Work together

Having the whole team on the ‘same page’ is essential for shared care. This will rely on good communication between team members. A strong team care approach will make sure care is given at the right time and in the right place.

Good shared care looks like:

• cohesive decision-making
• clear and timely communication between clinicians
• less burden and cost to the person, that might be caused by many settings of care
• less confusion for the person and their family e.g., emergency contacts
• a plan for emergency care.

Shared care can often be with team members across different settings with different health systems. It is good practice to support older adults to plan ahead, e.g.:

• if an ambulance must be called
• if going into hospital
• when meeting a new health team member
• when travelling away from home.

Information can be shared in the following ways:

• My Health Record. This is valuable for people who have health team members in different settings.
• Paper records that the older person might have, such as health summaries and medicine lists.
• Advance care plans, describing substitute decision-makers, the persons’ wishes and who to contact in an emergency.
• Case conferences.

• Training can help healthcare professionals and aged care staff to improve their knowledge and confidence in ACP discussions.
• Education resources include online courses, workshops, webinars, and information sessions.