Icon for Key Principle 5

PRINCIPLE 5: Communication processes to support person centred care

Communication processes and tools will support person-centred care for the older person throughout their hospital journey and at their transfer of care to the community.

Transfer of care

The care of an individual does not begin and end with the acute – or short term – hospital experience.

Communication between healthcare teams and providers needs to occur at all transfers – from emergency department to ward, from ward to residential aged care facility, and from hospital to community and back again.

Clear and succinct communication is required for all transfers of care, as well as between all members of the multidisciplinary team.

Clinical handover

Key principles for improving clinical handover (1) include:

  • Engage the older person and their carer/family The older person, their carer and/or family should be involved in decision-making about transfer of care. Clear and succinct communication

In many cases electronic communication will be the optimal method. Verbal communication must also occur when; follow-up care is required within 48 hours, if there is a concern regarding potential deterioration of the older person, or if the older person has complex needs.

  • Medication reconciliation

Medication reconciliation should occur at every transition of care. The older person and/or carer should always receive any updated medication list(s). Discharge plan When leaving the hospital, an older person, their carer and/or family must have a copy of their discharge communications, including an ongoing management plan. If the older person suffered delirium while in hospital, consider a follow-up referral with their GP, specialist services (e.g. Geriatric outpatients), community aged care team and/or a counsellor. Communication with GP

Systems should be in place to enable GPs to have access to electronic patient results.


  1. Principles are based on recommendations of NSW Agency for Clinical Innovation. Safe Clinical handover: A resource for transferring care from general practice to hospitals and hospitals to general practice. Sydney: ACI, August 2013.