Collaborative working with a wide range of professionals may be required to optimise Bills ongoing care. Professional input will vary across different geographical areas and will be responsive to patients needs.
Multi-disciplinary model – Bill is centre:
- district nurse
- carers
- social worker
- occupation therapist
- palliative care clinical nurse specialist
- heart-failure specialist nurse
- physiotherapist
- consultant cardiologist
- GP
Pulse point
Continuity of care is vital to be able to detect subtle changes in a patients condition. Where possible an appropriate member of the multi-disciplinary team should be identified to co-ordinate and implement advance care planning with the patient and carer.
“A joined up, consistent approach improves quality of life for the patient and family/carer” (NHS QIS 2010).
Page last reviewed: 28 Jul 2020
