Patient transitions and coordination of care

Patient transitions

For people with life-limiting illness, their individual circumstances will determine their need for palliative care. Many will move between care settings in line with illness trajectories whether they are a short period of evident decline, long term limitations with intermittent serious episodes, or prolonged and dwindling.

Three areas where health care professionals are likely to have a role when moving patients between care settings are: 

• Assessing and preparing for transition – this includes consideration of patient and family understanding and agreement, transition suitability in view of care needs, and system level influences.
• Organising and facilitating the logistics of transition including equipment, transport, and education
• Coordinating and collaborating transitional care across sectors with an emphasis on written and oral communication. [1]

Resources and examples

Some resources and examples to help optimise coordination of care transitions are highlighted below:

Curative to palliative

The transition to palliative care for patients whose illness cannot be cured requires: pace and timing of referral and transition, patient and family understanding of palliative care, acceptance, information, peer support, and supervision. The experience of transition to palliative care services: perspectives of patients and nurses, identifies the core issues of importance in the transition from acute to palliative care services.

Between care settings

In hospital care models are often unique and acute care teams can be large and diverse which can add complexity to the transfer of patients. The Australian Commission on Safety and Quality in Health Care, Safety Issues at Transitions of Care (625kb pdf), reports pain points relating to clinical information systems containing patient information that is important to providing a safe transition.

Hospital to home

Short term care maybe required once the patient returns home. The Transition Care Programme funded by the Australian Government can provide 12 weeks of care, while ongoing care arrangements are being finalised.

Paediatric to adult services

Moving from paediatric to adult services can be difficult for patients and families to navigate. Through the adoption of 7 Key Principles for Transition Care, from the Agency for Clinical Innovation for acute care clinicians aims to improve the transition of children with chronic conditions to adult health services.

To Residential aged care for palliative care

For older people in need of palliative care and with a life expectancy of up to three months, a residential aged care facility may be a more appropriate care setting. The Department of Health and Aged Care, Palliative Care Status Form is used for patients entering a residential aged care service for non-respite care at the end of life.

To survivorship

Patients entering remission or improvement in their health status might move from palliative care to survivorship and this often requires a change in the focus of their care. The Clinical Oncology Society of Australia (COSA) have a model of survivorship outlines the care for patients transferring from palliative care.

To home as place of death (rapid transition home)

Transitioning home to die requires consideration of symptom management including use of medicines. caring@home provides resources to support for subcutaneous administration of medicines to enable patients to die at home.

Home to country

Aboriginal and Torres Strait Islander patients often have unique cultural requirements that will influence their care needs. The wish to die on country may be one of these. The Australian Government Department of Health and Aged Care, Providing Culturally Appropriate Palliative Care to Aboriginal and Torres Strait Islander Peoples: Resource Kit, provides strategies to support clinicians to provide culturally appropriate care.

Interstate and intrastate

The transfer of patients between hospitals occurs frequently and can involve long-distance relocation. The Royal Flying Doctor Service, Transporting your patient - guidelines for organising and preparing patients for transfer by air (14.1MB pdf), can aid in patients accessing appropriate care.