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AKPS, Fall risk, skin asst, mini nutritional for deterioration

Communication through care conference including MDT, medication reviews, adequate symptom management, review ACP (truly holistic checked) . collaborative engagement with inreach and outreach. think cultural sensitivities. 1:1 time

Also consider trauma informed care and can ELDAC develop this

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Need to empower everyone in the team. Bedside care.

Educating need to start with them, Flip charts on acute episodes for pathways to act. This leads to escalation. But need to include feedback to AINs. Close the loop.

Check the ACP of the resident. Think about hospitalisation or is this the next stage. Consider the family readiness to hear and understand.

PACOP tool alongside the SPICT. Inform decision making for the person. Update care staff too. Need a good handover tool.

Involve GP: Involve pall care team via monthly needs rounds via telehealth. Helps to consider pallcare case or eol.

Pausing and reflecting on what is best. Celebrate detah and life

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RAC: My palliative care assessment after case conference - SPICT, trajectory, ACP, SDM or EPOA. LInks to MD team.

RAC: Have imprest systems so access to needed pall care.

Dreprescribing in place before eol . Review of the medications and what they would do if stopped. Expert advice supports. Syringe drivers so person isn't waiting for symptom relief and can adjust

Audits and falls support. monthly care audits. oathwyas to dying audits

Memorial type activities on success. Funding supports may be needed. Keep going with ELDAC.Upskill GPs. PA Toolkit amazing flip charts need to come back.

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Education resources to build knowledge skills

Empower staff

Self care

What is taught in tertiary education. Look at recruitment, PDs, transition programs. Develop internal programs, in-service training. Need right interpersonal skills. Give staff educational goals. (incentives to attend training). Snapshot training

Core skills: compassion, communication, bereavement and grief, self-care, teamwork and collaboration, respect, integrity, being friendly.

PCWs: Observation, dining service, ADLs, toileting, incontinence, following directions.

Lifestyle: Positive, energetic, certificate 4

RNs: Team leaders, assessment, clinical experience, advocacy

AHPs: Creative, realistic in care planning and goal setting

Internal records of education, CQI, KPIs for Bd. Benchmarking, Consumer advisory.

Work with other agencies and bodies

Clinical indicators, Feedback, complaints, mandatory competencies, audits, monthly reporting.

ELDAC: Quick videos, toolboxes, factsheets for specific roles

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Support ongoing eol planning conversations

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Support ongoing eol planning conversations

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RAC+HC on table. Homecare has to deal with reality of what supports and services can be added within funding.

Conversations are critical.

Collect information through client surveys, feedback form all parties, follow up on deteriorations. Report back to office

Handover notes, progress, audit and follow up

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identify and clarify who is authorised representative to know who will act when the resident can't. Problem often in after hours to know contact order.

Include inc clinical software. Transfers should have documents.

ELDAC: ACP documents vary. Not easy to share the details or identify which interventions wanted. (Don't want to upset the paramedics) Consistent ACP in aged care where sector understands the language.

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PHNs: Dying2Know days. Liaise with GP training

Homecare: after relationship set up, provide form then suggest talk to GP. Original copy with person

RAC: ACP on admission. Do with patient and family. Hard to get GP follow up in country. Digital copy on system. Hospital transfer pack held with ACP and SDM info for transfers

How to update: Include ACP updates in care conferences. PACOP has section on ACP. find out if into EHR or local stat solutions. Grey nomads highlight interstate needs.

RNs often lynchpin

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Holistic assessment (tools and processes)

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Holistic assessment (tools and processes)

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Early education, family conversations, use tools as needed, specific to the person (eg dementia), Comfortable communication. Get to

SPICT, EoL plans, ACP forms, PACOP,

Documentaion needed

ELDAC: Pulse check- checklist of individal sympotms issues for person

Rural and remote toolkits

Co-existence of VAD, Font size and videos to be considered. Go share to bundle infomraiton for clients.

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roles of workers and HPs in providing palliative care

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roles of workers and HPs in providing palliative care

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training should look with end of mind. What is our vision? this should shape training and model. Palliative care champions but also needs to be embedded in all staff.

Multimodal way of getting information through and different in RAC and HC. Funding model challenging for bereavement.

ELDAC coordinators need to be based in different states for specialistion.

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Stop and watch; SPICT tool, cognitive change, weight loss, exacerbations

Relationships: ELDAC linkages and reosurces, share with other HPs, case conferences. Revisit ACP, liaise with othr HPs.

Demonstrate: Document, care plan reviews, HP reviews. How to implement up the ladder to Board to care gov. Need stats and risk and Board benefit. rpeortable QI