Transitions of care
People are at higher risk of harm when they transition between different health care settings. It is crucial health providers communicate effectively with each another to ensure their patients can safely move from one setting to another.
What is a transition of care?
A transition of care is when all or part of a person’s health care is transferred between health professionals or when a person leaves care.
This may involve temporary or permanent transfer for some or all their care, transition between health care locations, settings, care delivery types and health professionals.
Types of transitions of care
| Type of transition | Example |
|---|---|
| Between care types | A person’s general practitioner refers them to an allied health professional |
| Between healthcare providers | Responsibility of a person’s health care is handed over from one nurse to another during clinical handover in a hospital |
| Between levels of care in the same location | A person is transferred from an emergency department to an intensive care unit within a hospital |
| Between healthcare locations or settings | In an emergency, a person is attended to by an ambulance service and is transferred to an acute care service |
| When care needs change | A person is transferred from an acute care service to an aged care home using telehealth |
| When a person’s preferences change | A person is transferred from an oncology ward in an acute care service to a palliative care service due to end-of-life care preferences |
| When access to services change | A person’s ongoing care is transitioned from paediatric and youth mental health services to adult mental health services |
| Between levels of healthcare | A person is discharged from a mental health inpatient facility back to their general practitioner |
Why are effective transitions of care important?
Poor transitions of care that do not involve clinical handover or communication of a person’s needs or history put them at risk of delays in care, higher readmission rates, medication errors, and adverse events.
As a person’s health care needs increase in complexity there is often increased interaction with different parts of the health care system, resulting in more transitions of care.
Effective transitions of care help to mitigate risk for people moving within the health care system, especially the most vulnerable (older people, people with disability and chronic and complex conditions) who are at greater risk of harm.
How we are supporting effective transitions of care
Transitions of care can happen many times between many different health professionals and health care settings depending on the person’s needs.
We have guidance and tools to support effective transitions of care throughout a person’s health care journey.
Principles of transitions of care
Our principles for safe, high-quality transitions of care and fact sheet with key enablers, guide safe and high-quality transitions of care wherever health care is received, including primary, community, acute, subacute, aged and disability care.
Safe medication management at transitions of care
More than 50% of all medication errors occur when people move from one health care setting to another.
Our medication management at transitions of care stewardship framework recommends a stewardship approach to support safe medication management at transitions of care.
Our framework focuses on transitions of care between hospital inpatient settings and primary and aged care settings, and is designed to be incorporated into existing systems, processes and clinical practice.
Our evidence briefings on strategies to facilitate safer medication management at transitions of care and digital approaches to facilitate safer medication management at transitions of care also provide key information about safe medication management during transitions of care.
For more information on continuity in medication management, please view the Department of Health, Disability and Ageing’s guiding principles.
Guidelines for electronic discharge summaries
An electronic discharge summary is a clinical document shared by hospitals at the end of a person’s hospital stay.
It explains what happened during their stay, the treatment they received, medicines to take and any follow up care.
Discharge summaries are important in understanding the care a person received in hospital and the next steps in a person’s care after they have left. This helps a person’s health care providers ensure continuity of care.
Hospitals can use electronic systems to create, store, and share a person’s electronic discharge summary with their health care providers and to their My Health Record.
These electronic systems make it easy for doctors and other healthcare professionals to enter information electronically and share it quickly and securely with a person’s health care providers outside the hospital.
Our national guidelines for presentation of electronic discharge summaries aim to enhance the quality and usability of electronic discharge summaries.
It provides recommendations on the structure and components of an electronic discharge summary, to improve the consistency in how information is displayed in electronic systems. This makes it easier to locate important information about what happened during a hospital visit and what follow up care is needed.
Poorly written or incomplete discharge summaries can lead to medication errors, confusion about the care a person received, and inadequate follow up care.
Model of care for aged care facilities
The Aged Care Emergency (ACE) service is a nurse-led, multi-agency model of care that provides consultancy, support and advice for residential aged care facilities and health professionals in the Hunter New England and Central Coast areas of NSW.
They support aged care facility staff in delivering care for acutely unwell residents and avoid unnecessary transfer to hospital when it is clinically appropriate and consistent with the person's goals.
Their model led to reduced transfers to the emergency department, stronger relationships between aged care facilities and the wider health care system, and uplifting of aged care facility staff.
You can read their case study and journal article to learn how you can implement this model in your own health care setting.