Care Coordination - Synthesis

Care Coordination - Synthesis


Care coordination ensures that an identified health professional can convey information between the multidisciplinary team and the person, but also to ensure the person and their family are able to effectively participate in forward planning.

Quality Statement

Nine systematic reviews [1-9] and one set of guidelines [10] were retrieved. Only two systematic reviews [1,2] were specific to older adults/aged care and palliative care, while five [5-9] were specific to palliative care but not aged care. The remaining two reviews [3,4] were not specific to palliative care but referenced end-of-life care in an aged care context. The quality of the systematic reviews was good, with two papers [1,2] scoring highly and with most relevancy to the topic, while three papers [3,5,8] scored poorly due to inadequate reporting on quality, bias and methods.

Evidence Synthesis

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 and the relationships between carers, the person, and a health professional, otherwise known as a continuing relationship with a health care professional. [2,11] Coordination is the alignment of care across providers and settings. [2] Transitions of care describes care as it moves across settings or providers of care. [2] Continuity of care can provide a solid platform for the effective collaboration and communication required to coordinate care and to improve the patient experience and outcomes. [11]

Key themes emerging from the literature review are the barriers and facilitators for

  • continuity, 
  • coordination,
  • transition of care for older adults requiring palliative care services.


Continuity is an overarching theme through the coordination and transition of older adults in palliative care. In the study by Dy et al. [2] Twenty-three studies examined interventions to improve continuity of care. Interventions sought more involvement of the family in decision-making, several employed additional patient assessment tools or care plans, and other studies examined the effectiveness of hospice/palliative specialist teams and planned coordinated care pathways. All of the interventions demonstrated at least some benefit, with more people putting in place advance care directives, reporting better symptom control, increased satisfaction with services, and deaths in place of preference. Interventions did not show improvement in quality of life, carer burden and healthcare utilisation; these warrant further research. [2] Further discussion of communication interventions to promote continuity in care are discussed in Communication at End-of-Life and Developing Communication Skills.


With people living longer and with multiple health problems, many are living and eventually dying in a residential aged care (RAC) facility. [1] Good care coordination between RAC staff and palliative care services is required for good outcomes for these older adults. The review by Afram et al. [4] suggests that the care transition starts at the time of considering placement until after adjustment of the move, and that both parties, the person and his/her carer, require support during this time. This is also discussed in Bereavement in the context of anticipatory grief.

While many studies have demonstrated the benefit of hospice and palliative care teams across a range of settings, older adults in RAC are known to receive proportionally less of these services. [1] One reason for this is the lack of recognition of older adults who may be suitable for referral. [5] The evidence is not conclusive for whether palliative care should be delivered by external services or whether expertise should be developed in RAC, as both strategies present challenges in implementation (discussed more fully in Models of Care and Workforce pages). However, authors conclude that there is clearly a need for effective palliative care coordination in RAC. [1] A review by Kirolos et al. [5] found that interventions to educate doctors in referral pathways and goals of care created significantly higher referral to palliative care or hospice services. Education of other care staff did not have the same effect. This may be in part due to role ambiguity discussed in Workforce.

In the review by Hall et al. [1] two randomised controlled trials (RCTs) and one controlled trial examined the delivery of palliative care service in RAC which included referrals to external services and/or palliative training for RAC staff. While all the studies were of low quality and had a likelihood of bias, all concluded positive outcomes in either satisfaction with end-of-life care or access to palliative care services. [1]


Interdisciplinary collaboration and coordination of care is particularly important in both the continuity in care of older adults in the community as well as the transition between settings, such as hospital admissions from home or RAC, or a move from home into RAC. [4,9] The literature suggests there is a positive correlation between interdisciplinary collaboration and a person’s satisfaction with care and reduced hospitalisation or readmissions. [9] As such, re-admission to hospital can be as a result of poor coordination or planning by the multidisciplinary team, and therefore adequate and continuing education should be provided to health professionals involved in this model of care. [7,9] Interdisciplinary work is discussed further in Workforce.

A systematic review by Albert et al. [8] examined the transitional care of older adults with heart failure. Lacking in this care was health professionals educating older adults on the progression of their condition, self-care, coordinated care and referral to palliative care services. Preventing re-hospitalisation after discharge is important for health cost savings but also quality of life for the individual. As such, the authors conclude that discharge planning should begin the first day of hospitalisation with recognition that health deterioration is high risk after discharge. Discharge planning could include early follow-up after discharge and advice for self-care (which might include medication adherence and symptom monitoring) as well as community contacts for support. [8] Medication reconciliation was particularly highlighted in the systematic review by Chhabra et al. [3] The transition to acute care or RAC was seen as an opportunity to verify and review appropriate doses and administration of medications, although a successful protocol by which to do this is yet to be verified. Evidence-based discharge planning guidelines for older adults being discharged to RAC have been published by The Joanna Briggs Institute. [10] These guidelines include a checklist of screening criteria for older adults at high risk of readmission to acute care.

Where it is recognised that a person’s health is deteriorating, timely end-of-life planning should be initiated by the multidisciplinary team and discussed with the person and his/her family. Where the trajectory of decline is unpredictable and variable, a phased transition into palliative care services may be warranted and requires a high level of coordination and clear goals for care. [6] Continuity of care is crucial to achieving a well-managed transition that is sensitive to the person’s and family’s needs. [6] Evidence suggests 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. [1,2,6,9]

In summary, care coordination is necessary across all palliative care settings and particularly important in the transition between settings, such as in acute care admissions or placement in RAC. Communication between health professionals and the family is imperative and all health professionals involved in a person’s care should be aware of the current care plans and management strategies.

Evidence Gaps

  • Assessment tools to be used in improving transition of care
  • Focus of research examining the journey of the older adult with life limiting illness in residential aged care and success of care coordination
  • Studies that demonstrate care coordination strategies are beneficial to the recipients (older adults in RAC)
  • Establishing pathways to identify older adults suitable for referral to palliative care services and clarification of personnel that can initiate referral
  • Comparison of palliative care provision by upskilled RAC staff as compared to specialist palliative care teams on patient outcomes

Page updated 15 June 2021

  • References

  1. 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.
  2. 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.
  3. 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.
  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. Kirolos I, Tamariz L, Schultz E, Diaz Y, Wood B, Palacio A. Interventions to improve hospice and palliative care referral: a systematic review (Provisional abstract). J Palliat Med. 2014 Aug;17(8):957-64.
  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. 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 Jul;18(7):339-47.
  8. 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.
  9. 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.
  10. Jayasekara R. Discharge: Residential Aged Care 2015. [cited 2017 May 16]. Available from:
  11. World Health Organization (WHO). Continuity and coordination of care: a practice brief to support implementation of the WHO Framework on integrated people-centred health services. Geneva: WHO; 2018. 67 p.