Transitions of Care

Transitions of care describes key principles that support the delivery of safe and high-quality transitions of care within Australia.

These principles should apply to transitions of care wherever healthcare is received including primary, community, acute, subacute, and aged and disability care.

How we use these principles?

To inform the Commission’s work and the consistent application of principles required for safe transitions of care within standards, policy and guidance.

When drafting standards, policy and guidance for improving the safety and quality of care the Commission considers:

  • Could this issue relate to / occur at / be important during a transition of care?
  • If so, does our policy, guidance or information reflect the principles required for safe and high-quality transitions of care?

What is a transition of care?

A transition of care is when all or part of a person’s health care is transferred between care providers. This may involve transfer of responsibility for some aspects of a person’s health care, or all of their health care. It may be temporary - to manage a brief illness, or long term - due to a permanent change in health status. Transitions of care may occur within and between healthcare locations, settings, care delivery types, levels of care and involve a range of health care providers.

Key triggers for transitions are changes in a person’s:

  1. life cycle
  2. health status
  3. population risk

Examples of transitions of a person’s care are described below:

Table 1: Examples of transitions of care

Type of transitions: Example
Between care types a person’s general practitioner (GP) 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 (ED) 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 GP

Why are transitions of care important to healthcare safety and quality?

The Australian healthcare system is multilayered and complex. Health care in Australia is provided by teams of clinicians working in partnership with patients, families and carers. It is delivered in a wide variety of public and private health service organisations, ranging from sole proprietorships to large statutory corporations and public companies. Health care also has close intersections with aged care services, disability services and other social support systems.

While the care a person receives from the Australian health system is generally of high quality, risks of harm emerge during transitions of care.

Health system data, literature and recent Royal Commission findings indicate people are at higher risk of harm during transitions of care. Poor transitions of care are associated with adverse events such as higher rates of readmission to hospital and medication errors. For example, more than 50% of medication errors occur when people move from one healthcare setting to another.

As a patient’s health care needs increases in complexity, there is often increased interaction with different parts of the healthcare system resulting in more transitions of care. Due to this increased exposure, it is also often the most vulnerable (older people, people with disability and chronic and complex conditions) who at greater risk of harm at transitions of care.

The growth of specialisation in many areas of health care provides people with access to high quality specialist care (e.g. medical, nursing and allied health) but results in a system where most providers focus on and are responsible for the part of the person’s care where they have expertise. They may not be aware of, see it as their remit, or be in the position to fully consider the person’s broader health context, and how care and treatment from different providers may interact.

People should be supported by, and be able to rely on, a central clinician to oversee and co-ordinate their care so that it is safe and high-quality including that it meets their needs, is clinically appropriate, has a low risk of harm, and is high-value.

The general practitioner, because of their clinical expertise, holistic relationship with a person and broad remit, can be a central custodian of, and conduit for, key patient clinical information. They are also in a good position to guide and monitor the safety and quality of a person’s care. For some people this role may be supported by other types of clinicians that they have a strong relationship and regular interaction with, such as a nurse practitioner, an Aboriginal Health Worker or a midwife.

Effectively ensuring the quality and safety of health care depends on efficient and effective communication of information between these central clinicians, the broader clinical team and the person.

Outcome

People experience safe and high quality transitions of care that are delivered in a timely and comprehensive way, taking into account the individual needs and preferences of the person.

Principles for safe and high-quality transitions of care

Key principles of safe and high-quality transitions of care include:

Facilitators to support safe and high-quality transitions of care

When considering how to support implementation of the principles of safe and high-quality transitions of care consideration should be given to the range of facilitators that influence the effective application of these principles including:

  1. Recognising the central role of primary care: The general practitioner, or other clinician[1] is the central point or coordinator of a person’s clinical care. Specialists provide advice when required but don’t always have a holistic view of the person. People without a regular general practitioner risk fragmentation and poor transitions of care.
  2. Acknowledging and addressing system complexity: Care needs, treatment pathways and the healthcare system are complex and lead to poor transitions. This complexity needs to be acknowledged and addressed aiming to reduce complexity from the perspective of the person.
  3. Supporting implementation of eHealth systems: High level of interoperability of digital systems and medical records for patient care supports transitions of care. Linked data sets enable ‘Whole of system’ health information and improvement
  4. Providing education and training of clinicians: Skills and training that is specific to transitions of care needs to be informed by data. Structured communication such as ISBAR facilitates transfer of accurate and important information
  5. Strengthening funding and resources: Funding models need to support safe and high-quality transitions of care and not promote silos that fragment care.

Good Medical Practice

These principles are consistent with the code of conduct for doctors in Australia set out in the Medical Board of Australia and Ahpra’s “Good medical practice: a code of conduct for doctors in Australia”. The code describes what is expected of all doctors registered to practice medicine in Australia. It states, “Good patient care requires coordination between all treating health practitioners. Good medical practice involves:

  • 6.2.1 Communicating all the relevant information in a timely way.
  • 6.2.2 Facilitating the central coordinating role of the general practitioner.
  • 6.2.3 Advocating the benefit of a general practitioner to a patient who does not already have one.
  • 6.2.4 Ensuring that it is clear to the patient, the family and colleagues, who has ultimate responsibility for coordinating the care of the patient."

Safety Issues at Transitions of Care: Pain points relating to clinical systems