Palliative care service delivery model

Tasmania’s Palliative Care Service Delivery Model is a framework for primary and specialist providers to deliver quality integrated palliative care services.

Purpose of the service delivery model

The model aims to achieve integrated palliative care service delivery across all clinical settings. It outlines the roles of primary and specialist providers in the care of patients with a life-limiting illness. It recognises that:

• patients require different support based on their needs and the capability of the primary care provider
• many patients receive primary palliative care without having any contact with our specialist palliative care services.

Levels of care

There are four levels of care for palliative care patients in Tasmania. These are outlined below.

Coordinator of care

As Coordinator of Care, your role involves:

• negotiating the most efficient way to provide care to the patient with health professionals, patients, carers and families
• communicating the agreed plan of care
• assisting in the transition of care between settings
• being the point of contact for the patient, carer and other health professionals.

Download the Palliative Care Service Delivery Model diagram

Level 1 palliative care patients

Level 1 palliative care patients have their needs met by primary care providers. They are not assessed by us.

Our role

• Provide training and professional development for primary care providers.

Primary care provider role

• Assess the patient's palliative care needs.
• Coordinate the management of the patient's needs.
• Provide culturally appropriate palliative care for the patient, carer and family.
• Involve the patient, carer and family in decision making.
• Control patient’s pain and symptoms.
• Provide social, spiritual and emotional support.
• Perform risk assessment.
• Deliver an agreed care plan.
• Provide after-hours support.
• Co-ordinate patient, carer and family needs including bereavement support.
• Consult with us if information is needed.
• Refer the patient to us for assessment if their needs exceed capability and/or capacity.

Level 2 palliative care patients

Level 2 palliative care patients have been referred to us due to an identified unmet need. Our assessment has determined that the patient's needs can continue to be met by the primary care provider. This is conjunction with our advice, resources and support to develop a care plan. The patient is not admitted to Palliative Care Services.

Our role

• Assess the patient's needs in consultation with the primary care provider.
• Consult with the primary care provider to negotiate, agree and formalise patient care arrangements.
• Review assessment, care planning and/or advice to the primary care provider.

Primary care provider role

• Co-ordinate and manage all the patient's needs using a palliative approach.
• Provide culturally appropriate palliative care for the patient, carer and family.
• Involve the patient, carer and family in decision-making.
• Control patient’s pain and symptoms.
• Provide social, spiritual and emotional support.
• Perform risk assessment.
• Deliver an agreed care plan.
• Provide after-hours support.
• Co-ordinate patient, carer and family needs including bereavement support.
• Consult with us if information is needed.
• Re-refer the patient to us for assessment if their needs exceed capability and/or capacity.

Level 3 palliative care patients

Level 3 palliative care patients are referred to us due to an identified unmet need or a complex or unstable condition. The patient is admitted to our Palliative Care Service for ongoing care and a care plan is developed.

• Complex problems are severe and intractable, involving difficulties in controlling physical and/or psychological symptoms, family distress and social and/or spiritual problems. They exceed the resources of the primary care provider.
• Unstable is where the patient experiences a new problem or rapid increase in the severity of existing problems. It also refers to a sudden change in the situation of the family or carer. These require an urgent change in management or emergency treatment.

Our role

• Assess the patient's needs and share care with the primary care provider based on those needs.
• Provide support and advice to the primary care provider.
• Negotiate, agree and formalise the arrangements to meet the patient’s needs
• Appoint one of our clinicians to be the co-coordinator of care if required.
• Provide an after-hours service.
• Review the plan of care with the primary care provider, patient, carer and family as required.
• Offer bereavement support.

Primary care provider role

• Share the care with us based on the patient's needs.
• Negotiate, agree and formalise patient care arrangements with us and patient/carer/family.
• Take on role of coordinator of care if required.
• Review the plan of care with the SPCS, patient, carer and family as required.

Level 4 palliative care patients

Level 4 palliative care patients are referred due to an identified unmet need and a complex and unstable condition. The patient's needs require ongoing high-level involvement from us. They are admitted for ongoing care and a care plan is developed.

• Complex problems are severe and intractable. They involve difficulties in controlling physical and/or psychological symptoms, the presence of family distress and social and/or spiritual problems. They exceed the resources of the primary care provider.
• Unstable is where the patient experiences a new problem or rapid increase in the severity of existing problems. It may also be due to a change in the situation of the family/carer. These require an urgent change in management or emergency treatment.

Our role

• Assess the patient's needs and co-coordinating the management of those needs.
• Appoint a clinician is a co-coordinator of care.
• Provide support and advice to the primary care provider.
• Negotiate, agree and formalise the arrangements to meet the patient's needs with the primary care provider, patient, carer and family.
• Provide an after-hours service.
• Review the plan of care with the primary care provider, patient, carer and family as required.
• Offer bereavement support.

Primary care provider role

• Consult with us and provide care to the patient, carer and family as agreed.
• Negotiate, agree and formalise patient care arrangements with us, patient, carer and family.
• Review the plan of care with us, patient, carer and family as required.