What is the outcome that needs to be achieved?
Critical information* relevant to the older person’s care and services is communicated effectively with the older person, between workers and with family, carers* and health professionals* involved in the older person’s care. Risks, changes and deterioration* in an older person’s condition are escalated and communicated as appropriate.
Actions
The provider implements a system for communicating structured information about older people and their care and services that ensures critical information is effectively communicated in a timely way to workers, family, carers and health professionals involved in the older person’s care.
The provider’s communication system is used when:
- the older person commences receiving care and services
- the older person’s needs, goals or preferences change
- risks emerge, there is a change, deterioration or an incident that impacts the older person
- handover or transitions of care occurs between workers or others involved in the older person’s care.
The provider implements processes for older people, family, carers and health professionals involved in the older person’s care to escalate concerns about the older person’s health, safety or wellbeing.
The provider implements processes to:
- correctly identify and match older people to their care and services
- provide Care Statements to older people in residential aged care.
Why is this outcome important?
Outcome 3.3 explains providers’ obligations to communicate critical information*, where appropriate, to older people and those involved in their care and services in a timely* manner. It also outlines how important effective communication is with older people, their family, carers*, workers and health professionals* to raise concerns.
Timely* sharing of critical information* with workers, older people, families, carers* and health professionals* helps you to provide safe and quality care* and services. This includes:
- during transitions of care*
- when an older person’s condition deteriorates
- when an older person has communication barriers*.
Putting in place effective processes* for sharing critical information* will help you make sure everyone involved in the older person’s care are informed about their needs. Outcome 3.3 highlights how important it is to share information with older people in a way that they understand and meets their communication needs and preferences.
Care statements* are provided to older people in residential aged care. They play an important role in keeping older people, their families and carers* regularly* informed about the care and services they receive. Older people and their representatives should find it easy to access care statements*, so they can make informed decisions about the care they receive.
Providers must have processes* in place to make sure older people are correctly identified and matched to appropriate care and services. This helps make sure older people receive care that meets their unique needs, goals, and preferences*.
You need to give focus to:
- effective communication of critical information*
- timely* communication
- formal processes* for escalating concerns about older people’s health and wellbeing*
- processes* to:
- identify and match older people to their care and services
- provide care statements* to older people in residential aged care.
Key tasks
Providers
Providers
Put in place a communication system*.
This system* should include processes* that make sure:
- the older person and those involved in their care are provided with critical information*. This can include their family, carers or others, workers and health professionals*. Information needs to be shared in a timely* manner. This will help make sure older people receive the care and services they need. Critical information* can include:
- information in a person’s care and services plan* when they start receiving care and services (Outcome 3.1)
- risks and control strategies (Outcome 2.4)
- incidents* that can affect an older person (Outcome 2.5)
- clinical information* . For example, comprehensive care* needs, changes or deterioration that can affect an older person (Outcome 5.4).
- transitions of care* (Outcome 3.4).
- you correctly store older people’s records, such as care and services plans*, in your information management system* (Outcome 2.7). Make sure you can identify these records, so the right records are matched to the right person. For example, you could use the older person’s Healthcare Identifiers*.
- you correctly identify and match older people to their care and services. You can do this can using the older person’s full name, date of birth and their Healthcare Identifiers*. For example, make sure you follow these processes* in situations where you are:
- delivering care and services to an older person. For example, before administering medication or referring an older person to an allied health* or health professional*.
- generating clinical handover, transfer or discharge information. This can also include information about an older person’s agreement, fees and invoices (Outcome 1.4).
- there are ways to escalate concerns about the older person. Older people, their families, carers, and health professionals* involved in the older person’s care need to be able to escalate concerns. Contact details for those involved in the care and services of the older person should be kept up to date and easily accessible. This information needs to be stored using your information management system* (Outcome 2.7).
- workers can communicate and share information with older people safely and effectively. They should base this on each older person’s language and communication needs and preferences.
If you provide residential care and services, your communication system* needs to have processes* to prepare and provide care statements to older people.
If you provide home care and services, make sure you have processes to communicate clinical information* to older people, families and other service providers.
Make sure workers are supported to communicate for safety and quality.
You can support workers by developing communication guides, training and strategies that are part of your organisation’s clinical governance* framework (Outcomes 2.9 and 5.1). It may be helpful to develop a list of common scenarios and how workers can share information in each situation.
Make sure workers use the communication system*:
- when the older person starts receiving care and services
- when the older person’s needs, goals and preferences* change. You should regularly* partner with the older person and those involved in their care and services (Outcome 2.1).
- when risks have been found (Outcome 2.4)
- when there is a change of circumstance, deterioration*, or after an incident* has occurred (Outcome 2.5)
- during handover or transitions of care*. For example, during a transfer to hospital (Outcome 3.4). For residential care providers, the guidance for Outcome 7.2 has more information on how you support older people during transitions.
- to correctly identify and match older people to their care and services.
When workers use the processes* and systems* in place to communicate for safety and quality, encourage workers to consider:
- what information they need to share
- how quickly they need to escalate information
- who should be involved
- how they can best share this information. For example, it may be better to make a phone call, send an email or have a conversation in person. Make sure these communications are documented in the information management system*. Workers should consider each older person’s language and communication needs and preferences (Outcome 1.1) and share information in a way that they understand (Outcome 1.3). This can include:
- using strategies such as simple language, large text and images as recommended by allied health* professionals (where relevant)
- language services like interpreters and translators
- routinely checking that the older person and those involved in their care have understood the information correctly.
You should record information that has been shared in progress notes or other documents in line with your information management system* (Outcome 2.7).
Monitor that workers communicate for safety and quality.
To check if your communication system* is effective, you can review:
- older people’s care and services (Outcome 3.1) such as care and service plans* and progress notes.
- complaints* and feedback* (Outcome 2.6)
- incident* information (Outcome 2.5).
Look for situations where:
- older people didn’t know or understand something
- critical information* was not shared.
Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if they know and understand information about their care and services, including critical information*. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).
Assess if workers are following your quality and communication systems* (Outcome 2.9). You can do this through quality assurance and system* reviews.
If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, you need to:
- practise open disclosure* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers
- put in place strategies to mitigate the risk of things going wrong again.
The guidance for Outcome 2.3 has more information on monitoring the quality system*.
