Some patients will transfer between health services for specific treatments or as needs change towards the end of life with transfers to specialist care and residential aged care being the most common. The important elements of any transition are the continuity and coordination. Continuity refers to the exchange of knowledge between carers, the person and health professionals while care coordination is the alignment of care across providers and settings.
A review by the Australian Commission on Safety and Quality in Health Care provides guidance on Improving documentation at transitions of care for complex patients. These recommendations aimed at improving documentation and hence care safety and quality for patients at transitions of care include at a minimum:
In addition to this information, it was recommended that for people with palliative care needs the following be included:
Examples of approaches to improving care transitions include:
Aged Care Home Transfer-to-hospital Envelope (the Envelope)
TOP 5 Toolkit for Residential Aged Care Facilities (2.6MB pdf)
TOP 5 Toolkit for the community (2.7MB pdf)
Last updated 24 August 2021