Collaboration, coordination and communication as key facilitators and mechanisms

Collaboration, coordination and communication are the key concepts of Pal-Cycles, as once palliative care needs have been identified (Pal-Cycles component 1), there is emphasis on ensuring compassionate communication with patients and family (Pal-Cycles component 2) throughout the transition process, including end-of-life discussions in the terminal phase (Pal-Cycles component 5). There is also a large focus on collaboration and co-ordination when creating a care plan, including multidisciplinary input, and also involving the patients and family (Pal-Cycles component 3). This is also the case when healthcare professionals review the plan with the patient (Pal-Cycles component 4). Collaboration and coordination are key elements during the end-of-life phase (Pal-Cycles component 5), when considering patient and family wishes at the end of life, which may involve multidisciplinary collaboration when considering things like spiritual needs alongside social, physical and psychological. These three elements to ensure patient-centred care, as multidisciplinary collaboration enables all healthcare professionals involved to understand the care plan and give consistent information to the patient and family members, to ensure they feel supported by the whole care team and can build up a level of trust and understanding [32].

Collaboration, coordination and communication were commonly cited as facilitators of transition models, and this has implications for multidisciplinary working in healthcare systems where palliative care provision may not be fully integrated or may be considered to work in silos with little pre-existing coordination and collaboration between professional groups [33]. Alongside the importance of collaboration, coordination and particularly communication, some include training and education as a key component, though there is little reported on the design of these development opportunities.

It is important to note that collaboration, coordination and communication does not just focus on professional providers, but also patients and families. Accessible information is a key mechanism for patients and families. This can promote involvement in developing goals of care that reflect their preferences and wider sense of empowerment and control, and given their importance, may be regarded as three major facilitators of transitional models. Though there are clear gaps in the evidence base, these facilitators of transition models are consistent with recent revised EAPC Norms and Standards for Palliative Care across Europe [3]. Specifically, it has been agreed that integrated multidisciplinary networks, collaboration, coordination and accessible information are important to enable people to receive care and die at home if they so wish [3]. However, based on this review, there is a need to examine practice, implementation and research in these areas.

Effective transition models as indicators of person-centred care

Taking this body of literature as whole, it is apparent that effective transition models are an indicator and perhaps, even a central pillar of person-centred care. Earlier in this paper we highlighted how person-centred care requires fast access to reliable advice, effective treatment, clear information, communication and support, involvement in decisions and respect for preferences, involvement and support for family and carers, emotional support, empathy and respect and attention to physical and environmental needs [1,2,3, 5, 6]. Many of these areas are apparent in the literature, many explicitly as being central features of transitions models.

Collaboration, coordination and communication between multidisciplinary teams and patients and families, underpins and acts as a thread through these transitional elements. Some highlight communication, and also relationships, as being central to person-centred care [1].

Eight of the fourteen studies present evidence for at least four of the components described. Only two studies have a focus on all five components, both from the USA. The first four components are presented in four studies, one in Singapore and three in Europe (Denmark, Norway and Sweden). This is of interest because it suggests that models with a focus on care transitions with advanced cancer that are subject to research in Europe may not adequately focus on the identification of the terminal phase and establish preferences around treatment, place of death, legal and culturally sensitive issues. Evidence in this vital area that can facilitate or present a barrier to high quality care coordination, transitions and home care is therefore underdeveloped. The extent with which evidence is mixed also suggests there may be issues with developing sustainable approaches to embedding transition models into routine practice, with this being cited as an issue in some less developed healthcare systems [30].

Two studies from, the UK [26] and Japan [25] evidence the final four components, although not the first component. Given the focus on care transitions for patients with advanced cancer, and that studying this issue will invariably have meant identifying patients at some stage, it may be that identifying a patient at hospital discharge with palliative and supportive care needs was not explicitly part of the study but was part of the model. However, equally it is ultimately unclear when patients in these studies were identified as having palliative and supportive care needs. Not including or adequately focusing on the first stage suggests that the authors are either not reporting this step or are not adequately integrated in order to identify patients at discharge from across their respective healthcare systems.

Despite this inconsistent evidence base, there is some evidence of transition models having beneficial outcomes. However, successful implementation cannot be considered straightforward and must consider the specific nuances of local healthcare systems.

Strengths and limitations

This review provides an overview of literature related to transitions in care, and the five components of the Pal-Cycles programme, for advanced cancer patients with palliative care needs. The current review has highlighted that research on transition models is mixed and often unclear and uncomprehensive due to inconsistent reporting. However, it is possible to synthesize and present some interesting and informative findings that are mostly based on research published since 2015.

Through using a scoping review method, no formal quality appraisal method was applied during record selection. However, the Hawker et al. [16] quality appraisal method was used when assessing completeness of information. Furthermore, this review only included records that were in English language. The current review also identified many records which related to one of the components described, however these were excluded as they did not provide sufficient relevant detail to answer review aims.

Implications for practice and opportunities for further research

Teams tasked with establishing and implementing transitions in care should think about how to develop and maintain collaboration, coordination and communication as central pillars of their practice and transition pathways. This is likely to require careful planning and be tailored to the specifics of each healthcare system. Furthermore, high quality and accessible information is important for all professional, patient and family stakeholders. It is highly likely that what constitutes high quality information will vary, be dependent on stakeholder group, and making this accessible for all within a transitional model will likely come with challenges. It is important that these elements are implemented appropriately, aligning with the Picker Principles [6] of person-centred care.

Further research should aim to develop the evidence base further using implementation research to test models in practice. Another avenue for further research is to implement and deliver a transitions model across different countries in order to begin to compare and learn about some of the mechanisms, barriers and facilitators that are highlighted in this paper across different cultures, countries and healthcare systems. The Pal-Cycles project seeks to address some of these gaps.