Assessment

All referrals received by the Palliative Care Service will be reviewed by the Service’s interdisciplinary team (ie. medical, nursing and social work).

Patients referring themselves will be asked to consent to the service contacting their general practitioner/specialist in order to obtain further health information and to facilitate ongoing collaboration.

Contact with the patient will be made by the most appropriate clinician as soon as possible, depending upon the urgency stated. If this is not possible due to a large number of urgent referrals, the referrer and the patient will be contacted and advised an estimated time when the patient will be assessed. If the patient’s condition changes, the referrer should notify the Service and request an urgent assessment.

A comprehensive assessment of the patient's needs will be conducted.

Following the assessment the person making the referral will be contacted by the Palliative Care Service clinician to:

  • Receive advice regarding findings/outcome of the assessment; and
  • Negotiate arrangements for the ongoing management and co-ordination of the patient's care and the level of involvement or the role of the primary care provider and specialist service in the care of the patient. This may be consultation only (Level 2) or ongoing shared care (Level 3) or a more involved role (Level 4) as per the Palliative Care Service Delivery Model.  This provides role clarity and prevents duplication by health professionals.

Patients are reviewed weekly at the Service’s clinical review meeting to determine ongoing care needs and any issues concerning their patient. Primary care providers may be invited to attend these meetings if a more detailed discussion is required.

Patients may also move between Levels of care (ie. from Level 2 to Level 4) as their care needs change. Changes will be discussed with the primary care provider/s, the patient and their family/carers.

Patients assigned to Level 2 may be re-referred to the Service at any time.

The Service provides limited after hours advice and support to primary care providers.