Strategies and practical advice for care transitions 

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.

What documentation is needed

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:

  • patient details
  • family and carer support details
  • document author and location
  • document recipients and location
  • encounter details
  • problems and diagnosis
  • clinical synopsis
  • relevant pathology and diagnostic imaging investigations
  • clinical interventions
  • medications
  • allergies and adverse drug reactions
  • alerts
  • arranged services
  • recommendations for management
  • information provided to patient, carer, and family
  • nominated primary health providers.

In addition to this information, it was recommended that for people with palliative care needs the following be included:

  • clinical synopsis: resuscitation code status
  • information provided to patients, carers, and family: preference for care, preferred place of death.

Good to know 

  • Patients advance care plan and / or advance care directive need to be uploaded to the patients My Health Record, so that the patients palliative care goals can be achieved regardless of which health care setting they are currently receiving care within.
  • eReferrals can be shared with all health professionals involved in a patient’s palliative care within the Primary Health Care setting. Having an eReferral as part of a patient’s My Health Record ensures a continuity of care.
  • palliAGED has evidence-based information for health professionals to ensure older adult patients care is well coordinated.

Last updated 24 August 2021