values and their expectations and aspirations for their health and wellbeing, as well as clinical issues and risks of harm are all essential to the establishing shared goals of care

Agreeing a plan for care

Developing and agreeing a plan for care provides an opportunity to document a single, clear and holistic plan that addresses diagnoses, goals of care, identified risks, action taken and proposed, and the key treatment information for the episode of care. It can also serve as a tool to support multidisciplinary collaboration where appropriate

Delivering comprehensive care

The delivery of comprehensive care should align with the comprehensive care plan and address the identified clinical and personal goals of care, diagnoses and risks

Recall to follow-up

Incorporating processes to contact and recall patients for subsequent health care must be established. This can be undertaken by the healthcare service or through referral to another healthcare service. An example of patient recall is required is when follow-up care is required after diagnostic imaging or pathology results are received

Review and improvement of care delivery

Reviewing and improving care are iterative processes; that can occur because of changes in a patient’s condition, their diagnosis, their location, their goals, or any other clinical and personal reason. These changes often require reassessment and adjustments in the care plan

Advance care plans

An advance care plan documents the stated preferences about a person’s health and personal care, and preferred health outcomes. Advance care plans ensure that patients’ preferences are known if they are no longer able to speak for themselves. They can reduce the likelihood of unwanted or inappropriate treatment. Not all patients will have an advance care plan. Where they are in place, healthcare providers need to be able to accept and action as appropriate.

• Identify relevant screening and assessment tools that may be used by the healthcare service
• Support workforce access to continuing professional development and/or training to ensure planning and delivery of comprehensive care is in line with current best practice
• Develop and implement a process to document agreed plans for care in a patient’s healthcare record and recall patients for follow-up
• Define and implement processes to receive, document, provide access to and communicate advance care plans

• What risk screening and assessment tools are used within the healthcare service?
• How are agreed plans for care documented?
• How are patients recalled for follow up care? Is this process effective?
• How does the healthcare service ensure that, when a patient presents with an advance care plans, these are documented in the patient’s healthcare record and that care is provided in accordance with these plans?

• Training records or documents relating to screening, assessment, diagnosis, goal setting and delivery of comprehensive care in relevant clinical areas
• Screening and assessment templates or forms
• Examples of documented care plans
• Documents outlining patient recall process
• Reviews of the use of advance care plans to evaluate alignment with actual care given
• Examples of healthcare records with advance care plans documented
• Examples of healthcare records indicating recall of patients 

Australian Commission on Safety and Quality in Health Care: Implementing the Comprehensive Care Standard: Essential elements for delivering comprehensive care (August 2018) was published to provide practical support for the implementation of the comprehensive care actions in the National Safety and Quality Health Service Standards. The principles and strategies outlined in this resource are broadly applicable.

Australian Commission on Safety and Quality in Health Care: Implementing the Comprehensive Care Standard - Approaches to person-centred screening was published to provide practical support for the implementation of the comprehensive care actions in the National Safety and Quality Health Service Standards. The principles and strategies outlined in this resource are broadly applicable.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for Health Service Organisations Providing Care for Patients from Migrant and Refugee Backgrounds. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for health services providing care for people with mental health issues. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Advanced Care Planning Australia. The process of planning for your future health care.

CareSearch: Primary health care. Provides evidence-based guidance including triggers for consideration and recommendations for action, for health professionals working within primary health care.

People of Aboriginal and Torres Strait Islander origin can be at greater risk of avoidable differences in health outcomes when compared with other Australians.

A person’s Aboriginal or Torres Strait Islander heritage is personal to them and generally, no formal letter of confirmation is required to identify as an Indigenous Australian.⁴⁵ Aboriginal and Torres Strait Islander people are more likely to feel comfortable identifying if they are in a welcoming and culturally safe environment, free of racism and discrimination.

Links to actions 1.09 and 1.10 Patient populations and social determinants of health; and 1.25 Safe environment.

Ensuring culturally safe opportunities for people to identify as Aboriginal and/or Torres Strait Islander will:

• Support Aboriginal and Torres Strait Islander people to feel comfortable and safe when using your service
• Assist your healthcare service deliver high-quality and culturally safe care to all Aboriginal and Torres Strait Islander people
• Reinforce self-identification as important in enabling access to services
• Support Aboriginal and Torres Strait Islander patients access to relevant services

The National Best Practice Guidelines for Collecting Indigenous Status in Health Data Sets provides best practice guidelines for:

• how to ask the question
• how to record responses
• common scenarios, such as what to do when the workforce is reluctant to ask the question, and how to respond when a person wants to know why they are being asked.

• Establish processes for people to self-identify as Aboriginal and/or Torres Strait Islanders
• Facilitate access to training the workforce to build cultural safety capacity.  Training can be provided to the workforce via eLearning such as Asking the Question of Origin e-learning module (identification training)

• What processes are used to identify patients who identify as Aboriginal and/or Torres Strait Islander?
• How is this information recorded and used in care planning and delivery?
• What training does your workforce undertake to support them in asking the question?

• Patient record form on which patients can identify as being of Aboriginal or Torres Strait Islander origin
• Communication material displayed in common areas that provides patients with information about why they will be asked if they identify as being of Aboriginal or Torres Strait Islander origin
• Evidence of workforce training on cultural safety and how to ask the question

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User guide for Aboriginal and Torres Strait Islander health. Provides practical support for the implementation of the Aboriginal and Torres Strait Islander-specific actions in the NSQHS Standards. The principles and strategies outlined in this resource are broadly applicable.

AIATIS: Proof of Aboriginality. Reviews the three ‘working criteria’ used as confirmation of Aboriginal or Torres Strait Islander heritage.

Heart Foundation: Asking the Question of Origin e-learning module (identification training). This course provides training for health professionals on how to identify Aboriginal and Torres Strait Islander patients. 

AIHW: National Best Practice Guidelines for Collecting Indigenous Status in Health Data Sets. Developed to ensure the standard Indigenous status question is asked correctly and consistently of all clients of health services, and that this information is correctly recorded.

This action focusses on the role of the healthcare service in supporting the workforce to meet the individual needs of its patients, including those with disability and from diverse backgrounds.

People with disability or from diverse populations are more likely to face barriers in accessing healthcare services, which can in turn lead to avoidable differences in health outcomes.⁴⁶ Barriers may include inadequate staff training, cultural competency, expertise and capacity, limited access to skilled patient advocates, costs, accessibility of buildings and health care equipment, and discriminatory attitudes.⁴⁷

Information on patients from diverse populations that were identified from implementing Action 1.09 Patient populations and social determinants of health can be used to tailor strategies for individuals from different population groups. The strategies used may vary widely between groups and will need to be tailored to an individual’s health needs. Health care and referral pathways delivered by the healthcare service should incorporate risk management strategies, for example, providing access to translators or mobility assistance.

A ‘reasonable adjustment’ is when action is taken to meet the particular needs of a person with disability and prevent inequity. Reasonable adjustments can improve safety and quality in health care as they facilitate:

• Preventative health care
• Person-centred approaches
• Comprehensive care

Links to actions 1.09 and 1.10 Patient populations and social determinants of health.

• Periodically review local community and patient demographics to identify the diversity of the patients using the healthcare service and incorporate into planning for care
• Build staff confidence and awareness of the issues for people with disability
• Identify the reasonable adjustment of strategies or services that can be used when providing comprehensive care for patients who are more likely to face barriers in accessing healthcare services
• Facilitate access to training to support planning and delivery of health care that is inclusive
• Identify tools and resources that can be used to support safe care for people with disability and from diverse backgrounds

• What are the sociodemographic characteristics of the healthcare service’s patient population?
• What strategies is the healthcare service implementing to optimise health outcomes for these patients?
• What tools and resources are available for the workforce?

• Demographic data for the healthcare service’s patient population and the local community that are used for planning purposes
• Evidence of culturally informed training and comprehensive care planning
• Tools and resources used by the workforce to support safe care of people with disability and from diverse backgrounds
• Training documents on diversity and cultural awareness
• Consumer information that is available in different formats and languages that reflect the diversity of the patient population
• Observation of healthcare providers communicating with patients in their preferred language
• Equipment or design of the facility to enable access to care for people living with a disability

Australian Commission on Safety and Quality in Health Care: Cognitive impairment: Clinicians can take action to reduce the risk of harm. Lists steps and details a quality and safety pathway.

Australian Commission on Safety and Quality in Health Care: Cognitive impairment resources. A range of resources to help improve the safety and quality of health care for people with cognitive impairment or at risk of delirium. 

Australian Commission on Safety and Quality in Health Care: Delirium Clinical Care Standard. Describes the key components of care that patients can expect when they have delirium. It supports the provision of high-quality, evidence-based care.

Council for Intellectual Disability: Resources for health practitioners. Resources for healthcare providers to support better appointments when working with people with intellectual disability.

Acon: Pride Training. Offers training, information, and educational services to assist health, wellbeing, and community organisations in increasing their knowledge of LGBTQ people and communities, and provide guidance on inclusive practice. 

Rainbow Health Australia: Supporting LGBTIQ health and well being. Through research and knowledge translation, training, resources, policy advice and service accreditation through the Rainbow Tick.

Reconciliation Australia: The lead body for reconciliation in Australia. Promotes and facilitates reconciliation by building relationships, respect and trust between the wider Australian community and Aboriginal and Torres Strait Islander peoples.

Australian Human Rights Commission: Access for all: Improving accessibility for consumers with disability. Provides practical tips for businesses on improving access to goods, services, facilities, premises and information for consumers with disability.

Australian Human Rights Commission: Disability Rights. Promoting the rights of people with disabilities and building a more accessible, more inclusive community.

Translating and Interpreting Service (TIS). The Free Interpreting Service aims to provide equitable access to key services for people with limited or no English language proficiency. TIS National delivers the Free Interpreting Service on behalf of the Australian Government.

Australian Government: National Relay Service. For people who are deaf and/or find it hard hearing or speaking with people who use a phone.

Australian Government Department of Health: National Roadmap for improving the health of people with intellectual disability. Aims to address serious health inequities faced by people with intellectual disability.

Australian Government Department of Social Services: National Disability Strategy 2021-2030. A national framework that sets out a plan for continuing to improve the lives of people with disability in Australia over 10 years.

UNSW: Department of Developmental Disability Neuropsychiatry resources for health professionals. Provide information and education on intellectual disability physical and mental health.

Note: This action is only applicable if your healthcare service delivers end-of-life care.

‘End of life’ refers to the period when a patient is living with, and impaired by, a fatal condition, even if the trajectory is ambiguous or unknown. This period may be years in the case of patients with chronic or malignant disease, or very brief in the case of patients who suffer acute and unexpected illness or events, such as sepsis, stroke or trauma.

The health care that people receive in the last years, months and weeks of their lives can help to minimise the distress and grief associated with death and dying for the individual, and for their family, friends and carers. People living with a life-limiting illness have end-of-life care provided in many different settings – in their homes, acute hospitals, hospices (which may be community-based or led by tertiary facilities), general practices, specialist clinics, aged care facilities, and other organisations where  people may be living (such as correctional facilities and locations caring for people living with severe mental illness or severe disabilities).

The National Consensus Statement: Essential elements for safe and high-quality end-of-life, describes guiding principles and essential elements of end-of-life care. Many of these are relevant to care delivered in primary and community healthcare settings.

Healthcare providers in primary and community healthcare settings have an important role to play in the delivery of care at the end of life, and there are increasing calls for allied health professionals to be involved in a multidisciplinary approach. Allied health professionals can help with symptom management including with nutrition, communication and mobility; help the person maintain function and independence, offer emotional support; share information about disease progression and help to plan future care; and help connect the person and families to support services.

The consensus statement describes triggers for recognising when patients are approaching the end of life. Considering the likelihood of a patient dying creates opportunities to identify their needs and preferences, review their goals and comprehensive care plan, and consider how best to align care with the individual’s expressed values and wishes. Routine use of simple trigger tools and questions can prompt clinicians to use their clinical judgement to make a holistic assessment of whether a patient has end-of-life care needs.

• Use the National Consensus Statement: Essential elements for safe and high-quality end-of-life care to implement processes for identifying patients with end-of-life care needs and improving end-of-life care
• Describe key considerations and actions healthcare providers would take when planning and delivering health care for someone who is at the end of life
• Where required, the healthcare service should seek specialist palliative care advice through referral pathways or informal contact with specialist palliative care services

• How does the healthcare service organisation identify patients who are at the end of their life?
• How does the healthcare service ensure that these processes are consistent with the National Consensus Statement: Essential elements for safe and high-quality end-of-life care?
• How does the healthcare service ensure care is provided in accordance with advance care plans?
• How does the healthcare service seek advice from other healthcare professionals including specialist palliative care services?
• How are clinicians supported to share decisions about end-of-life care with patients, carers and families?

• Communication (for example, posters on clinic walls, emails to clinicians, information on noticeboards) that outlines processes for accessing specialist palliative care advice
• Observation of clinicians accessing specialist palliative care advice
• Resources and tools to help clinicians identify patients who are at the end of life
• Training documents (for example, syllabus, attendance records, competency assessments) about identifying patients who are at the end of life
• Tools and resources for shared decision-making with patients, carers and families about end-of-life care
• Observation of discussions on shared decision-making about end-of-life care between clinicians, patients, carers and families
• Patient and carer information packages or resources about end-of-life care options.

Australian Commission on Safety and Quality in Health Care: National Consensus Statement: Essential elements for safe and high-quality end-of-life care. Describes 10 essential elements for the provision of end-of-life care in settings where acute care is provided. Principles and strategies are broadly applicable.

Advance Care Planning Australia. Reviews the process of planning for future health care.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

CareSearch website. Consolidates online palliative care knowledge for health professionals, people needing palliative care and their families and for the general community.

Palliative Care Australia website. Provides access to training and resources for patients, carers, health professionals and service providers.

End-of-life essentials website. Provides online learning opportunities and practice resources for doctors, nurses and allied health professionals to improve the quality and safety of end-of-life care in hospitals.

Talking End of Life (TEL) with people with intellectual disability website. Resources for disability support professionals, healthcare providers, families and educators to teach people with intellectual disability about end of life.

Australian Government Department of Health: National Palliative Care Strategy 2018. Provides guidance across a range of health care settings to develop access protocols. The strategy articulates a cohesive national approach to the development and delivery of palliative care across Australia. The overarching vision as outlined in the strategy for palliative care in Australia is ‘people affected by life-limiting illnesses get the care they need to live well’.

ACON: LGBTQ+ Toolkit for Palliative Care and End of Life Decisions. Consumer resources on end-of-life care through an LGBTQ+ lens. 

Talking end of life with people with intellectual disability, tool kit: Provides resources to help people with disability learn about and deal with dying and death, just as they learn about every other aspect of life.