Put in place strategies to coordinate transitions.

Put in place strategies for planned and unplanned transitions in situations where an older person:

• is transitioning to and from hospital
• moves between other care services or stays in the community
• is receiving home support and is transitioning between short-term and ongoing service pathways.

Make sure:

• those involved in an older person’s aged care and services have been identified. This includes:

  • supporters
  • family members
  • carers
  • health and registered providers
  • workers
  • other registered health practitioners and allied health professionals. 

  These people need to be involved in planning activities if the older person wants or needs them to (Outcome 2.1). For example, you should inform supporters and others they wish to involve, when an older person transfers to and from hospital or between service providers. This makes sure they understand any relevant changes to aged care services.

• the transition is planned and coordinated. You need to document the transition process needs to be documented in line with the information management system (Outcome 2.7). You need to communicate the transition process to the older person and those involved in their care and services. Do this using your communication system (Outcome 3.3). This supports continuity of aged care services for the older person.

Make sure workers have the time, support, resources and skills to coordinate aged care services.

Provide workers with guidance and training on how to coordinate aged care services (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers understand how to:

• identify who is involved in the older person’s care
• talk with older people, their supporters and others they want to involve, such as families and carers, about transitions and coordinating aged care services
• use your organisation’s communication system and information management system to plan for and support transitions and coordinating aged care services.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training. 

Monitor that workers are partnering with older people and others involved in their aged care services.

To check if workers are partnering with older people and other providers well, you can review:

• how well workers are following your systems (Outcome 2.9)
• older people’s aged care 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:

• aged care services have not been planned and coordinated effectively
• the older person, their supporters, family, carers and others involved in their care have not been included during transitions of care.

Also, talk with older people, their supporters, families and carers about the aged care services they receive (Outcome 2.1). Ask them if their provider and workers partner with them, their supporters and others involved in their care during transitions of care. Ask them if they feel their aged care services are effectively planed and coordinated. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve, 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.