CG5 – Transitions of care

Transitions of care, including clinical handover of care, occur frequently in general practices. Inadequate handover of care is a major risk to patient safety that could result in:

• delayed treatment
• delayed follow-up of significant test results
• unnecessary repetition of investigations
• medication errors
• adverse events
• legal action.

The Australian Commission on Safety and Quality in Health Care has published best practice guidance for transitions of care, which cover:

• care that is person-centred
• multidisciplinary collaboration
• documenting and accessing information via a comprehensive and secure record system
• ongoing continuity and coordination of care.

Transitions of care occur whenever there is a transfer of care from one provider to another. For example, when:

• a practitioner is covering for a fellow practitioner who is absent or otherwise unavailable
• a solo practitioner is handing over to a locum GP
• a practitioner is handing over care to another health professional (for example, a nurse, physiotherapist, podiatrist, psychologist)
• a practitioner is referring a patient to a service outside the practice
• there is a shared-care arrangement
• there is an emergency, such as handover to and from hospitals, mental health inpatient facility, or ambulance
• a person is discharged from a hospital or mental health inpatient facility, and care returns to their GP
• the patient makes a request to transfer their health records to, for example, a different general practice.

Transitions of care during an acute health emergency can present higher risks of harm to patients, particularly if the receiving health service is not well prepared for such an event. Acute emergency situations in general practice could include (but are not limited to): acute medical episodes such as a heart attack; mental health events; asthma attacks; convulsions; traumas such as head injuries; or pregnancy-related events such as premature delivery.

The practice could implement processes addressing transitions of care during emergency health situations. These processes could:

• recommend using the ISBAR approach (Identify, Situation, Background, Assessment and Recommendation) when managing transitions of care
• outline how to communicate all relevant health information to the practitioner or service taking over the patient’s care (which could include providing physical documentation)
• include reviewing whether the patient’s medical record (which could include My Health Record, with the patient’s consent) is current and accessible to responsible services and/or clinicians.

The practice could also have protocols relating to the follow-up care of patients who have been admitted to hospital or another facility (either while attending the general practice or otherwise). These could include processes to review and follow-up documentation such as discharge summaries, including those received electronically.

Crisis intervention refers to immediate action taken to support a patient experiencing a mental health emergency, such as suicidal ideation, psychosis, or severe distress. These situations may require urgent coordination with external services and careful consideration of legal and ethical responsibilities.

Aligning with relevant state or territory mental health legislation is essential when responding to mental health crises. This includes understanding criteria for involuntary assessment or treatment, and the obligations of practitioners under laws relating to mandatory reporting.

Referral protocols may include:

• contacting local crisis assessment and treatment teams (CATT)
• coordinating with emergency departments and/or ambulance services
• using HealthPathways or Primary Health Network (PHN) tools to identify appropriate localised crisis response options.

Documentation of crisis interventions supports continuity of care and legal compliance. This could include recording:

• the nature of the crisis
• actions taken
• referrals made
• any legal obligations fulfilled.

When coordinating care during crises, the practice needs to share safeguarding information relevant to safe communication or handover, such as preferred contact arrangements, privacy flags, or existing court or protection orders.

The RACGP has developed a resource that explains the risk associated with emailing certain types of information to patients or other healthcare providers, depending on the practice’s policies and processes.

Although the Privacy Act 1988 does not prescribe the method of communication a healthcare organisation should use to pass on health information to patients or third parties, it does require that the practice takes reasonable steps to protect the information and the patient’s privacy. Therefore, unless the patient has consented otherwise, the practice needs to protect patients’ privacy when communicating electronically with or about them, by using a secure messaging system or another method of encryption. See F9 – Confidentiality and privacy of health and other information for further advice.

A patient’s health information may be requested by the patient, another practice, or other third party. For example, a patient’s new practice may request a copy of the patient’s health record.

The practice’s privacy policy needs to address the timely, authorised, and secure transferral of patient health information in response to valid requests.

If the practice has concerns about third-party requests for the transfer of patient health information, contact the practice’s medical indemnity insurer or medical defence organisation (MDO).

When transferring patient health information to others, follow the relevant processes in the Australian privacy principles (APPs) and all requirements of relevant state or territory laws.

In line with F9 – Confidentiality and privacy of health and other information, practices need to transfer patient health information securely. If the practice chooses to send patient health information via email, security measures need to be in place to protect the information.

To further facilitate timely transitions of care, the practice could:

• keep records of any issues in a clinical handover system that were identified and addressed
• have a policy explaining how to conduct internal and external handovers, including to locum practitioners
• have a shared-care arrangement when appropriate
• create and document a buddy system
• use internal messaging or internal email for members of the clinical team to communicate with each other
• use a clinical information system that enables the practice to upload a patient’s shared health summary/record or event summary to the patient’s national shared electronic health record at the patient’s request
• have a policy or process that specifies how the practice responds to all correspondence (including paper and electronic communication) in a timely and appropriate manner
• inform patients of any potential costs associated with the transfer of their health information.