The TCPC Program uses an interdisciplinary team (IDT) approach with the core team consisting of the patient and family plus a physician (M.D.) and registered nurse (R.N.), both possessing expertise in pain and symptom management, and a social worker (L.C.S.W. or M.S.W.) proficient in bio-psychosocial care. This team approach encourages patients, family members, and professional caregivers to exchange knowledge and facilitates communication on treatment preferences. Typically, a nurse and social work team act in the capacity of care managers for the patient, remaining a constant in the patient's life throughout his or her stay in the program.
Collectively the IDT improves outcomes by proactively anticipating problems, seeking them out, and addressing them, rather than waiting for consequences to manifest. The core team is responsible for coordinating and managing care across all settings and providing assessment, evaluation, planning, care delivery, follow-up, monitoring, and continuous reassessment of care.
Depending on the needs of the patient and family, additional team members may join the core team in service provision. These adjunct staff members provide care under the supervision of the core team. Adjunct team members include the following:
For more information about the TriCentral Palliative Care Toolkit visit www.growthhouse.org/palliative/. All content is Copyright © 2002, 2003 by Richard D. Brumley, M.D. All rights reserved. No part of this toolkit may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publishers. This guide to developing home-based outpatient palliative care services was developed through a grant to the Kaiser Permanente TriCentral Service Area from The Project on Death In America. The Kaiser Permanente TriCentral Palliative Care Program is a Sustaining Member of the Inter-Institutional Collaborating Network On End-of-life Care (IICN) which links major organizations internationally.
