Care Coordination in practice

Care Coordination

What we know

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.

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 care coordination is the alignment of care across providers and settings. Continuity of care and care coordination have significant impact on satisfaction and quality of life as well as reducing the number of acute care re-admissions. Both require that people and services have the capacity to adequately forward planning.

What can I do?

If a person’s health changes or deteriorates, you can signal that the documented goals of care may need to be reviewed.

Clarify your role in the palliative care team and how you will stay ‘in the loop’ with care planning.

Identify the substitute decision-maker and the key family member; establish regular communication with them and notify them of important changes in health or to care.

Suggest that people in your care use the palliAGED Contact List (163kb pdf) to keep track of the care team and the palliAGED Medicines List (129kb pdf) to keep track of the medicines. These are useful for the person, their family and carers.

Establish a list of relevant contact information so that the family and the members of the health team know how to contact the correct people.

If a person is moved to or from your care, ensure that letters and/or summaries are forwarded or received and that these are filed correctly.

When a transfer does occur, ensure that beneficial treatments aren’t discontinued.

Suggest a comprehensive medication review which can be funded through Residential Medication Management Review (RMMR) or Home Medicines Review (HMR).

Consider whether a case conference or a family meeting would be useful.

When decisions need to be made about care, you may need to refer to the advance care planning documentation; it’s an advantage to all to have these documents easily accessible.

What can I learn?


Check out the following articles:

Take a look through the CareSearch Review Collections: Transitions, Care Pathways and Communication

Check out the online learning modules:

What can my organisation do?

Use the suite of resources from The Palliative Care Outcomes Collaboration (PCOC) to support integration of palliative care into practice.

Embed the Residential Aged Care End of Life Care Pathway (RAC EoLCP) into policies and practices of the residential aged care facility. This resources indicates how to implement the (RAC EoLCP) in a supportive framework.

To define the palliative care team and roles within the team, you can use the suggestions in the Who's who in a palliative care team and The palliative care team.

Support regular meetings of the palliative care team to maintain a good level of communication between team members and with the family; helpful resources are:

Provide the capacity for advance care planning documents to be easily accessed and used in care planning and care coordination when needed.

Page updated 07 July 2021