Building Support Teams Around Complex Clinical Needs

Every community or complex care nurse has one type of patient they know: the one whose needs are more than a few hours of weekly help at home; the one whose needs require a ventilator; the one with a tracheostomy; the one enterally fed; and the one who has a combination of needs that would once have been only talked about in hospital or residential care settings.

More and more, these patients live at home; home is where they want to be and funded supports can follow them. It isn't any one professional that makes it work, or not. It's whether or not someone has actually developed the team around the clinical requirement intentionally, or whether the group is indeed a collection of separate services discovering one another accidentally.

Nurses play a natural role as architects here. You are aware of which work is a nurse's job, which is a trained worker's, and which is an everyday person's, and you're fluent in both of the languages the team needs to communicate in. This article is the architecture.

Layer the team by what each task actually requires

As there are three layers of complex care in the home, confusing them is the first failure. The clinical layer contains what you need nursing judgement and a regulated scope for: assessments, wound care beyond routine, decisions about administering medicines, and what your registration exists to cover.

The trained support layer: supports that workers can provide only if they have specific accredited training, a large proportion of which falls within the high intensity category of the NDIS, such as enteral feeding, tracheostomy suctioning, complex bowel care and catheter care, provided by named workers who have verified and recorded their competency, in accordance with the delegation and oversight arrangements the task requires.

The rest of life, personal care, meals, household, community access and presence, and the observation that presence enables, is in the everyday layer. A good team will assign all tasks to the correct layer in writing, so that no one is performing tasks that are above their training and no nurse will have to spend clinical time on tasks that the everyday layer can perform.

Design the redundancy before the first roster

Complex care teams fail at their thinnest points, and the thin points occur regularly: the one person trained to provide the gated support, the one nurse who knows all the answers, the family member who hasn't had a good night's sleep. Design principle: no critical task is dependent on one person.

This simply translates to training more staff members than the minimum each gated support requires, and documenting it with such detail that a competent new member can be safely integrated, and ensuring that the care plan is a living document, not a one-person document that only the staff member in charge knows how to work. Sourcing also plays a role here: workers with complex support experience are out there, but need to be specifically sought out, people who have undergone documented training and have experience with complex support.

Build the communication spine

Without a communication system, a layered team is nothing more than shifts that are close together. Three components: one document of present care, which each layer works from at the depth they need to; a defined escalation ladder, who each layer reports to, with names, numbers and expectations for response; and a rhythm of actual contact, that is, a brief period of time where the layers meet as people before the 2am phone call requires them to. Normally, nurses will hold the spine, and holding the spine is part of their legitimate work, not administrative overflow.

How this plays out in practice

Think of a young man who has been discharged after a prolonged stay in hospital, with a tracheostomy and enteral feeding, and a household tired before day one. The version that is built layers deliberately: the clinical layer is community nursing and the care document; the gated supports are completed by four support workers who have undertaken accredited training, with the competencies recorded; and the everyday layer is rostered with two more workers than the minimum required across the days, evenings and social hours. The escalation ladder is printed out and lived by.

One trained worker resigns after 8 months, and another worker is on leave the same fortnight. The team bends, the surplus takes it, and the crisis never comes. The clinical needs didn't get easier. The architecture around them held.

Next steps

Select one complex patient on your books and trace each task to the appropriate layer, and circle each task that has only one person involved. The circles are your work plan.