Communication between Acute Care Hospitals and Residential Aged Care facilities (RACF) is essential for optimal continuum of care. The communication between facilities within the area was identified as an area for improvement. A project was designed and implemented that improved communication between Bathurst Base Hospital (BBH) and the RACF within the Bathurst region.

A communication tool was developed that allowed the individuals health information to travel with them throughout their entire journey between the acute care facility and the RACF. The communication tool was implemented and initial results show a 50% improvement in the continuum of care between hospital and the RACF, resulting in improved communication as well as patient satisfaction and a better health care experience.

To provide a standardised tool to improve the continuity of care between the acute care facility and the RACF within the Bathurst region.

Communication of an individual's clinical information between different levels of care providers was found to be inconsistent or absent. A critical step in the continuum of care cycle is the communication between an acute care facility and a RACF. There was no formal procedure followed when transferring a patient between facilities which could lead to miscommunication of medication issues. This often resulted in additional work for both hospital and community pharmacists, and for the nursing and medical staff at both facilities.

During the diagnostic phase of the Eastern Cluster's Aged and Chronic Care Redesign project, the issue of inadequate communication and excessive time spent in chasing up patient information was a recurring theme. Community pharmacists also reported difficulties dispensing medications after hospital discharge, as medications charts included medications not necessarily required in the outpatient setting. This could result in medication errors and confusion about the intended ongoing treatment.

Other issues included RACF staff being unable to legally recognise and thus administer medications from the Hospitals inpatient chart which could lead to missed doses of medications. There was also a lack of information passing between BBH and the RACF regarding other care needs of the individual such as advanced care directives. This type of issue impacts greatly on the safety and quality of the health care experience for an individual.

As part of the 2007 GWAHS strategic plan, the Area Health Service committed to improve the services offered to an ageing population and improve the continuum of care between health care environments. This project clearly contributes to this goal.

Medication errors on discharge more than double the risk of hospital readmission or adverse medicine events. (APAC Guidelines, 2005) By 2010 GWAHS aims to reduce potentially avoidable admissions by 15%. This project will achieve a reduction in readmission rates due to a reduction in medication errors and an improvement in the patient experience.

A working party was established including representatives from the local RACF, the Aged Care Assessment Team (ACAT), BBH Nursing Unit Managers, the Division of General Practice, the hospital pharmacy and a BBH executive. The project team was supported by the Eastern Cluster Clinical Redesign Project Manager and an external consultant.

It was recognised that a simple tool was needed to improve the information flow between health facilities. A standardised Communication Tool Interchange Envelope (yellow envelope) was implemented. This was based on work done by Redcliffe Bribie Caboolture Division of General Practice, Queensland.

The envelope was designed to travel with the patient between and within the facilities. It acts as a single repository for all information required to be communicated between facilities. A check list is included on both sides of the envelope with one side to be completed by the RACF when transferring a patient to the hospital and the other side to be completed when discharging a patient to a RACF.

The envelope also includes a seven day interim medication chart, enabling hospital medical staff to review and alter the patient's medications, and RACF staff to administer medications prior to recharting by their own medical staff. This reduces the risk of medication errors and readmission to the hospital due to these errors as well as reducing the expenditure on staff time and medical staff call backs.

The envelope was implemented with the support of the Nursing Unit Managers, education staff and the support of the Directors of Nursing at all facilities. Inservices ensured all staff was aware of the envelope and how to use it appropriately. The medical staff was informed of the envelope via a letter outlining the goals of the project and their responsibilities regarding the seven day interim medication chart.

Four weeks after implementation, an audit evaluated the progress of the envelope. There were seven facilities participating in the pilot program. During this time eight envelopes had been used. The following information summarises the initial audit results:

• There were four admissions to BBH from the RACF during this time, of these two were returned to the RACF with the envelope completed.
• There were four new admissions to the RACF from BBH and all of them had envelopes completed on discharge.

Qualitative data collection reflects a very positive response to the tool with increased communication and better patient/resident outcomes. The envelope has made identification of required information for transfer between facilities less time consuming and more accurate. This project has improved appropriate communication between services. A further audit has been commenced and the results will be available at the end of May.

The project will be sustained with nursing, pharmacy and ACAT team involvement, ensuring that all patients awaiting nursing home placement have an envelope in their progress notes for the hospital staff to complete at discharge. The project will also be supported by the Aged Acute Residential Care Coordinator commencing at BBH in the near future who will case manage each patient transferring between facilities. Feedback to the ward staff regarding the improvement in patient outcomes and the recognition of the ease of transfer should encourage the envelopes continued use.

Despite the brevity of this project it is obvious that the patients' health service experiences are greatly improved. The yellow envelope has the potential to be implemented across the Area Health Service and may also have a role in transfer between acute care facilities as well as improving the care of not only adults but others such as the developmentally delayed, and transfer of children between foster carers. There is currently communication taking place between the Department of Health and the NSW Alliance of General Practice in regards to implementing this tool state wide.

 Australian Pharmaceutical Advisory Committee 2005, Commonwealth of Australia, Guiding principle to achieve continuity in medication management. viewed 24 Oct 2008.

Patient Safety & Clinical Quality Manager, Clinical Governance Unit
Greater Western Area Health Service
Ph: 02 6393 3559