People affected by cancer have access to an appropriate health and supportive care provider(s) to coordinate their care, and the documentation clearly states who the identified contact(s) is.
All health care plans identify what supportive care needs exist for the person affected by cancer and how they will be addressed.
Services to people affected by cancer are provided by many disciplines and types of organisations. The person affected by cancer may have complex needs throughout their pathway, which requires the collaboration and coordination of responses to these needs.
Recognition of the value that all services bring is best supported by collaborative care models which incorporate input from a variety of health and supportive care workers in a way that is understood and clear to the person affected by cancer. This cannot be assumed to be occurring, but needs direct intervention and attention to ensure organisations are working together effectively. It is well recognised that continuity of care across providers depends on communication and sharing of information so that the person affected by cancer can be supported in a timely and consistent way.
Care and support coordination is a shared responsibility for the workforce, service and system. For the person affected by cancer the key is that they know who to contact, and how, at any point within their cancer journey.
Good Practice Points
· Promote the use of information systems/ mechanisms which support the combination of biomedical, psychological, cultural and social care.
· Supportive care is integrated within clinical pathways such as Map of Medicine and Health Pathways.
· People affected by cancer have access to appropriately skilled supportive care services at the point of need.
· In both policy formation and practice, palliative care is recognised as an essential component of the care and support coordination for people.
· Palliative care provision reflects the interdisciplinary skills, communication and understanding of the roles required to deliver a comprehensive service.
· Services actively take steps to ensure they are working together rather than in silos.
· Administration processes and IT support have a role in supporting care coordination.
· Health and supportive care workers communicate with people affected by cancer to develop a plan that identifies how their goals of care, including functionality, wellbeing and whānau stability, are to be addressed.
· The process for transferring care between services is clear and transparent and accompanied by the appropriate documentation.
Good Practice Points System
· Supportive care providers establish healthy networks which model collaborative practice to support the person affected by cancer.
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Cancer Stories Aotearoa –
Kahui Korero Taumahatanga o Te Mate Pukupuku
· Is able to engage collaboratively with other providers to support the person affected by cancer and their whānau and give information about other providers accurately.
· Is aware of the specialist and community palliative care resources which exist and how to utilise them.
· Is able to address any concerns about role confusion and overlap with other professions.
· Is able to communicate with people affected by cancer to develop a plan that identifies how their goals of care, including functionality, well-being and whānau stability, are to be addressed.
· Is aware of the different needs a person has dependent on their age and that these may vary, particularly in childhood, adolescence and when assisting an older person.
Training and Resources Available
· Person centered care video around how to improve shared decision making
· An organisation which works with families who may have several services involved with them to improve coordination.
· An outline of resources across the palliative care spectrum
· Ministry of Health. (2014). Building of Knowledge and Skills for Cancer Nursing. Wellington: Ministry of Health. Has a section on Care Coordination skills and expectations.
· Te Ara Whakapiri (Last days of Life)
Last Updated October 2016