Continuity of Care Between Settings - Transfers - Managing Risk

Continuity of Care Between Settings

Continuity of care between settings needs to be prioritised.

  • Those caring for the person do not have the information they need to deliver safe and quality care consistent with the person’s individual needs and preferences.
  • Medications or treatments are disrupted and the person experiences unnecessary harm and suffering.
  • Ensure the person is provided with an adequate supply of medication for the transfer and immediately following.
  • Discuss care needs, as well as providing information in writing to those receiving the resident. This includes ensuring the receiving service is aware of and has copies of the person’s Advance Care Directive and other planning documents. Checklists can ensure that comprehensive handover information is provided to a receiving environment.
  • Provide tailored support and advice to family/friends if the person is transferring to a private residence.
  • Review care planning documentation to monitor whether comprehensive information is collated and provided in the event of transfer at the end of life.
  • Undertake reflective practice to understand experiences of transfers at the end of life.
  • Review incident reports for insights about why and how issues may have occurred during the process of a transfer.

Continuity of care is critical when a person is being transferred to ensure that:

  • their needs, goals and preferences are understood and respected
  • they receive uninterrupted care and services
  • they experience maximum comfort and quality of life
  • important treatments can continue when they are moved.

Continuity relies on the effective exchange of knowledge between the various health professionals, care staff, organisations and family or friends involved in a person’s care.

Transfers to hospital or other health service

Where a person is being transferred to a hospital or health service e.g. a specialist palliative care provider, the receiving organisation will need:

  • Medical information (e.g. the person’s clinical synopsis, reasons for transfer, current medication/treatments etc.)
  • Advance Care Directives or other advance care planning documents that the person has made
  • Personalised information about the individual so the receiving environment can understand the person, what’s important to them and deliver person centred care aligned with the person’s needs, goals and preferences.
  • Advice about information the facility will want if or when the person returns to the residential aged care facility.

Transfers to a private residence (e.g. family home)

Where a resident is being transferred to a home in the community, information will need to be provided to health professionals involved in their care (e.g. a private nurse, GP or specialist palliative care service) and family or friends involved in their care.

If the person is to be supported at home by a home services provider, private nurse, GP and/or specialist palliative care service, they will need the same information that would be provided to a hospital or other health service (see above).

Information, education and support needs for family members or friends providing the care will differ. They may benefit from:

  • advice about planning for home care
  • support to understand clinical information (including in relation to medication regimes or ways to maximise the person’s comfort)
  • advice about how to access any required medications
  • advice about support services they can engage at home
  • information about the dying process.

Consider how information can be communicated in a way, and in a language, that will be readily understood.

Regardless of where the person is being transferred to, it is good practice to:

  • provide contact details of the person responsible for coordinating the person’s care at the residential aged care facility so the receiving organisation/individual can contact them to ask questions and seek further information as needed
  • provide critical information both in writing and verbally through discussions with key people and organisations involved in the resident’s care, including through case conferences with the care team
  • ensure the person is provided with an adequate supply of medication including any pain medication for the transfer and immediately following. Medications must be clearly identifiable and transported appropriately.

Practical tips for a person-centred approach when sharing information

Think about ways that you can make the transfer as smooth as possible for the person and their family and friends. Consider whether there is information that can be shared with the receiving organisation that would help them to understand the person and what’s important to them. This is particularly important when transfers are planned when the person may be transferring to another care environment with which they are unfamiliar.

  • What does the person like to be called? By their first name, a nick name, with a salutation, etc. Some people appreciate pet names such as ‘dear’ or ‘love’, while others find them condescending.
  • Does the person have any preferences around the way that care is provided? For example, the person might like care staff to sit them up a certain way, have their teeth brushed first thing in the morning, or have a cup of tea before bed.
  • What does the person like to eat or drink? They may have strong likes or dislikes that the receiving organisation should be aware of.
  • How does the person want you to communicate with their family, friends and support network? They may have preferences regarding who is contacted and when.

Are there things care staff can do to help reduce anxiety for the person, during transfer and as they settle into a new environment? For example, the person might like listening to music, want to look at a particular photo, have a certain item nearby, etc.

Page updated 18 January 2024