Tips for Nurses:
Continuity of Care

What it is: Continuity, coordination and transition of care are part of 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 so that care is not interrupted or compromised.

Continuity of care has three main parts:

The care provider knows and follows the care of the older person.
There is good exchange of relevant information between different care providers.
Different care providers cooperate so that care is connected care.

Why it matters: Continuity of care helps care providers to be aware of a person’s preferences and care needs. It also helps with the smooth coordination of a person’s care. It is particularly important for the care of a person who may be at the end of life. It also helps care providers to have the information they need so that the person’s choices are respected.

What I need to know: Continuity of care can:

avoid unnecessary hospitalisations
ensure the older person receives uninterrupted care based on their needs
make sure that important treatments continue when a person is moved to or from a care setting (home, hospital, residential aged care)
make sure that a person’s preferences and needs are considered
regular meetings between team members and with the family helps to maintain a good level of communication
transition between acute care and home/residential aged care (RAC) should include early discharge planning with advice for self-care, medications, and community support as appropriate.

Actions

Document the person’s goals of care and regularly review these as a person’s care needs change.

Prepare plans for managing exacerbations of their health condition. Also review the person’s Advance Care Directive (ACD).

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

Make certain that all care providers understand the goals of care for the older person.

If you identify signs of imminent death communicate the person’s end-of-life stage to the GP.

Ensure that all appropriate documents accompany a person when transferred between care settings.

Tools

Tools that may be useful include:

Continuity of care can be supported by use of an end-of-life care pathway such as Residential Aged Care End of Life Care Pathway (RAC EoLCP).

SPICT tool (315kb pdf) helps health and care professionals to identify people who are declining in health and might benefit from better supportive and palliative care.