Outcome statement
The provider must ensure that critical information relevant to the delivery of funded aged care services to individuals is communicated effectively to the individuals, between aged care workers delivering the services, with supporters of the individuals and other persons supporting the individuals and with registered health practitioners, allied health professionals, allied health assistants and others involved in the individual’s care.
The provider must ensure that risks to individuals, and changes and deterioration in the condition of individuals, are escalated and communicated as appropriate.
Actions
The provider implements a system for communicating structured information about individuals and their funded aged care services that ensures critical information is effectively communicated in a timely way to aged care workers, supporters of the individual, other persons supporting the individuals and health professionals involved in the individual’s care.
The provider’s communication system is used when:
- the individual commences receiving funded aged care services
- the individual’s needs, goals or preferences change
- risks emerge, there is a change, deterioration or an incident that impacts the individual
- handover or transitions of care occur between aged care workers or others involved in the individual’s care.
The provider implements processes for individuals, supporters of individuals and health professionals involved in the individual’s care to escalate concerns about the individual’s health, safety or wellbeing.
The provider implements processes to:
- correctly identify and match individuals to their funded aged care services
- provide Care Statements to individuals in residential aged care.
Why is this outcome important?
Outcome 3.3 explains providers’ obligations to communicate critical information, where appropriate to the delivery of aged care services, to older people and those involved in their aged care services in a timely manner. It also outlines how important effective communication is with older people, workers, registered health practitioners, allied health professionals, supporters and others the older person may want to involve, such as family and carers, to raise concerns.
Timely sharing of critical information with workers, older people, their supporters, registered health practitioners and, allied health professionals helps you to provide safe and quality care and services. This includes:
- during transitions of care
- when an older person’s condition deteriorates
- when an older person has communication barriers.
Putting in place effective processes for sharing critical information will help you make sure everyone involved in the older person’s care are informed about their needs. Outcome 3.3 highlights how important it is to share information with older people in a way that they understand and meets their communication needs and preferences.
Care statements are provided to older people in residential care homes. They play an important role in keeping older people, their supporters and others they want to involve, regularly informed about the aged care services they receive. Older people and their supporters should find it easy to access care statements, so they can make informed decisions about the care they receive.
Providers must have processes in place to make sure older people are correctly identified and matched to appropriate aged care services. This helps make sure older people receive care that meets their unique needs, goals, and preferences.
You need to give focus to:
- effective communication of critical information
- timely communication
- formal processes for escalating concerns about older people’s health and wellbeing
- processes to:
- identify and match older people to their aged care services
- provide care statements to older people in residential care homes.
Providers delivering aged care services in a residential care home, home or community setting are expected to put in place a system to communicate critical information with the older person and others involved in their care and services. This may differ between residential, home and community settings.
Providers delivering aged care services in a home or community setting should have processes in place for workers to effectively communicate critical information with other providers, the older person’s supporters and others involved in the older person’s care without direct oversight. This is due to the intermittent nature of care delivery and the frequent changes in workers assigned for each older person receiving aged care services in a home or community setting. For example, if there is a change, deterioration or incident that impacts the older person, providers delivering aged care services in a home or community setting should make sure that workers consistently update supporters and other providers through regular communication. This can be done through detailed care logs that can be easily accessed, phone calls or scheduled meetings. Making sure up-to-date critical information is effectively communicated across all relevant parties, helps to ensure the delivery of safe and coordinated care when the provider delivering aged care services in a home or community setting is not in-person or there are multiple providers and people involved.
Disclaimer - In this outcome, references to ‘registered health practitioners and allied health professionals' may also refer to allied health assistants and others involved in the individual’s care. Refer to the Strengthened Quality Standards under the ‘legislation’ tab for more information.
Key tasks
Providers
Providers
Put in place a communication system.
This system should include processes that make sure:
- the older person and those involved in their care are provided with critical information relevant to the delivery of their aged care services. This can include their supporters, family, carers, workers and registered health practitioners and allied health professionals. Information needs to be shared in a timely manner. This will help make sure older people receive the aged care services they need. Critical information can include:
- information in a person’s care and services plan when they start receiving aged care services (Outcome 3.1)
- risks and control strategies (Outcome 2.4)
- incidents that can affect an older person (Outcome 2.5)
- clinical information. For example, comprehensive care needs, changes or deterioration that can affect an older person (Outcome 5.4).
- transitions of care (Outcome 3.4).
- you correctly store older people’s records, such as care and services plans, in your information management system (Outcome 2.7). Make sure you can identify these records, so the right records are matched to the right person. For example, you could use the older person’s Healthcare Identifiers.
- you correctly identify and match older people to their aged care services. You can do this can using the older person’s full name, date of birth and their Healthcare Identifiers. For example, make sure you follow these processes in situations where you are:
- delivering aged care services to an older person. For example, before administering medication or referring an older person to a registered health practitioner or allied health professional.
- generating clinical handover, transfer or discharge information. This can also include information about an older person’s agreement, fees and invoices (Outcome 1.4).
- there are ways to escalate concerns about the older person. Older people, their supporters, families, carers, registered health practitioners, allied health professionals and others involved in their care need to be able to escalate concerns. Contact details for those involved in the care and services of the older person should be kept up to date and easily accessible. This information needs to be stored using your information management system (Outcome 2.7).
- workers can communicate and share information with older people safely and effectively. They should base this on each older person’s language and communication needs and preferences.
If you provide residential aged care services, your communication system needs to have processes to prepare and provide care statements to older people.
If you provide home aged care services, make sure you have processes to communicate clinical information to older people, supporters and other service providers.
Outcome service context
For providers delivering aged care services in a home or community setting, make sure clear processes are in place to effectively communicate critical information between the older person, the worker and others involved in their care and services, particularly where there are multiple parties involved, and providers may not have direct oversight. This includes situations where older people self-manage their care. This may differ from providers delivering aged care services in a residential care home, where providers may typically have more direct, continuous oversight of the older person’s aged care services, and systems and processes to communicate critical information are more streamlined.
Others involved in an older person’s care may include:
- multiple other service providers and workers (including associated providers and their workers sub-contracted to deliver services on the provider’s behalf)
- allied health and health professionals
- their supporters, family and carers, as well as friends and neighbours.
Make sure you identify everyone that is involved in each older person’s aged care services and put in place strategies to make sure critical information is communicated effectively to all relevant parties.
Make sure workers are supported to communicate for safety and quality.
You can support workers by developing communication guides, training and strategies that are part of your organisation’s clinical governance framework (Outcomes 2.9 and 5.1). It may be helpful to develop a list of common scenarios and how workers can share information in each situation.
Make sure workers use the communication system:
- when the older person starts receiving aged care services
- when the older person’s needs, goals and preferences change. You should regularly partner with the older person and those involved in their aged care services (Outcome 2.1).
- when risks to the older person have been found (Outcome 2.4)
- when there is a change of circumstance, deterioration, or after an incident has occurred (Outcome 2.5)
- during handover or transitions of care. For example, during a transfer to hospital (Outcome 3.4). For providers delivering aged care services in a residential care home, the guidance for Outcome 7.2 has more information on how you support older people during transitions.
- to correctly identify and match older people to their aged care services.
When workers use the processes and systems in place to communicate for safety and quality, encourage workers to consider:
- what information they need to share
- how quickly they need to escalate information
- who should be involved
- how they can best share this information. For example, it may be better to make a phone call, send an email or have a conversation in person. Make sure these communications are documented in the information management system. Workers should consider each older person’s language and communication needs and preferences (Outcome 1.1) and share information in a way that they understand (Outcome 1.3). This can include:
- using strategies such as simple language, large text and images as recommended by allied health professionals (where relevant)
- language services like interpreters and translators
- routinely checking that the older person and those involved in their care have understood the information correctly.
You should record information that has been shared in progress notes or other documents in line with your information management system (Outcome 2.7).
Outcome service context
Providers delivering aged care services in a home or community setting should have processes to make sure workers are informed of changes to an older person’s needs, goals and preferences in a timely way and have access to current and detailed care and services plans. In particular, when workers are only delivering part of the services. For example, if an older person’s mobility needs change, all relevant parties should be promptly updated, especially if the change affects how their aged care services will be delivered across multiple providers. This helps make sure each provider can continue delivering the appropriate care to the older person.
Monitor that workers communicate for safety and quality.
To check if your communication system is effective, you can review:
- older people’s aged care and services (Outcome 3.1) such as care and service plans and progress notes.
- complaints and feedback (Outcome 2.6a and 2.6b)
- incident information (Outcome 2.5).
Look for situations where:
- older people didn’t know or understand something
- critical information was not shared.
Also, talk with older people, their supporters and others they may want to involve, such as families and carers, about the aged care services they receive (Outcome 2.1). Ask them if they know and understand information about their care and services, including critical information. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).
Assess if workers are following your quality and communication systems (Outcome 2.9). You can do this through quality assurance and system reviews.
If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:
- practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers
- put in place strategies to mitigate the risk of things going wrong again.
The guidance for Outcome 2.3 has more information on monitoring the quality system.
Further resources about this outcome can be found on the Commission's Quality Standards Resource Centre.
