Communication and coordination processes supporting integrated transitional care: Australian healthcare practitioners’ perspectives

Identifying strengths and weaknesses in transitional care for older adults in an Australian setting.


The implementation of transitional care from hospital to home for older adults is challenging within healthcare contexts characterised by service fragmentation and an increasing demand for aged care. Poor care integration during care transitions often results in unmet needs at home, unnecessary readmission to hospital and unwanted permanent placement in residential care.


Care integration must focus on improved communication with patients and carers to understand their needs and to support their increased responsibility and decision making in care transitions.


The study demonstrates factors that can improve service integration during care transitions of older adults. Health services organisations and planners need to modify systems allowing health practitioners to assess patients’ self-care abilities regarding negotiation and navigation of their own care transitions.


Monash University School of Nursing and Midwifery

Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners’ experiences of care provision.

Transitional care is referred to as continuous and unified care for patients across different health programs and settings [1]. Communication, care coordination, medication reconciliation, functional improvement and self-management are important features of transitional care [1, 2]. In accordance with contemporary research [1, 3, 4, 5], we focussed on communication and care coordination as essential processes in clinical care that support care integration during older adults’ care transitions.

Previous studies have found that compared with usual care, formal transitional care interventions including discharge assessment, planning, care coordination, communication, medication reconciliation, and self-management reduce length of stay and re-admission rates, and improve patient satisfaction with care [5, 6]. Two well-researched US-based models of care, the Care Transitions Intervention [4] and the Transitional Care Model [1] have been influential in re-orienting health services towards the importance of self-management and advanced practice nursing support. Other studies of transitional care have explored care integrated with multidisciplinary teams and aged care teams and found reduced readmission rates and reduced functional decline in older adults [7, 8].

This study aimed to identify implementation strengths and weaknesses in integrated transitional care for older adults in an Australian setting by describing how healthcare practitioners experience care provision across acute, sub-acute and community care programs. Data was collected in two phases using interviews and focus groups. Participants in phase one interviews included multidisciplinary practitioners working across acute, sub-acute and community settings. Phase two focus groups were conducted to confirm the findings in phase one. Participants included healthcare practitioners with a key role in transitional care and patients and carers involved in transitional care. Phase one of the study identified four key themes including: (1) rapid and safe care transition, (2) discussing as a team, (3) questioning the discharge, and (4) engaging patients and carers and these were endorsed by participants involved in the phase 2 focus groups.

The findings highlight the need for health practitioners to adapt their care coordination and communication practice to an evolving care context of stronger expectations that older adults and their informal carers will take greater responsibility for their own care in the community. In care transition contexts shaped by multidisciplinary teams, sub-acute care and consumer-directed care, health practitioners should focus on supporting older adults and their informal caregivers to navigate their own care transitions. To improve care integration during older adults’ care transitions, health services organisations and planners should adapt systems to support health practitioners in assessment of patients’ self-care abilities regarding negotiation and navigation of their own care transitions.

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