Continuity of Care Between Settings
Ensuring continuity of care during transfers is critical to providing safe, quality care that respects the person's needs and preferences.
- Caregivers lack the information needed to provide care that meets the person’s preferences and needs.
- Medications or treatments are interrupted, causing unnecessary harm or distress.
- Provide medications: Ensure the person has enough medication, including pain relief, for the transfer and immediately after.
- Share information clearly: Give written and verbal information about the person’s care needs, preferences, and Advance Care Directives. Use checklists to ensure all details are communicated.
- Tailor support for home care: If the person is moving to a private residence, offer practical advice and support to family or friends, including education about care routines and how to access medications or services.
- Review documentation: Ensure care plans include all necessary information for transfers, such as preferences and Advance Care Directives.
- Reflect on practice: Analyse transfer experiences to identify what worked well and what could improve.
- Check incident reports: Look for insights into any issues during transfers to guide future improvements.
Continuity of care is very important when a person is being transferred. It helps to make sure that:
- their needs, goals, and preferences are understood and respected
- they receive ongoing care and support
- they have the best comfort and quality of life
- important treatments can keep going when they are moved.
Continuity depends on sharing information clearly between health professionals, care staff, organisations, and family / support networks involved in the person's care.
Transfers to hospital or other health service
When a person is transferred to a hospital or health service (like a specialist palliative care provider), the receiving organisation will need:
- Medical information (e.g. the person’s health summary, reasons for transfer, current medications, and treatments).
- Advance Care Planning documents (e.g. Advance Care Directives, details of a substitute decision maker), if available.
- Personal information to help the receiving team understand what is important to the person and provide care that suits their needs, goals, and preferences (e.g. cultural, spiritual, and wellbeing needs, communication preferences, or support for behaviours).
- Information about what the facility will need if or when the person returns to residential aged care.
Transfers to a Home in the Community
When a person moves from hospital to a home in the community or into residential aged care, the same type of information (as sent to the hospital) needs to be shared with health professionals and service providers involved in their ongoing care. This is especially important if care plans have changed.
The family or support network should also get a copy of this information so they can share it with other health professionals or services as needed. This may include a private nurse, GP, specialist palliative care service, or home care provider.
Families and support networks caring for the person at home will need different information and support than staff in a residential aged care home. They may find it helpful to get:
- advice on planning for home care
- support to understand medical information (e.g. treatments available and ways to keep the person comfortable)
- advice on how to get and safely give any needed medications
- information about support services, including respite care options
- details about the dying process
- links to resources on self-care, grief, loss, and bereavement,
It is important to share this information in a way that is easy to understand. If needed, a free interpreter or translation service may be available through the Australian Government’s Translating and Interpreting Service (TIS National).
Support continuity of care during transfer
No matter where the person is being transferred to, it’s good practice to:
- Give contact details for the person who is usually in charge of the person’s care so the team at the transferred site can reach them if they have questions.
- Provide important information in writing and by talking to key people and organisations, including through case conferences with the care team. Ensure names, roles, and contact details are included.
- Check the person has enough medication, including pain medication, for the transfer and right after. Medications should be clearly labelled and transported properly. If the person is going home, ensure someone is there to help them take their medication safely.
Practical tips for a person-centred approach when sharing information
To make the transfer as smooth as possible for the person and their family or friends, think about what information could help the receiving team understand the person better. This is especially important when the person is moving to a new care setting, they may not be familiar with.
Consider the following:
- What does the person like to be called? Do they prefer their first name, a nickname, or something else? Some people like terms of endearment like "dear" or "love," while others may not feel comfortable with that.
- Does the person have any preferences for how care is given? For example, they might want staff to help them sit a certain way, brush their teeth first thing in the morning, or have a cup of tea before bed.
- What does the person like to eat or drink? They might have strong preferences that the receiving team should know about.
- How does the person want their family / support network to be contacted? They might have specific people they want to hear from and certain times they prefer to be contacted.
- Are there things that can help reduce the person’s anxiety during transfer or as they settle into a new environment? For example, they might feel comforted by listening to music, looking at a particular photo, or having a special item nearby.