Care coordination helps older people, especially those with complex needs, receive smooth and person-centred care across different settings. In aged care, this means effective and clear communication across the full care team, shared care planning, and organised management of services to prevent gaps, preventable hospital visits, and stress for families. Aged care nurses and careworkers play a key role in keeping care on track, supporting teamwork, and ensuring care aligns with the older person’s wishes.
What I can do
Keeping all care providers informed helps prevent miscommunication, care gaps, and unnecessary hospital transfers. You can:
- Use clear communication tools like iSoBAR (197kb pdf) to share information and handovers
- Identify key providers (GP, nurse practitioner, case manager, specialist) and keep them connected
- Keep care plans, advance care documents, and medication records up to date.
Proactive planning reduces distressing hospital transfers and care disruptions. You can:
- Support anticipatory prescribing to ensure essential medications are available
- Discuss emergency care plans with older people, families, and carers to clarify when hospital transfers are appropriate
- Encourage staff training on recognising and managing deterioration.
Families can feel overwhelmed by care coordination. You can help them by:
- Explaining the care plan and how the aged care system works
- Guiding carers on who to contact for urgent or after-hours support
- Supporting conversations about end-of-life care.
What I can learn
The palliAGED Practice Tips give helpful guidance on supporting older people with psychosocial care needs at the end of life. There is a version for nurses as well as one for careworkers.
Read the Communicating for safety national standard from Australian Commission on Safety and Quality in Health Care (ACSQHC).
Complete the learning modules: (Free: Registration required)
What I can give
If an older person, their family or carer wishes to know more about care coordination, these resources may help:
What I can suggest
Older people often receive care from multiple providers. To keep everyone informed and working together, your organisation can:
- Identify all individuals and services involved in the person’s care
- Set up clear and reliable ways for everyone to communicate, so care stays consistent and any changes are shared
- Recognise the role of family and informal carers and include them in care discussions and decisions.
To help make changes in care, such as hospital stays or moving between home and aged care, as smooth as possible:
- Plan for both expected and unexpected transitions, so care continues without disruption
- Keep a record of transition plans and explain them clearly to the older person, their carers, and the care team
- Share up-to-date information with everyone involved to keep care on track and avoid confusion.
To support staff in coordinating care:
- Provide training and guidance on working across different teams and services
- Make sure staff have the time, resources, and support they need to manage care coordination
- Create a workplace culture where staff feel comfortable raising challenges and working with families and other providers.
Page created 28 February 2025