Palliative Care

Care for Adults With a Serious Illness

Resources Quality Statements Working Group About

12

Interdisciplinary Team-Based Care

People with identified palliative care needs receive integrated care from an interdisciplinary team, which includes volunteers.

Background

The model of care used to deliver health services can affect the quality of the care received. Team-based, integrated care facilitates continuity for people with a progressive, life-limiting illness, their family, and their caregivers. The team-based model of care includes the patient, family, and a nurse or physician with the knowledge and skills to deliver palliative care. The team may also include people in other roles, such as social workers, psychologists, spiritual advisors, personal support workers, healers, medicine people, Elders, or volunteers. The services provided by the team include symptom management, psychosocial care, care plan development, advance care planning conversations, goals of care discussions, and care coordination.

What This Quality Statement Means

For Patients, Families, and Caregivers

You should have access to care providers who are knowledgeable about palliative care and who will work together to meet your needs and goals of care.

For Clinicians

Collaborate with other health care providers, volunteers, family, and caregivers to meet the needs of people receiving palliative care.

For Health Services

Provide adequately resourced systems and services to ensure that health care professionals, volunteers, and caregivers can work in teams to provide integrated palliative care.

Quality Indicators

Process Indicators

Percentage of people who receive palliative care (or their caregivers) who state that they have received care from two or more health care providers, such as a physician, nurse, social worker, psychologist, spiritual care provider, volunteer, and others

Denominator: total number of people who receive palliative care (or their caregiver)
Numerator: number of people in the denominator who state that they have received care from two or more health care providers, such as a physician, nurse, social worker, psychologist, spiritual care provider, volunteer, and others
Data source: local data collection
Note: The survey respondent will be asked to select all that apply. Consider reporting by number and type of health care provider

Percentage of people who receive palliative care (or their caregivers) who state that their health care providers work well together

Denominator: total number of people who receive palliative care (or their caregivers) from more than one provider
Numerator: number of people in the denominator who state that their health care providers work well together
Data source: local data collection
Similar question available in the CaregiverVoice Survey: “When he/she was at home in the last 3 months of life, did the homecare providers work well together?” (Response options: “Yes, definitely; Yes, to some extent; No, they did not work well together; Don’t know”)

Definitions Used Within This Quality Statement

Integrated care

Health services are managed and delivered so that people receive care that is coordinated across the health system, at all levels and settings, and according to the patient’s needs throughout their life course. Integrated care involves the delivery, management, and organization of services for diagnosis, treatment, care, rehabilitation, and health promotion. Integration of care brings about better access, quality, user experience, and efficiency.

Interdisciplinary health care team

An interdisciplinary health care team consists of two or more individuals with different types of training and skills who work together to provide care based on a person’s care plan (see Quality Statement 5). The composition of the team varies depending on the services needed. The team may include various roles, as needed: physicians, nurse practitioners, registered nurses, registered practical nurses, social workers, psychologists, spiritual care providers, pharmacists, personal support workers, dietitians, and volunteers.

Team-based care

Team-based care refers to the provision of health services by a group of health care providers who work collaboratively with patients, family, and caregivers to meet their shared goals of care within and across settings of care.

Evidence to Improve Care