Outcome statement
The provider must ensure that individuals receive funded aged care services that are planned and coordinated, including where multiple health providers and registered providers, supporters of individuals and other persons supporting individuals are involved.
Actions
The provider, in partnership with the individual, identifies others involved in the individual’s funded aged care services and ensures coordination and continuity of care.
Supporters of individuals and other persons supporting the individuals are recognised as partners in the individual’s care and involved in the coordination of funded aged care services.
The provider facilitates a planned and coordinated transition to or from the provider in collaboration with the individual and other providers of funded aged care services, and this is documented, communicated and effectively managed.
Why is this outcome important?
Outcome 3.4 explains providers’ obligations to effectively plan and coordinate care and services in partnership with older people, their supporters and others involved in their care and services. Clear, effective communication and using the information management system is an important part of providing planned and coordinated care and services. It’s particularly important during transitions of care. For example, when a person moves between hospitals, homes or different care settings.
Including the older person, their supporters, health professionals and others involved in the older person’s care is also important. It helps to maintain continuity of care and make sure everyone involved knows about any changes. This can also help reduce adverse events, harm and disruption to the older person.
You need to give focus to:
- identifying others involved in an older person’s care and communicating effectively to coordinate their care
- recognising and involving carers as partners in the older person’s care
- effective planning and coordination during transitions of care.
Providers delivering aged care services in a residential care home, home or community setting should have strategies to manage transitions of care and coordination. These strategies will involve the use of the information management system to plan, coordinate and review transitions of care.
Key tasks
Providers
Providers
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:
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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.
Outcome service context
For providers delivering aged care services in a residential care home, the guidance for Outcome 7.2 has more information on managing transitions for older people.
For providers delivering aged care services in a home or community setting, your strategies for transitioning and coordinating care need to:
- involve your communication system (Outcome 3.3)
- include processes to plan and coordinate transitions before decisions are made (Outcome 5.4). You should partner with older people, their supporters and others they may want to involve, such as family and carers, and other service providers to plan transitions of care. Clearly document all parties’ roles and responsibilities in the transition plan.
- communicate critical information about the older person’s care to those involved in transitions. For example, information on the older person’s medication, medical equipment and risk management strategies.
- include processes to record and monitor older people’s hospital or emergency department visits. This may involve having regular communication with other service providers and the older person’s supporters, family, friends and neighbours.
- include processes to review and reassess older people’s care and services plans when they transition back into your care. This may involve:
- reviewing hospital discharge and transfer summary information
- communicating critical information with other service providers for each older person
- reviewing care goals with respect to reablement with the older person
- storing, managing, using and sharing advance care planning documents with relevant parties, if needed (Outcome 5.4).
- use your risk management system when planning transitions (Outcome 2.4).
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.
Further resources about this outcome can be found on the Commission's Quality Standards Resource Centre.
