Multidisciplinary Assessment and Documentation in Community Palliative Care

Croydon Community Health Centre implemented a new model of care, including scheduled multidisciplinary team meetings, revised documentation and communication processes, as well as training for emergency department (ED) and generalist nursing staff.


To ensure that by 31 May 2017, 100 per cent of patients referred to Croydon Community Health Centre have a documented assessment of their palliative care needs at the beginning of each new episode of care, which will be communicated to their general practitioner (GP) and referrer.


  • Improves communication with the patient’s GP and healthcare team.
  • Improves advance care planning to help patients stay in control of their health.
  • Reduces the risk of futile and burdensome treatments on palliative care patients.
  • Ensures ED staff can access the patient’s documentation and care goals.
  • Reduces the number of palliative care patients presenting to the ED.
  • Increases community nursing staff knowledge and use of the Palliative Care Outcomes Collaborative (PCOC) system.
  • Increases revenue for the hospital from billing multidisciplinary team meetings.


Historically, patients referred to Croydon Community Health Centre did not have a scheduled discussion with a multidisciplinary team about their health, or undertake advance care planning. There was also no documentation or communication processes in place to ensure that all healthcare professionals involved in the care of the patient were aware of their health problems.

A review of new patients undertaken in November 2016 found that patients with high levels of distress were not always cared for with the same urgency as those with physical symptoms. In a survey conducted during the same period, registered nurses reported a lack of confidence when using the PCOC system and GPs did not understand the palliative care services available at Croydon Community Health Centre.

These problems meant that patients presenting to the ED either did not have an Advance Care Plan, or if they did it could not be found by hospital staff. GPs were often unaware that their patient had an Advance Care Plan or were being seen by the community palliative care team. In addition, the focus on physical symptoms caused delays in recognising psychosocial or functional issues.


  • Prior to the project, weekly meetings were not structured or well attended. Structured weekly multidisciplinary team meetings were established, with two palliative care specialists, a registrar, clinical nurse coordinator, clinical nurse specialist, occupational therapist and social worker required to attend.
  • Documentation was standardised to improve the assessment of the patient’s care needs and goals (if known). This documentation included information on:
    • diagnosis
    • current active treatment
    • who to contact in palliative care
    • domains for physical, functional and psychosocial issues
    • a management plan and who is responsible for each element
    • the most appropriate place for admission if required
    • goals of care
    • the Advance Care Plan, Advance Care Directive and NSW Ambulance Adult Palliative Care Plan, if completed.
  • The outcomes of the team meeting were communicated to the patient’s GP via a form that was developed as part of the project.
  • Advance Care Plans and Palliative Care Plans identified during multidisciplinary team meetings were sent to the patient’s GP once completed.
  • ED medical staff were provided with education via a one-hour face-to-face session and emailed instructions with screenshots on how to access the patient’s documentation and incorporate it into their medical record.
  • The structure of community morbidity and mortality meetings were changed to incorporate PCOC assessments as a case-based learning tool.
  • Monthly case reviews of current patients were established, led by a palliative care registrar or specialist and attended by generalist nursing staff.
  • As of November 2017, a plan to start billing for multidisciplinary team meetings is underway. This will sustain the project, as the billing unit will take over the administrative responsibilities of sending letters to GPs, while raising funds which will be allocated to the service.

Project status

Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.

Key dates

October 2016 – May 2017

Implementation sites

Croydon Community Health Centre, Sydney Local Health District


Clinical Excellence Commission Clinical Leadership Program


  • The number of new referrals with assessments of palliative care needs that were documented and sent to the patient’s GP increased from zero to 57 per cent. The stretch goal of 100 per cent was not achieved, partly due to the fact that patients had died or were admitted to hospital before receiving a multidisciplinary assessment, and partly due to time constraints for the meeting.
  • The number of palliative care patients with psychosocial and functional information recorded, increased from 50 per cent in January 2017 to 100 per cent in May 2017.
  • The number of palliative care patients with documentation of advance care planning in their electronic medical record increased from 15 per cent in December 2016 to 49 per cent in May 2017.
  • The number of palliative care patients presenting to the ED reduced from 19 per cent in December 2016 to 14 per cent in May 2017, although it is difficult to know if this was a result of the project.
  • The use of PCOC improved, with patients who scored high distress from symptoms more likely to be categorised as being in an unstable phase.

Lessons learnt

  • Make sure there is a good understanding of the project and buy-in among stakeholders, especially in a service where generalist community nursing services also provide palliative care.
  • Involving generalist nurses who provide patient care early in the project is essential, as the changes may affect their workload so their input is extremely helpful in minimising disruption.
  • When sending the results of a multidisciplinary team meeting to the patient’s GP, include any advance care planning documents and a cover letter to explain what you are sending.

Further reading

  • CareSearch, Palliative Care Knowledge Network.
  • NSW Agency for Clinical Innovation (ACI). Palliative and End of Life Care - A Blueprint for Improvement. Chatswood, NSW: ACI; 2017.
  • Palliative Care Outcomes Collaboration
  • Spencer L. Hospice to home: a patient-centric multi professional community approach. International Journal of Palliative Nursing 2015;21(5):245-50.
  • Ventura AD, Burney S, Brooker J et al. Home-based palliative care: a systematic literature review of the self-reported unmet needs of patients and carers. Palliative Medicine 2014;28(5):391-402.
  • Walshe C, Luker KA. District nurses’ role in palliative care provision: a realist review. International Journal of Nursing Studies 2010;47(9):1167-83.


Katalin Urban
Palliative Care Staff Specialist
Concord Repatriation General Hospital
Sydney Local Health District
Phone: 02 9767 6799


Fill in our feedback form to find out more about this project or get in touch with the project manager.

Is this your project?

Fill in our feedback form to update your story or contact details.

Browse similar projects

End of life and palliative careSydneyPrimary careMetropolitanClinical Leadership Program
Back to top