Spotlight issue: Transitions of care
Transitions of care are points at which valuable information for safety, quality and continuity of care can be lost. For people with intellectual disability, all transitions of care can be high risk, as information about reasonable adjustments may not be considered as essential clinical information. This includes information about disability support needs, psychosocial needs, communication needs, behavioural supports and comorbidities.17,20,27
Important NSQHS Actions
| Action 2.10 | The health service organisation supports clinicians to communicate with patients, carers, families and consumers about health and health care. |
|---|---|
| Action 6.10 | The health service organisation ensures that there are communication processes for patients, carers and families to directly communicate critical information and risks about care to clinicians. |
Strategies for improvement
Strategies to support Actions 2.10 and 6.10 include:
- Ensuring that the person’s intellectual disability, communication needs and other reasonable adjustments are recorded. Use a peer review process to maintain continuity of knowledge about the person or check that all important information about the person is included in any transition
- Coordinating with the person’s family, supporters or guardian so they are able to attend transitions of care meetings or are informed shortly afterward. This is especially important for people who are non-verbal
- Allocating a consistent point of contact to provide regular updates to the family, supporters or guardian.
The Commission has developed Principles to guide safe and high-quality transitions of care. These principles and their enablers apply to transitions of care wherever health care is received, including primary, community, acute, subacute, aged and disability care. It is important to apply these principles consistently within practice, standards, policy and guidance, to ensure safe transitions of care. The principles state that:
- Transitions of care are person-centred
- There is multidisciplinary collaboration to support the transition of care
- There is an enduring, comprehensive and secure record system to document and access information about the person’s current and ongoing care
- There is ongoing continuity of care.