Safer Care Transitions Between Hospitals And Nursing Homes

A transfer from an acute hospital to a skilled nursing facility is a clinical handover, a medication reconciliation exercise and a coordination task at the same time. If information is incomplete, the receiving team may have to reconstruct the patient’s history while managing wounds, delirium, falls risk, oxygen therapy or complex medicines.

The lessons associated with Hospital Medicine 2017, held at Mandalay Bay Resort and Casino in Las Vegas from 1–4 May 2017, remain useful because they focus on practical hospitalist communication. The conference addressed research, best practice, innovation, patient care, continuing medical education and professional networking. Its HM17 learning resources provide useful context for thinking about structured discharge communication.

In Australia, the equivalent pathway commonly runs from a public or private hospital to residential aged care, a transitional care programme or a skilled nursing-style rehabilitation service. Terminology varies between states, and patients may move between metropolitan hospitals in Sydney, Melbourne, Brisbane, Perth or Adelaide and facilities in regional communities with fewer doctors and limited after-hours coverage.

A good transfer template must therefore work for a busy ward nurse, an aged-care registered nurse, a general practitioner, a pharmacist, a physiotherapist and the patient’s family. It should be concise enough to use during a Friday afternoon discharge, yet detailed enough to support safe care over the weekend.

Why The Handover Needs A Shared Structure

A discharge summary is often written for a doctor, while a facility handover must support several disciplines. The receiving nurse needs to know what changed today, what must happen tonight and which observations should trigger escalation. A GP needs a reliable account of diagnoses, investigations and follow-up. Personal care workers need clear information about mobility, cognition, diet and supervision.

The safest format begins with an action-oriented clinical snapshot. State the reason for admission, major diagnoses, significant complications and the patient’s current baseline. Avoid copying a long progress note into the transfer document. A concise summary should distinguish resolved issues from active problems and identify uncertainty, pending results or treatment decisions that still require review.

HM17’s hospital medicine focus also supports a useful principle: communication should be designed around the next clinician’s work, rather than the sender’s record-keeping habits. A template is successful when the receiving team can locate the essential facts without calling the ward repeatedly.

A Transfer Template That Works At The Bedside

The first section should identify the patient with at least three identifiers, the sending ward, the facility destination, the discharge date and the clinician responsible for questions. Record the patient’s usual GP, substitute decision-maker or nominated contact, preferred language, interpreter needs and relevant advance care planning information.

The clinical section can follow this sequence:

• Reason for admission and important hospital events
• Current diagnoses, risks and unresolved concerns
• Allergies, adverse drug reactions and infection precautions
• Cognition, behaviour, mobility, falls risk, continence and nutrition
• Wounds, devices, oxygen requirements and nursing procedures
• Medicines stopped, started or changed, with the reason for each change
• Pending pathology, imaging, cultures or specialist reviews
• Follow-up appointments, monitoring requirements and escalation instructions

Each item should answer a practical question. For example, “warfarin ceased” is incomplete without the reason, the current anticoagulation plan and the clinician responsible for reassessment. “Mobilise as tolerated” is weaker than “two-person assistance with a four-wheel walker; physiotherapy review within 48 hours”.

Medication Reconciliation And Clinical Accountability

Medication discrepancies are common at transitions because the admission list, inpatient chart, discharge prescription and facility medication administration record may differ. The transfer pack should include the pre-admission regimen, the discharge regimen, ceased medicines and newly introduced medicines. Highlight high-risk drugs such as insulin, opioids, anticoagulants, sedatives, antiepileptics and medicines requiring renal dose adjustment.

Australian facilities may receive medicines through community pharmacies, dose administration aids or Residential Medication Management Review processes. A discharge completed late in the day can create a gap if the pharmacy is closed or the prescribed medicine is unavailable. The template should state what has been supplied, what is due next, and who is responsible for obtaining missing items.

The legal and clinical context matters. Medication handling must align with local health-service policy, state or territory requirements and the facility’s procedures. The national medication safety standards and the Aged Care Act 1997 provide a broader framework, but they do not replace a direct verbal handover for a patient with unstable symptoms or a complicated treatment plan.

Follow-Up Across Australian Services

A follow-up plan should name the task, the timeframe and the accountable person. “GP review” has little value without a date or trigger. A stronger entry might specify review by the facility’s GP within 48 hours for fluid status and renal function, with pathology collected before the appointment and results sent to the nominated practice.

Australia’s geography makes this especially important. A patient discharged from a tertiary hospital in Melbourne may return to a regional Victorian facility several hours away. A resident transferred from a Brisbane hospital may depend on a visiting GP, telehealth or a Queensland Health service. In rural Western Australia, distance can affect pathology collection, specialist access and ambulance response times, so transport and contingency plans should be recorded before departure.

The plan should also account for My Health Record, where appropriate, while recognising that a digital upload does not guarantee that the receiving nurse or GP will see the information at the right moment. Send the essential documents directly through the approved secure channel, confirm receipt and record the name of the person who accepted the handover.

Observation, Escalation And Equipment

A receiving team needs more than a diagnosis; it needs an observation plan. Specify the frequency of vital signs, blood glucose checks, neurological observations, fluid balance, wound review or respiratory monitoring. Include the patient’s usual baseline when available, since a mildly confused person may deteriorate without becoming obviously agitated.

Escalation instructions should use observable signs and clear actions. “Monitor closely” is vague. “Call the GP urgently for new oxygen requirement, systolic blood pressure below the agreed threshold, fever with rigors or reduced urine output; call 000 for severe breathlessness, chest pain, collapse or suspected stroke” is easier to follow. The exact thresholds should reflect the patient’s condition and the treating team’s plan.

Equipment must be confirmed before transfer. This may include a pressure-relieving mattress, hoist, walking aid, oxygen concentrator, continence supplies, wound products or a modified diet. Point-of-care assessment can support inpatient decision-making before discharge; the practical POCUS checklist from HM17 is a useful example of how structured clinical tools can reduce omissions, although imaging findings still need to be communicated in plain language.

Recommendations For Reliable Implementation

Templates are most effective when they are embedded into workflow instead of treated as an optional form. Build required fields into the electronic discharge process, use a short verbal handover for higher-risk patients and make confirmation of receipt visible in the record. A nurse-to-nurse call can resolve practical issues that a written summary cannot.

Training should include realistic cases: a patient discharged after pneumonia, a person with delirium and falls risk, and a resident returning with insulin changes and pending cultures. Include the patient and family where possible, especially when goals of care, diet, mobility or medication preferences have changed.

• Assign one clinician to check the final transfer pack before departure.
• Use plain language, defined abbreviations and a consistent order across wards.
• Mark pending results with a named owner and a due date.
• Confirm medicines, equipment, transport and follow-up appointments before discharge.
• Audit readmissions, medication discrepancies and failed follow-up calls each quarter.

A Handover That Protects Continuity

The strongest transition record connects the hospital episode with the patient’s next setting. It explains what happened, what has changed, what remains uncertain and what must happen next. It also recognises that residential aged-care staff may be working under time pressure, with variable access to medical review and limited opportunity to interpret an overly long clinical narrative.

A structured template cannot replace professional judgement, a direct conversation or a patient’s own account of their goals. It can, however, make essential information visible at the moment it is needed. For Australian services, that means adapting the format to local legislation, aged-care practice, pharmacy supply, digital records, regional access and the realities of weekend discharge.

What the reader should remember is simple: a safe transition is complete only when the receiving team knows the patient’s current risks, the next required actions, the responsible clinician and the signs that demand escalation.