Transfer of care: Building partnerships instead of puzzle-pieces

What is ‘transfer of care’?

According to the Compliance Transfer of Care Definition, it is defined as the “process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate”.

That definition focuses on the role of the physician and hints at what many believe is indicative of the lack of real communication or planning with other members of the healthcare team and the patient themselves. As a promising sign of changes to physician-focused care, most services are now incorporating exciting initiatives to provide the patient with more certainty of their transfer of care, providing healthcare staff with a more secure way of dealing with transfer of care on weekends, public holidays and even out-of-hours.

We had the opportunity to speak with Walter de Ruyter, Service Manager of UnitingCare Ageing, on the challenges in facilitating this process, its impact on the care of older patients, and the role patients play to ensure a safe and timely flow of care.

What does transfer of care mean for organisations and individual patients?
i) The objective for organisations is to develop a continuity of care model, achieved through the alignment and sequencing of care needs through the collective umbrella of affiliated organizations. This results in a greater number of access points of care becoming a planned event. Examples of tools used to reflect this are agreed pathways of care between provider organisations and integrated health staff placement programs across services.

ii) The challenge for clients are current processes associated with care have a focus on supporting the organisation in delivering a service to a client, whilst the process of care to support the client across organisations in accessing their health and wellness needs is poorly developed. The latter is the expectation of consumer directed care.

What are some of the current challenges in improving the information flow between organisations and ensuring continuity of care?
The focus has been on developing technically sophisticated information platforms such as the national patient record and despite the amount of money spent the uptake has been relatively low. The challenge is more to do with common purpose through collective leadership which allows us to gain the trust of and engage the broader community. This in turn allows us to work collaboratively to better use information platforms such as the national patient record addressing the significant challenge of managing the health and wellbeing of our rapidly aging community.

Focusing on the transfer of care of older patients, does health have a bed shortage or is it a matter of how beds are used between hospitals and aged care facilities?
Aged care beds out-number hospital beds by greater than two to one (> 2:1). When aged care residents are admitted to a hospital the reason is often the need for a small increment of clinical care beyond the scope of the residential facilities routine support of Activities of Daily Living (ADL’s). This keeps the resident from returning to their vacant aged care bed. The subsequent impact on the occupancy of hospital bed days is significant. We have yet to collectively work as a single connected service and until then the problem is more to do with the delivery of care than the number of beds.

There has been a heightened focus on keeping the patient at the centre of care. What role can the patient play in working towards a safe and timely transfer of care?
The future is one where the patient is becoming the central player in managing their care as detailed in a short paper on consumer directed care from an aged care perspective. The difficulty for the Patient/Consumer is the process of guiding the flow of care information is not coherent, as the focus of care is often an isolated ‘puzzle-piece’ expressed in the jargon of the service. The puzzle-piece of care (often Health) has not been dovetailed in a culturally and socially inclusive way that is relevant to the consumer.

What do you believe are some of the essential elements in developing a whole of community response to promoting the health and wellbeing of an aging population?
A priority is to develop a collective will by stakeholders in the provision of health and wellbeing e.g. each provider to quarantine a small percentage of their budget as allocated by federal and state governments to ensure these funds are directed to integration of care strategies across services. Rapid change and improvements can be undertaken through the reorientation of social and physical capital. An example is the statement in question 3; “does health have a bed shortage or is it a matter of how beds are used between hospitals and aged care facilities”.

Providing that small increment of care at point of need such as in the aged care facility rather than at point of delivery at the hospital. The technology and trained staff are available here and now to address these increments of care at “Point of Need”, unfortunately it often takes a disaster such as the NZ Christchurch earthquake where the imperative to respond to such a crisis resulted in transfer of care innovations leading to significant improvements in service delivery over the past seven years. This was encapsulated in the statement; where the collective effort of Canterbury health 7 years post-earthquake resulted in a 30% reduction in unplanned admissions and a 45% increase in elective surgery when compared to other district services across New Zealand.

Melanie Dicks of Uniting Care NSW ACT and Narelle Evry of Illawarra Shoalhaven Local Health District NSW will be discussing the topic of “Building Partnerships: Not a Bed Problem; It is a Service Delivery Opportunity” at the upcoming Transfer of Care Conference, held on the 22-23 June in Sydney.