Care Coordination

Care Coordination

Key Messages

  • Continuity of care and care coordination has significant impact on satisfaction and quality of life as well as reducing the number of acute care re-admissions. [1-5]
  • Quality care should involve the person, the family, care pathways and the collaboration of a multidisciplinary team. [1,3,6]
  • Adequate referral pathways for older adults in residential aged care are necessary for them to access palliative care services. [3,7]
  • Transition between acute care and home/residential aged care (RAC) should include early discharge planning with advice for self-care, medications and community support. [4,8,9]
  • Where the trajectory of decline is unpredictable, a phased transition into palliative care services may be warranted which requires a high level of coordination and clear goals for care. [6]
  • Continuity of known primary providers is important in forming multidisciplinary teams in palliative care. [1-3,6,10]


Continuity, coordination and transition of care are key domains for providing quality care to older adults at the end of life. Continuity refers to the exchange of knowledge between carers, the person and health professionals while coordination is the alignment of care across providers and settings. [1] This may include managing transition of care to a hospice or residential aged care facility for end-of-life care as well as acute admissions and return to residence that may occur during this period. [1]

Evidence Summary

Multiple health professionals are likely to be involved in the care of a person approaching the end of life. Care coordination ensures that an identified health professional can convey information between the multidisciplinary team and the individual, but also to ensure they and their family are able to effectively participate in forward planning. [1-3,6]

A number of interventions have been trialled to address effective transition of care. A systematic review by Dy et al. [1] concluded that effective strategies were those which increased communication and involvement from the person and their family or some form of advance planning. However, there appears to be a paucity of quality evidence on this topic and the quality of the evidence is not robust and findings have limited generalisability.

Findings by Dy et al. [1] were also supportive of previous studies validating the need for specialist palliative care teams, particularly in the coordination of transition between acute and community care settings. 

Good care coordination between residential aged care (RAC) staff, community and palliative care services is required for optimal quality of life and satisfaction of older adults and their families. In supporting families, the transition experience can start as early as planning an admission and not finish until after adjustment to the move. [3,4] 

There is clearly a need for effective palliative care coordination in RAC. [3] Evidence on different approaches to care provision such as palliative care delivered by external services or through development of expertise within RAC is still being developed. This is discussed more fully in Models of Care and Workforce. Case-conferences and family meetings can be beneficial in the coordination of care.

Collaboration and coordination of care is essential in the transition between settings, such as in hospital admissions from home or RAC [2,7] and rely on good communication between health professionals, carers and the individual to establish usual care and preferences. This is discussed more fully in Communication at End-of-Life and Developing Communication Skills.  Effective discharge planning from acute care admissions should include early follow-up after discharge and advice for self-care (which might include medication adherence and symptom monitoring) as well as contacts for community support. [8] Evidence-based guidelines for older adults being discharged to RAC, been compiled by The Joanna Briggs Institute, include a checklist of screening criteria for older adults at high risk of readmission to acute care. [5]

Where it is recognised that health is deteriorating, timely end-of-life planning should be approached within the multidisciplinary team and with the individual and their family. [7] Where the trajectory of decline is unpredictable and variable, a phased transition into palliative care services may be warranted which requires a high level of coordination and clear goals for care from all team members. [6] The evidence proposes that a multidisciplinary team approach of palliative care provided by generalist providers may be the most effective and acceptable to older adults; particularly where relationships have already been established with these health professionals. [1-3,6,10]

Quality Statement

The quality of the systematic reviews was good, with only three out of the nine papers rating poorly for reporting on quality, bias and methods.

Page updated 24 May 2017

  • References

  • About PubMed Search

  1. Dy SM, Apostol C, Martinez KA, Aslakson RA. Continuity, coordination, and transitions of care for patients with serious and advanced illness: A systematic review of interventions. J Palliat Med. 2013 Apr;16(4):436-45.
  2. Joseph R, Brown-Manhertz D, Ikwuazom S, Singleton JK. The effectiveness of structured interdisciplinary collaboration for adult home hospice patients on patient satisfaction and hospital admissions and re-admissions: a systematic review. JBI Database System Rev Implement Rep. 2016 Jan;14(1):108-39.
  3. Hall S, Kolliakou A, Petkova H, Froggatt K, Higginson IJ. Interventions for improving palliative care for older people living in nursing care homes. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007132.
  4. Afram B, Verbeek H, Bleijlevens MH, Hamers JP. Needs of informal caregivers during transition from home towards institutional care in dementia: a systematic review of qualitative studies. Int Psychogeriatr. 2015 Jun;27(6):891-902.
  5. Jayasekara R. Discharge: Residential Aged Care 2015. [cited 2017 May 16]. Available from:
  6. Gardiner C, Ingleton C, Gott M, Ryan T. Exploring the transition from curative care to palliative care: a systematic review of the literature. BMJ Support Palliat Care. 2011 Jun;1(1):56-63.
  7. Kirolos I, Tamariz L, Schultz EA, Diaz Y, Wood BA, Palacio A. Interventions to improve hospice and palliative care referral: a systematic review. J Palliat Med. 2014 Aug;17(8):957-64.
  8. Chhabra PT, Rattinger GB, Dutcher SK, Hare ME, Parsons KL, Zuckerman IH. Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm. 2012 Jan-Feb;8(1):60-75.
  9. Albert NM. A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure. Heart Lung. 2016 Mar-Apr;45(2):100-13.
  10. Procter E. Collaboration between the specialties in provision of end-of-life care for all in the UK: reality or utopia? Int J Palliat Nurs. 2012;18(7):339-47.


Describes the connection and coordination of care between patients and providers across time and settings. Includes transition between hospital and community or residential aged care setting.

…In primary care, continuity is viewed as the relationship between one patient and one clinician. In the field of acute care nursing, continuity is viewed as communication between nurses, and in mental health it is viewed as a consistent relationship between a patient and a team of clinicians with accessibility playing a key role.

…Three types of continuity exist in every discipline; informational, management, and relational. Information continuity focuses on communication between providers over time. It is concerned with more than just medical data but important personal knowledge that is necessary for caregivers to form a trusting bond with the patient. Management continuity focuses on the care of the patient with multiple co-morbidities who is managed by multiple providers. It centres around the importance of shared management plans so that all clinicians are working together to optimise the patient‘s health. Relational continuity bridges care across the past, present, and future. There exists a set of core providers who establishes predictability for the patient. The context of care determines which of these three types of continuity are employed.

(Santomassino, M., et al. (2012). A systematic review on the effectiveness of continuity of care and its role in patient satisfaction and decreased hospital readmissions in the adult patient receiving home care services. JBI Library of Systematic Reviews, 2012;10(21)1214-1259.)

Continuity can be defined as the exchange of knowledge and the relationships between providers and patients or families, or between providers and/or provider groups; an example of improving continuity is standard assessment of palliative care needs. Coordination can be defined as the alignment of care across providers and settings; an example is a palliative care nurse coordinating care among the radiation, medical, and surgical oncologists for a patient. Finally, transitions of care generally refers to care across settings or providers of care. Improving transitions in palliative care often refers to facilitation, when appropriate, of patient care goals to more comfort-oriented care; an example is helping appropriate patients transition to hospice care. (Dy, S. M., et al. (2013). "Continuity, Coordination, and Transitions of Care for Patients with Serious and Advanced Illness: A Systematic Review of Interventions." Journal of Palliative Medicine 16(4): 436-445.)


“Continuity of Patient Care"[MAJR:NoExp] OR "Patient Handoff"[MAJR] OR "Patient Transfer"[MAJR] OR "Transitional Care"[MAJR] OR "Case Management"[MAJR] OR patient discharge[majr] OR case management[ti] OR Transition care[ti] OR Transitional care[ti] OR Care coordination[ti] OR Care co-ordination[ti] OR Patient Transfer[ti] OR Patient handoff[ti] OR Care transition[ti] OR Care continuum[ti] OR nursing hand over*[ti] OR nursing handover*[ti] OR nursing hand off[ti] OR nursing handoff[ti] OR "Hospitalization"[Mesh:NoExp] OR "Patient Admission"[Mesh] OR  hospitalize[ti] OR hospitalization*[ti] OR hospitalisation*[ti] OR hospitalise[ti] OR hospital admission*[ti] OR admission to hospital[ti] OR transfer to hospital[ti] OR hospital transfer[ti] OR patient admission*[ti] OR admit  to hospital[ti] OR patient discharge[ti] OR discharge planning[ti] OR Hospital to home[ti] OR post acute transition*[ti] OR post discharge[ti]