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.  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. 
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.  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.  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.  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.  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. 
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.  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.  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]
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