TriCentral PC Toolkit : Chapter 4: TriCentral Palliative Care Program Operations : Team goals and team conference

Interdisciplinary Team Goals

In the TCPC Program, the patient/family unit and the healthcare providers are equal partners. The patient and his or her family actively participate in developing and evaluating a plan of care, and attaining outcomes that reflect their personal wishes, values, and goals. Overall, interdisciplinary team goals are to:

focus on patient/family as the unit of care
develop a plan of care consistent with patient and family goals
provide appropriate management of the patient's medical condition
prevent crises
coordinate and communicate among team members including primary and specialist physicians on a planned and regular basis
discuss prognosis and reasonable expectations
discuss basic pathophysiology of the disease and the effects of various measures being taken to improve health
provide support and education to the patient and family, including teaching them about the expected course of disease, preventive care, medication use, and self-management and crisis intervention in the home
teach the family how to successfully provide end-of-life care
discuss advance care plans
plan for home death, if possible
provide 24/7 support and access to care

In general, team goals are directed at delivering care that meets the patient's personal preferences, treatment goals, and service needs. They also aim to help patients and their family members to anticipate and oftentimes avoid problems, thereby averting potential crises.

Interdisciplinary Team Conference

The interdisciplinary team (IDT) depends on clear, open, and positive communications among team members to work effectively to meet patients' needs and goals and to avoid unnecessary duplication of services. Regular team meetings help foster such communication. They also synthesize and augment individual expertise, leading to the collective development of a comprehensive, collaborative, and coordinated plan of care.

All IDT members, including both core and adjunct members, meet to discuss ongoing care of patients at least once every two weeks. During each one- to two-hour conference, about 40-50 patients are presented and discussed. The palliative care physician leads the discussions. An IDT conference note is completed following each team meeting.

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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.