What is the outcome that needs to be achieved?
Older people receive planned and coordinated care* and services, including where multiple health and aged care providers, family and carers are involved in the delivery of care and services.
Actions
The provider, in partnership with the older person, identifies others involved in the older person’s care and ensures coordination and continuity of care.
Carers are recognised as partners in the older person’s care and involved in the coordination of care and services.
The provider facilitates a planned and coordinated transition to or from the provider in collaboration with the older person and other providers of care and services, and this is documented, communicated and effectively managed.
Why is this outcome important?
Outcome 3.4 explains providers’ obligations to effectively plan and coordinate care* and services in partnership with older people, their families, carers* and others involved in their care and services. Clear, effective communication and using the information management system* is an important part of providing planned and coordinated care* and services. It’s particularly important during transitions of care*. For example, when a person moves between hospitals, homes or different care settings.
Including the older person, their families, carers*, health professionals* and others involved in their care is also important. It helps to maintain continuity of care and make sure everyone involved knows about any changes. This can also help reduce adverse events*, harm and disruption to the older person.
You need to give focus to:
- identifying other health professionals* and providers involved in an older person’s care and communicating effectively to coordinate their care
- recognising and involving carers* as partners in the older person’s care
- effective planning and coordination during transitions of care*.
Key tasks
Providers
Providers
Put in place strategies to coordinate transitions.
Put in place strategies for planned and unplanned transitions in situations where an older person:
- is transitioning to and from hospital
- moves between other care services or stays in the community
- is receiving home support and is transitioning between short-term and ongoing service pathways.
Make sure:
- those involved in an older person’s care and services have been identified. This includes:
- family members
- carers
- health and aged care providers
- workers
- other health professionals*. These people need to be involved in planning activities if the older person wants or needs them to (Outcome 2.1). For example, you should inform family members, carers and substitute decision-makers* when an older person transfers to and from hospital or between service providers. This makes sure they understand any relevant changes to care and services.
- the transition is planned and coordinated. The transition process* needs to be documented in line with the information management system* (Outcome 2.7). You need to communicate the transition process* to the older person and those involved in their care and services. Do this using your communication system* (Outcome 3.3). This supports continuity of care and services for the older person.
For residential care providers, the guidance for Outcome 7.2 has more information on managing transitions for older people.
Make sure workers have the time, support, resources and skills to coordinate care and services.
Provide workers with guidance and training on how to coordinate care and services (Outcome 2.9). This needs to be in line with:
- the organisation’s policies* and procedures*
- contemporary, evidence-based practice*
- workers’ roles and responsibilities*.
Make sure workers understand how to:
- identify who is involved in the older person’s care
- talk with older people, their families and carers about transitions and coordinating care and services
- use your organisation’s communication system* and information management system* to plan for and support transitions and coordinating care and services.
The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.
Monitor that workers are partnering with older people and others involved in their care and services.
To check if workers are partnering with older people and other providers well, you can review:
- how well workers are following your systems* (Outcome 2.9)
- 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:
- care and services have not been planned and coordinated effectively
- the older person, their family, carers and others involved in their care have not been included during transitions of care*.
Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if their provider and workers partner with them, their family, carers and others involved in their care during transitions of care*. Ask them if they feel their care and services are effectively planned and coordinated. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).
Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.
If you find any issues or ways you can improve, 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*.
