Put in place processes to support coordinated transitions for older people.

Transitions can happen between:

• locations
• provider organisations
• providers of other care services. This includes hospital, emergency, community and specialist care services.  
• levels of care in the same location. For example, as the older person’s condition and care needs change.

Find, document, and share all current information when an older person is transferred. Make sure the older person has given their informed consent for you to share this information and that their information is managed in accordance with privacy principles. You can do this by using your communication (Outcome 3.3) and information management systems (Outcome 2.7). The information you share might include the older person’s:

• needs, goals and preferences (Outcome 1.1), including:
  • language and communication needs and preferences (Outcomes 1.1 and 5.4)
  • specific needs for older people with diverse backgrounds (Outcome 1.1)
  • food, drink and dining needs and preferences (Outcome 6.2).
• advance care planning documents (Outcome 3.1)
• clinical assessment, priorities and goals of care (Outcome 5.4)
• relevant registered health practitioners and allied health professionals involved in their care (Outcome 5.4)
• supporters, family, carers, their substitute decision-maker (if they have one) and other people the older person wants involved in their care.
• equipment, aids and products they need (Outcome 5.4)
• risks of harm or clinical concerns (Outcomes 2.4, 5.4 and 5.5)
• information about changes in the older person’s condition (Outcomes 3.3 and 5.4)
• infection risks (if there are any) (Outcomes 4.2 and 5.2)
• medication history and current medicines list. Including, for example, information about adverse drug reactions (Outcome 5.3).
• behaviour support plan, for those who experience changed behaviours or may require the use of restrictive practices (Outcomes 3.2 and 5.6).

It’s important to make sure you maintain continuity of care during transitions. Make sure your transition processes:

• include using your communication system (Outcome 3.3)
• make clear who is responsible and accountable for the delivery of aged care services between workers, registered health practitioners and allied health professionals and across organisations.
• include processes to plan and coordinate transitions of care and services before a decision is made (Outcomes 3.4 and 5.4). This should happen in partnership with the older person, their supporters and others they may want to involve, such as family and carers and other providers of aged care services. It also applies to whichever setting or service the older person is transitioning to and back. Make sure everyone involved is clear about their responsibilities and accountabilities.
• consider each older person’s identity, culture, ability, diversity, beliefs and life experiences (Outcome 1.1). Make sure this information is documented in their care and services plan and discussed with the older person (Outcome 3.1). For example, an older person may need to transition to a health service of their choice to access specialist services.
• help workers and others caring for an older person to have access to the older person’s current medication, medical equipment (if needed), important personal possessions (such as reading glasses or hearing aids) and other supporting information (Outcomes 5.3 and 5.4). This also includes any infection risks, so measures can be put in place to protect the health and safety of everyone involved in transitions of care (Outcome 4.2). You need to review this information before the transition. It also needs to be current, complete and provided in a timely way. Your information management system and clinical information system need to make sure the privacy of older people is in line with data security requirements (Outcomes 2.7 and 5.1).
• record and monitor older people’s hospital or emergency department visits. This includes monitoring the reasons why the older person has been admitted to hospital and using this information to improve clinical care services (Outcome 5.4). You also need to review if their care and service plan has been updated with any changes in their discharge plan. Make sure you assess and apply any changes to older people’s care and services plans when they transition back to your care.
• are in line with comprehensive care needs (Outcome 5.4). Make sure:
  • you check and review hospital discharge and transfer summary information. This informs changes to older people’s aged care services in a timely way. Make sure this information is correct and check clinical information with external services if needed. You can do this by actively partnering with people who provide aged care services to the older person.
  • medications are up to date at the time of transition (Outcome 5.3). Also, make sure current and complete medication information is available throughout the transition process. This includes a record of reasons for any changes to medications.
  • you monitor clinical conditions. For example, increase your observation of an older person in the days after their transition from hospital. This may be included in their discharge summary or return from hospital monitoring process.
  • you review goals of care with the older person while considering their reablement. This means, trying to help the older person to regain their physical, mental and cognitive functions.
  • you review the older person’s care and services plan when the transition happens (Outcome 3.1) and update it as needed. This includes monitoring and evaluating how effective their care and services plan is.
  • you store, manage, use and share advance care planning documents with relevant people (Outcome 3.1).
• use your risk management system to address challenges and risks when planning transitions (Outcome 2.4). Make sure you consider:
  • transitions at night. For example, risks with low-light situations, impact on sleeping patterns, and less resources available at night.
  • additional resources you need that should be available to provide continuity of care, such as equipment, supplies and medication
  • circumstances that mean the older person has a higher risk of harm when their care is transferred. This can include those who
    • identify as Aboriginal and/or Torres Strait Islander
    • have a disability
    • have experienced trauma, particularly chronic or complex trauma
    • have cognitive or physical impairment
    • live with dementia
    • have mental illness
    • are culturally and linguistically diverse
    • need palliative care and end-of-life care
    • have co-morbidities. This means, having more than one health condition or illness at the same time. 

Put in place strategies to help older people access specialist aged care services when they need or want to.

As part of comprehensive care, there are services that a person needs to address their clinical needs (Outcome 5.4). These can be:

• medical
• rehabilitation
• allied health
• palliative care
• specialist nursing
• advisory services.

For example, a person might need specialist dementia care services.

You need to provide comprehensive care once you understand each older person’s needs (Outcome 5.4). This means, you need to address these needs and minimise the risk of harm (Outcome 5.5). Your strategies need to make sure that you help older people receive the specialist care and services they need. For example, specialist services can be accessed to:

• maintain and improve a person’s oral health
• manage pain
• manage wounds
• access palliative care and end-of-life care (Outcome 5.7)
• support mental health
• optimise mobility
• manage sensory impairment
• manage cognitive impairment and support changed behaviours associated with dementia (Outcome 5.6)
• make sure people feel culturally safe (Outcome 1.1). For example, access to interpreters and translators, translated resources or culturally appropriate healthcare and community supports.

For regional and remote providers, limited resourcing may affect timely access to multidisciplinary care and specialist services. These providers should consider strategies to make sure older people are appropriately referred to specialist services, registered health practitioners and allied health professionals to support continuity of care and effective coordination during transitions of care.

Where needed, you need to maintain connections with specialist services so that older people can get timely support when they need it.

Make sure workers who provide aged care services have the time, support, resources and skills to use your processes for transitions.

Provide workers with guidance and training on how to use your processes for transitions and support an older person’s transition to and from their provider (Outcome 2.9). This needs to be in line with:

• your organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities (Outcome 2.9).

Make sure workers understand how to:

• plan and coordinate older people’s transitions between services, provider organisations and levels of care
• facilitate access to registered health practitioners and allied health professionals and specialist health services when needed
• share and access information about the older person during transitions of care. You can do this using the communication (Outcome 3.3) and information management systems (Outcome 2.7). For example, this can include information about their:
  • needs, goals and preferences
  • care and services plan
  • clinical needs (Outcome 5.4).

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

Monitor how well your processes for transitions of care are working.

To check if you’re managing transitions of care well, you can review:

• older people’s aged care service documents, such as their care and service plans and progress notes (Outcome 3.1)
• complaints and feedback (Outcome 2.6)
• incident information (Outcome 2.5).

Look for situations where you haven’t:

• coordinated transitions of care effectively
• communicated information effectively during transitions
• facilitated access to specialist health services, registered health practitioners and allied health professionals when an older person needed them.

Also, talk with older people, their supporters, families and carers about their experiences during transitions of care (Outcome 2.1). For example, ask them if they feel their transitions to and from the provider have been well-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 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 wish 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.