Essential Component 6
Seamless transitions across all care settings

Patients, their families and carers often have to navigate unnecessarily complex systems of care that can change over time

Why is this an Essential Component?

Evidence for Inclusion

Approaching and reaching the end of life requires people, their families and carers to navigate increasingly complicated care systems to address their needs.

The Palliative and End of Life Care Diagnostic Report to inform this Blueprint found that current patient journeys are often poorly coordinated. This is particularly true for people with advanced chronic disease who have multiple comorbidities and a much slower and more unpredictable trajectory of functional decline (ACI, 2013). The Report also found that the needs of the patient, family and carer during their end of life journey vary over time and care setting. Services need to be responsive, coordinated and flexible in meeting these changing needs.

It has been demonstrated that navigation support and or care coordination improves clinical outcomes and the experience and satisfaction of patients, families and carers.

The ACI Fact of Death Analysis (ACI, 2015) found that in NSW, people who were in their last year of life and were hospitalised between 2011 – 2012 experienced frequent hospitalisations, being admitted on an average of 4 occasions with an average length of stay of 10 days (compared to the overall average length of stay in hospital of 4 days).

This cohort utilised approximately 1.4 million bed days at an estimated cost of over $977 million (ACI, 2015).  There is evidence that community palliative care teams are effective at reducing acute care use and hospital deaths (Seow et al, 2014).

Acute care settings, particularly hospital emergency departments, cannot always provide the best outcomes or experiences for people approaching the end of life. Hospital emergency departments can be distressing, and the needs of people approaching the end of life are often incompatible with the principles of emergency medicine (Forrero et al, 2012).

We also know that nationally, 76% of residents of aged care facilities have high care needs (AIHW, 2012) and approximately 24% of residents will require a hospital transfer (AIHW, 2010).

A key action area of the NSW Government Plan to Increase Access to Palliative Care 2012 – 2016 (NSW Ministry of Health, 2012) is to drive greater integration across primary, aged, acute care and specialist palliative care services across the state.

Understanding patient journeys and designing care to improve their outcomes and experience ensures that we deliver person centred care.

Intended Beneficial Outcomes

  • People are able to receive care aligned with their goals as they transition between settings of care (i.e. hospital, home, aged care).
  • Care is well coordinated and support is provided to patients, carers and families to assist in navigating health and community care systems.
  • Care providers across all settings have an understanding of their unique roles and are skilled in providing care to people as they approach and reach the end of their lives.
  • Clinical handover of care is optimal and supported by clear communication and clinical tools.
  • Changes in care requirements are identified and responded to appropriately.
  • Formalised referral and access arrangements support the patient’s transitions of care.
  • Clinical information to support seamless care is available at the point of care.
  • Transfer of care occurs in consultation with patients, families, carers and care providers across all settings.
Patients, their families and carers often have to navigate unnecessarily complex systems of care that can change over time

What tools/resources could support the implementation of this component?

The Agency for Clinical Innovation commissioned CareSearch (Palliative and Supportive Services, Flinders University) to identify local, national and international tools or resources that can potentially be used to implement each of the ten (10) Essential Components of Care within the Blueprint.

To be included, tools and resources were required to be in English, be applicable to the Australian context and be supported by evidence (such as published validation studies, clinical guidelines representing expert consensus, or advice from expert clinicians who were consulted).

The set of tools and resources provided is not intended to be exhaustive, nor is any one tool specifically recommended. Click here for more information on the methodology adopted by CareSearch in identifying these tools and resources.

Core Palliative Care Tools

Core Resources

Additional Resources for Specific Populations

Core Palliative Care Resources