Planning, Risk Assessment and Communication
Transfers should be informed by effective planning, risk assessment and communication
- The person experiences physical or psychological harm during transfer e.g., pain, discomfort, confusion where the person has dementia or delirium, etc.
- The person receives unwanted or inappropriate care in the receiving environment.
- The receiving environment is not well-equipped to manage the care of the person.
- Substitute decision-makers or family, friends and support networks are unaware of a transfer and are unable to support the person.
- Delays in being transferred back to the facility. The person may have to wait for an available ambulance to take them back to the Residential Aged Care Facility. This can take hours, causing the person more stress and discomfort because they cannot return to their home.
- Create and maintain strong linkages with referring and referral services near the facility and ensure key contacts are known to staff.
- Establish transfer of care policies, protocols and practices including clear steps to be taken, defined roles and responsibilities, risk assessment tools and documented lines of accountability for decision-making about transfers.
- Clearly communicate with the person and the relevant people involved in their care when transfer is being considered.
- Check in with receiving services to understand their experience of transfers and where improvements can be made.
- Undertake reflective practice to assess the process of transfers at the end of life.
- Seek feedback from substitute decision-makers, family, friends and support networks.
Preparation for transfers should occur prior to the planned transfer and as soon as possible in the event of an emergency. The aged care provider should have protocols guiding transfers of care (both into and from the residential facility), including documented lines of accountability for decision-making about transfers, clear steps to be taken and defined roles and responsibilities. Transfer of care policies, protocols and practices should be sensitive to the needs of different resident cohorts and individuals.
Key elements of effective planning include the following.
Strong relationships and linkages with local services (such as hospitals, specialist palliative care services, etc.)
To support smooth transfers of care and information exchanges as the person moves between settings.
Undertaking a risk assessment
To identify risks to the person’s safety and wellbeing as part of the transfer and strategies to mitigate risks associated with the transfer and receiving environment (see box).
Estimating the date of transfer
This should be recorded on the person’s care documentation and communicated to those involved in their care. The date can be revised as appropriate, for example where the receiving service does not have arrangements in place or if the person’s condition changes.
Allocating, documenting and communicating roles and responsibilities
For coordinating and implementing the transfer, including:
- a person to support the resident (and where relevant their family, support network or substitute decision-maker) to participate in forward planning
- a health professional to ensure effective collaboration and communication between all health professionals and care staff involved in the transfer and care
- a key contact to communicate with the receiving or discharging service.
Developing an individualised transfer of care plan
Risk assessment considerations
- Is the person approaching or in in the terminal phase?
- What is the risk of the person dying while being transported?
- Will the receiving environment pose risks for the person?
- If the transfer is to the person’s or their family’s or friend’s private residence:
- are the person’s family or friends well equipped and well informed?
- is there adequate support for personal and medical care in place?
- will there be 24–hour care?
- do the family or friends have emotional support?
- What actions need to be taken or information exchanged to manage any risks?
The provider can choose the number and type of medications appropriate for residents in that facility. Medications may include pain relief, sedation or other end of life medications that residents may require urgently.
Learn more about Imprest Medication Systems: Southern Metropolitan Region Palliative Care Consortium – Imprest Medication Systems for RACFs.
This plan should:
- be informed by the person, their family and those involved in the resident’s care
- include relevant information from the risk assessment
- identify the planned date and time of transfer
- describe the transport arrangements for the transfer
- include information about medications and how these will be transferred
- include information about any personal items to be transferred and how these will be transferred
- describe how continuity of care will be ensured, including handover information (see continuity of care between settings).21
Clear communication
Clear communication with the person about the transfer and what to expect at the new setting including:
- how their personal possessions will be transferred
- how they will be able to communicate with family and friends if desired and connect with cultural and/or spiritual supports at the transferred service
- what they can expect in the receiving service environment
- when the person can expect to be transferred back to the facility (if known).
Reassessing the person if they re-enter residential aged care
It is good practice to undertake reassessment of a person’s end of life care needs and preferences if they are re-entering residential aged care from another setting.