What is care coordination?
Care coordination ensures that older people, especially those with complex needs, receive well-organised, continuous, and person-centred care by integrating various healthcare providers. It involves effective communication, shared care planning, and structured management of services, ensuring smooth transitions between home, hospital, and aged care. [1-4]
Why care coordination matters in aged care
Older people with a life-limiting illness often receive care from multiple professionals across different settings. Multimorbidity further complicates care, making integrated coordination essential to manage multiple conditions effectively. [5] Without coordination, gaps in care may arise, leading to unnecessary hospital visits and stress for the older person and their family. [2-4] A well-coordinated approach reduces fragmentation, care gaps and confusion, ensures timely interventions, and supports older people to get personalised care that is not burdensome to them or their carers. [3,4,6]
The RACGP Silver Book highlights the importance of collaborative multidisciplinary care in supporting older people in residential aged care facilities and the community. [2] GPs play a key role in leading multidisciplinary teams, facilitating clear communication, and ensuring comprehensive care. [2] A collaborative approach balances specialist with generalist care, keeping care well-planned and connected [2] with, sometimes, when there are more complex needs, specialist palliative care taking the lead. [7,8]
The Aged Care Quality Standards Outcome 3.4 states ‘Older people receive planned and coordinated care and services, including where multiple health and aged care providers, family and carers are involved in the delivery of care and services.’ [9] This Standard stipulates clear care processes, where all care providers involved in a person’s care, understand and follow a coordinated care plan, in partnership with the older person and their carer. [9]
What the evidence tells us
For care coordination to be effective, care teams must share information efficiently. Electronic care systems can help keep everyone across the team up to date. [1,4] However, understanding how well they work across different settings is important to how information from multiple different systems is successfully shared. [10] Regular meetings with the older person and their families help to align the care plan with the person’s preferences and provide families with the support they need. [2,3] Advance care planning documentation helps care teams work together when a person’s preferences are clear and easy to follow. Clearly defining roles prevents gaps in care and confusion and improves accountability and efficiency. [2]
Having clear care processes is helpful. This includes identifying everyone involved in the person’s care ad outlining their responsibilities. Key responsibilities might include: [2,3,5]:
- Maintaining prescriptions for palliative medications
- Regularly reviewing symptoms and care arrangements
- Acting as the emergency contact
- Determining who should be contacted in an emergency and after-hours
- Providing home visits for those unable to attend a GP clinic
- Leading multi-disciplinary case conferences
- Writing a death certificate for an at-home death.
Appointing a care coordinator
A care coordinator can assign these responsibilities. [2-4] In residential aged care, this role is often led by senior nurses, while in community settings, social workers or case managers may take the lead. [2] General practitioners (GPs) might also lead aged care teams. [2] A care coordinator serves as the primary contact for the person and their family or carer, guiding them through care transitions, explaining complex information, and ensuring all needs are met. [3,4] By overseeing care, the care coordinator reduces stress for the person and their family. [4]
Reducing unnecessary hospital transfers
Older adults in aged care are often transferred to emergency departments (EDs) due to infections, falls, or deteriorating health. [11,12] These transfers can be distressing, disrupt routines, and increase hospital-related complications, while also adding to healthcare system demands. [6,11,12] Effective care coordination can prevent many of these transfers through:
- Proactive planning including who should be contacted in an emergency and after-hours
- Clear communication
- Dedicated care coordinators
- Telemedicine and virtual consultations
- Regular health check-ups and timely clinical reviews
- Ongoing staff training on recognising and managing deteriorating health. [5,6,11-14]
Nurse practitioners can play a key role in providing timely assessments, facilitating advance care planning, and educating care staff, ultimately reducing hospitalisations and improving care transitions. [15]
Medication management
Proper medication management is essential during care transitions, particularly when older people move between hospital and residential aged care. Collaboration among healthcare providers, medication reviews by pharmacists, and accurate medication records ensure safety and continuity. These steps help streamline transitions, prevent medication delays, and reduce hospital readmissions, improving overall patient outcomes. [16]
Anticipatory prescribing, coordinated between GPs or nurse practitioners and aged care staff, ensures timely access to medications, particularly for symptom management at the end of life. [17]
Care of people with dementia
People with dementia often require careful care coordination processes to overcome of challenges with memory and communication. [18,19] Personalised care plans and shared decision-making help align care with their needs and preferences. [19]
Effective care coordination for people with dementia includes [20]:
- Ensuring consistency in care providers to reduce confusion
- Supporting smooth transitions between home, hospital, and aged care settings
- Reducing unnecessary hospital stays through proactive management.
Carers may find coordinating dementia care overwhelming. [19] Providing education, emotional support, and practical guidance can help them manage care more effectively at home. [18-20]
More research is needed to better understand the carer experience and improve care coordination. [19]
Considerations for families, carers and home care
Families often play a key role in coordinating care but can feel overwhelmed by the responsibilities. [19] They may need help understanding the care plan, managing emotional stress, balancing their responsibilities and navigating the care system. [3,18-20] Providing families with clear guidance and support can ease their burden and improve the caregiving experience. [1,3,4]
A key named contact person or care coordinator serves as the central communication link between the older person, their family, and the care team. [3,4,6] Shared care plans and telehealth can further support home-based care, ensuring all involved parties work together efficiently. [3,19,20]
GPs, nurse practitioners and aged care services can support carers and families by guiding them as to how and when to contact service providers in an emergency or after-hours. [3,5] Families can use simple tools such as an Emergency Contact List (163kb pdf) and Medicines List (129kb pdf).
Page updated 19 February 2025