Palliative Care Strategy for HIV and other diseases - FHI 360

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At the service delivery level (e.g., district level) a palliative care program management team
and program coordinator are responsible for developing and maintaining the referral network,
training, procuring supplies, reporting to funders and authorities, monitoring activities,
coordinating community support activities, recruiting and managing human and financial
resources, mobilizing resources, and providing any other programmatic oversight. They
are also responsible for the quality of care provided and ensuring that services follow national
standards or standard operating procedures. Again, there may be a program management
team in place that can fulfill this role. However, it is important to assure that the management
team and program coordinator are well versed in and supportive of palliative care services.
Interdisciplinary Teams
Palliative care requires a team of professionals representing different disciplines as well as
lay caregivers and supporters with other expertise. It may not always be possible to have all
the members listed below, but it is important to make strong links between people who can
provide input from that discipline’s perspective. For example, if the pharmacist is not able to
be a regular team member, the nurse may be able to identify issues that require input from a
pharmacist and consult with him or her as needed. The team composition will also depend
on the nature of the service and service delivery level. For example, outpatient or inpatient
care and CHBC teams will likely have different compositions. Ideally, the interdisciplinary
team would cross levels of service, representing the continuum of care. This team includes
members from inpatient, outpatient, and community palliative care services. In South Africa,
the Integrated Community Palliative Care program brings health professionals from the
nearby clinic, home-based caregivers, lay counselors, spiritual counselors, social workers,
traditional healers, and allied health professionals into the interdisciplinary team.
Illustrative Interdisciplinary Team
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medical doctor or clinical officer
social worker
nurse
pharmacist
PLHIV peers/expert patients
home-based caregiver coordinator
social worker/case manager
counselor
spiritual counselor
nutritionist
substance use specialists
traditional healer
physiotherapist
vocational counselor or occupational therapist
Patients and family caregivers are also part of the team. Patients are educated about every aspect
of care, diagnosis, and treatment so as to be able to make decisions, prioritize resources,
and lead as much as possible the course of their care. When patients are incapacitated, care-