Clinical handover and continuity of care – medication management

The Royal Australian College of General Practitioners (RACGP) defines clinical handover as the transfer of professional responsibility and accountability for some or all aspects of a patient’s care from one professional person or group to another.¹ Clinical handover is important in supporting continuity of care. Continuity of care builds long-term relationships, mutual knowledge, understanding and trust, all of which are essential elements in a therapeutic relationship that generates the potential for healing, empowerment and beneficial change.²

Polypharmacy and adverse medication events are of particular concern in older people and are associated with avoidable hospitalisations and negative health outcomes (refer to Part A: Polypharmacy). Having accurate and up-to-date medication information helps GPs to provide safe, high-quality care and ensures that all healthcare providers who see a person in a residential aged care facility (RACF) are able to have the current and correct medication information (refer to Part A: Medication management and Part B: Principles of medication management).

Effective communication about medication changes needs to take place between the person residing in the RACF, their family or substitute decision makers, GP, hospitals, the RACF and the community pharmacies that are contracted to an RACF.

This chapter outlines clinical handover responsibilities to support people’s continuity of care in RACFs.

On admission to RACFs, staff members usually ask new residents, and their family or substitute decision makers, who they have or wish to have as their GP and whether they consent for their medical information to be shared by the RACF. It is helpful for people in RACFs who do not have a local GP to be given information on local GPs who visit the RACF (eg practice brochures or links to practice websites). This also provides people the opportunity to nominate a secondary GP to see should their regular GP not be available.

It is recommended that each RACF has a register of attending GPs with a record of their preferred work arrangements. The checklist tool in Part C: Services, systems and templates provides a useful starting point for clarifying and documenting work arrangements with each GP.

In the case that a person’s regular GP does follow their care into the RACF, it is important that the RACF provides information about after-hours services that the GP uses and clarify when the GP will be available for contact.

In some cases, a person’s regular GP may be unable to follow their care into the RACF and the patient’s care will need to be transferred to another GP associated with the facility. It is important that the regular GP hand over an up-to-date comprehensive health summary (including all identifying details, Medicare and pension details, past history, medications, vaccinations, allergies) and recent hospital discharge summaries to the RACF and nominated GP so that continuity of care is supported. Any specialist, allied health or other professional reports (eg recent pathology and radiology results) should be included as part of this handover. In addition, any clinical evaluations performed as part of the Australian National Aged Care Classification at admission to an RACF, if available, should be included in the handover. Including a copy of these clinical evaluations within a resident’s health record is important to ongoing patient care.

A person’s regular GP should be the first point of contact regarding their healthcare needs. RACFs must take steps to make sure people in RACFs, as well as their carers and substitute decision makers, can access their regular GP (refer to RACGP Standards for general practice residential aged care, Criterion RACF1.1 – Access to care).

If a person sees a GP other than their regular GP, an event summary describing significant events from the consultation, such as any medication changes, must be provided to the person’s regular GP. Likewise, all tests and investigation results need to be sent to a person’s regular GP and copies retained in their health record. It is expected that the other GP will also perform all necessary administrative aspects to support the person at this time (eg charting antibiotics).

Clinical handover needs to occur whenever there is a transfer of a person’s care from one provider to another. When a person has been admitted to hospital or visited the emergency department, obtaining relevant discharge information is necessary to ensure ongoing patient care and safety, and to help prevent additional hospital admissions.³

It is important that, when this transition occurs, hospitals ensure discharge summaries are sent to a person’s regular GP at the time of discharge. This summary must include information about the reasons for medication changes and what ongoing monitoring is required by the GP, so that they may follow up care. In the case where the GP receives a patient’s discharge summary, the GP needs to review the summary to check all information is current before sending it to the RACF. Likewise, the RACF has the responsibility to check that a person’s regular GP receives a copy of the discharge summary if the person was referred by an after-hours or medical deputising service.

Communication and information sharing between services is vital to providing quality care to people in RACFs.⁴ Access to current health information, such as medications, in patient records is critical to a quality clinical handover.

In Australia, each aged care facility has its individual information management system and technical infrastructure to manage health information and medications in the facility (refer to Part C: Information technology systems and RACFs). It is important for RACFs to consider the importance of GPs in the clinical governance of their facility and involve them in quality care discussions around information management systems within their facility. Increasing interoperability between GP services and RACFs will be important to ensuring accurate patient records.

It is important that RACFs provide information about the after-hours services they use to GPs who service their facility. It is desirable for after-hours services to have a formal agreement in place with general practices.⁵ When a service is affiliated with a general practice through a formal agreement, the service can maintain continuity of care for patients in their care (refer to Part B: Provision of after-hours aged care services). 

Continuity of care during after-hours requires established communication pathways to ensure that a person’s regular GP knows what transpired during an after-hours locum visit. It is important that a person’s regular GP receives:

• a copy of the discharge summary
• information on medication changes that may occur in an after-hours setting that are discussed and implemented with the GP
• notification about any RACF-initiated pathology tests.

If a resident’s regular GP is unavailable, and/or urgent and emergency care is required, appropriate care for the resident needs to be determined and agreed upon. A collaborative agreement is an appropriate tool/document that could be developed between the regular GP and RACF. Effective follow-up of abnormal and life-threatening results relies on robust and reliable systems for contact and escalation of care.

A comprehensive medical assessment (CMA) is a review of a person residing in an RACF that involves an assessment of their physical and psychological health.⁶ The CMA may highlight issues such as an immediate medical need, problems with medication management and needs for specialist referral or allied health services. 

GPs can be renumerated to undertake a CMA annually for new and existing permanent residents in RACFs. A medical practitioner may select Medicare Benefit Schedule (MBS) Item 701 (brief), 703 (standard), 705 (long) or 707 (prolonged) to undertake a CMA for a permanent resident of an aged care facility depending on the length of the consultation and the complexity of the patient’s presentation⁶ (see RACGP MBS Aged Care guide for more information, as well as the CMA section in Part B: Medicare Benefits Schedule item numbers, which outlines important CMA criteria and MBS requirements). 

Overview of how to complete a CMA

In general practice, a CMA is often completed by practice staff; however, in RACFs it is likely than a CMA will need to be completed by the GP. The CMA template for use in an RACF is similar to the template used in general practice, but it is likely the GP will need to print a copy to bring to the RACF. 

The components of the assessment include:

• information collection, including taking a patient history and undertaking or arranging examinations and investigations as required
• making an overall assessment of the patient
• recommending appropriate interventions
• providing advice and information to the patient
• keeping a record of the health assessment, and offering the patient a written report about the health assessment, with recommendations about matters covered by the health assessment
• providing a written summary of the outcomes of the assessment for the resident’s records and to inform the provision of care for the resident by the RACF, as well as to assist in the provision of medication management review services for the resident.⁶

GPs undertaking a CMA must ensure consent to the assessment has been given by the resident or a representative with an enduring power of attorney. 

CMAs must include:

• a written summary of the CMA
• a list of diagnoses and medical problems
• a copy of the summary that must be provided to the RACF
• a copy of the summary that must be offered to the resident or guardian/family.

A sample CMA form is provided in the resources below.

A comprehensive care plan is a document (paper or digital) that describes agreed goals of care and outlines planned medical, nursing and allied health activities for a patient.⁶ The plans are different from traditional nursing care plans or medical treatment plans because they require the expertise of each clinician group (eg GPs, nurses, pharmacists, allied health clinicians) to be brought together to coordinate and progress a patient’s care and reach agreed goals.⁷ 

Comprehensive care plans reflect shared decisions made with patients, carers and families about the tests, interventions, treatments and other activities needed to achieve the goals of care. The content of comprehensive care plans will depend on the setting and the service that is being provided, and its name may vary depending on the health service organisation.⁷

The National safety and quality health service (NSQHS) standards provide good advice on how to prepare a comprehensive care plan.⁸

Case conferences are useful in RACFs. Arranging a case conference with staff at the RACF and inviting the resident’s family to attend allows for good communication and the setting goals and plans for the resident. Case conferences are also important for communicating with other sessional visiting staff (ie geriatricians, consultant pharmacists, physiotherapists, palliative care). Please refer to the case conferences section in Part B: Medicare Benefits Schedule item numbers for further information on patient eligibility for case conferences, as well as case conference criteria and MBS requirements

• RACGP MBS aged care guide
• RACGP CMA template
• Medicare Benefits Schedule (MBS): Comprehensive medical assessment for residents of residential aged care facilities
• Local HealthPathways for local processes