The Intended Outcomes are statements describing the anticipated and desirable results of implementing the Blueprint.
1
Essential Component 1
Communities will have an increased understanding of the need for and benefits of quality care for people approaching and reaching the end of their life.
Through community engagement and awareness raising, death and dying will be more openly discussed by more people outside of crisis events.
An increase in forward planning will be evidenced by the appointment of enduring guardians, the completion of Advance Care Plans, Directives and other legal instruments.
There are increased opportunities for earlier and ongoing conversations about end of life issues with health care providers.
Communities increasingly recognise the limitations of active treatments when approaching the end of life and consider quality of life in discussing their goals of care.
Death is considered a natural event and will be increasingly destigmatised.
Community volunteer programs are supported and well-recognised for their contributions.
2
Essential Component 2
Patients, families and carers are well-informed about their illness and treatment options.
Goals for patient, family and carer are defined and appropriately documented.
Care providers across all settings are skilled in engaging with patients, families and carers on end of life discussions and setting goals of care.
Advance care planning is undertaken and documented.
Advance Care Plans are regularly reviewed.
Preferred place of care and death is articulated and documented.
There is enhanced community awareness, understanding and ability to engage in conversations regarding end of life.
3
Essential Component 3
Patients and families have access to care in a setting appropriate to their needs.
Care providers understand the unique contribution they make to the care of people who may be approaching or reaching the end of life, and are supported to fulfil that potential.
Care providers have access to the resources and supports required to achieve high quality outcomes.
Care providers are supported through the development and dissemination of clinical practice guidelines and pathways.
Preventable hospital admissions are reduced.
Specialist palliative care providers are structured and resourced to support other services caring for people approaching and reaching the end of life.
Skills in caring for people approaching and reaching the end of life are core competencies for all health, aged and community care workers.
Support and resourcing for the development of new collaboration initiatives.
Non-beneficial or burdensome care is minimised.
4
Essential Component 4
Clinical staff are able to identify those people who may benefit from integrated care as they approach the end of life.
Standardised screening tools are available and used.
People have an opportunity through early recognition to benefit from enhanced care models.
Conversations about goals of care commence earlier to optimise opportunities to align care to those goals.
There are earlier opportunities for advance care planning.
Negotiated goals of care guide service provision to prioritise quality of life for patients, their families and carers.
Liaisons and partnerships are built with other services to provide multidisciplinary and cross-sectoral care.
Liaison and coordination with other specialists occur.
Patients, carers and families are informed and educated about the expected course of the patient’s illness and can plan for that.
Earlier involvement of specialist palliative care services based on assessed need can improve quality of life, potentially improve survival and reduce distress for patients, their carers and families.
5
Essential Component 5
All people receive timely, quality care in the appropriate setting, in accordance with their assessed needs and in consultation with them, their families and carers.
Care is delivered in accordance with quality and safety standards.
All people are assessed using common assessment tools that identify needs particular to their end of life care.
Cultural, spiritual and other values of patients, their families and carers are respected.
Partnerships with Aboriginal stakeholders (including Aboriginal Community Controlled Health Services) are fostered to address the health needs and interests of Aboriginal people.
Patients’ pain and or other physical symptoms will be effectively controlled.
Psycho-social and spiritual support is available and offered.
Access to grief and bereavement support is available and offered.
Patients, families and carers are provided with appropriate equipment to ensure a safe home environment.
6
Essential Component 6
People are able to receive care aligned with their goals as they transition between settings of care (i.e. hospital, home, aged care).
Care is well coordinated and support is provided to patients, carers and families to assist in navigating health and community care systems.
Care providers across all settings have an understanding of their unique roles and are skilled in providing care to people as they approach and reach the end of their lives.
Clinical handover of care is optimal and supported by clear communication and clinical tools.
Changes in care requirements are identified and responded to appropriately.
Formalised referral and access arrangements support the patient’s transitions of care.
Clinical information to support seamless care is available at the point of care.
Transfer of care occurs in consultation with patients, families, carers and care providers across all settings.
7
Essential Component 7
All people in NSW have access to services and health professionals that have the necessary skills and expertise to meet their needs.
A networked approach to care (referral, education, data and research) connects specialist palliative care services with other care providers across all care settings.
Best available evidence informs clinical practice.
Care providers across all settings know when and how to access specialist palliative care services.
Shared care arrangements are fostered between specialist palliative care providers and other care providers across all settings.
Unplanned hospital admissions are reduced.
Specialist palliative care services are resourced to provide networked support across the system.
Ongoing access to specialist palliative care services is based on regular assessment of need and adapts to these accordingly.
8
Essential Component 8
Timely recognition of the imminently dying person occurs.
Quality care in the last days of life is safe, effective, responsive and appropriate.
Care is provided in the most appropriate environment as close to home as possible in accordance with the needs of patients and in consultation with them, their families and carers.
Patients, families and carers are provided with information and support.
Care plans are developed, implemented and reviewed regularly to support people who are imminently dying, their families and carers.
Preventable transfer of patients who are imminently dying is avoided.
Patients and care providers across all settings have access to 24-hour-a-day, 7-day-a-week support.
9
Essential Component 9
Grief and bereavement support is available.
Family members, carers and significant others are supported as they grieve.
Care providers across all settings are supported and resourced to support carers and families through their loss and grief.
Bereavement services are recognised as an essential component of care to family and carers.
Bereavement services are resourced and are a routine part of palliative and end of life care.
There are models and guidelines to support best practice in bereavement services including bereavement risk assessments.
10
Essential Component 10
Access to and use of high quality patient-level data informs efforts to improve patient experiences and outcomes.
Access to and use of high quality service-level data informs efforts to improve care coordination and integration.
Access to and use of high quality system-level data informs efforts to improve funding models, planning and policy development.
Medical records are electronically integrated and available across all care settings at the point of care throughout NSW.
Clinical information is available at the point of care in all care settings.
Access to and use of high quality data supports effective benchmarking and service evaluation.
Access to and use of high quality data enhances quality improvement outcomes and research.