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Seamless Transitions: The Pathway Home

Project Added:
12 October 2015
Last updated:
27 October 2015

Seamless Transitions: The Pathway Home


Royal North Shore Hospital (RNSH) redesigned the process of transferring information from RNSH to Primary and Community Health (P&CH) services, including reintroducing a Transfer of Care Risk Screening (TCRS) tool and expanding the Acute and Post-Acute Care (APAC) liaison role.

View a poster from the Centre for Healthcare Redesign graduation, April 2014. 

Seamless transitions [poster]


To improve the referral process from RNSH to P&CH services, by increasing the number of patients referred to APAC services by 10% and improving identification of patients requiring P&CH services by 40%.


  • Improves the patient journey.
  • Better matches resources to needs.
  • Improves communication and exchange of information.
  • Delivers a more coordinated and robust process for the transfer of care.

Project status


  • Start: April 2013
  • Finish: August 2013
  • Final presentation: April 2014


Implementation - The initiative is ready for implementation, is currently being implemented, piloted or tested.


The process for the transfer of patient information from RNSH to P&CH services via the Health Contact Centre (HCC) was time consuming, fragmented and inconsistent, which diverted clinical care away from inpatients and increased the risk of an extended length of stay. The referral process via HCC was also fraught with duplication, multiple phone calls and limited technology.

Key findings from patient tracking

  • 44% were offered a community service on transfer.
  • 87% had no transfer of care risk screen.
  • 72% of patients had two or more co-morbidities.
  • 40% of patients had a discharge diagnosis vastly more complex than admission diagnosis.

Staff focus groups and surveys results

  • 88% of staff were unsatisfied with referral process via HCC.
  • 69% of staff were unaware of the range and availability of P&CH services.

Patient surveys results

  • 73% were happy with transfer process.
  • 13% were confused by the current transfer process.
  • 15% may have benefited from a P&CH service if it had been offered.

Objectives developed 

To address this issue, the following objectives were developed.

  • Increase the identification of potential patients requiring P&CH services at RNSH by 40%, by December 2014
  • Implement an improved referral process for the transfer of patient information to P&CH services from RNSH via the HCC, by December 2014
  • Increase the number of patients referred to APAC services from RNSH via HCC by 10%, by December 2014.


  • Provided education and resources for staff at RNSH.
  • Redesigned and updated the Discharge Planning: Transfer of Care Resource Manual.
  • Updated the Transfer of Care Patient Information Brochure and provided to all patients on admission.
  • Expanded the APAC liaison role to include attendance at daily board rounds and facilitation of referrals to APAC.
  • Developed a ‘How to refer to APAC’ poster and displayed in all inpatient areas to simplify and speed up the referral process.
  • Secured Executive commitment (community and acute) for the formation of a collaborative working party to improve the transfer of care.
  • Engaged staff in the reintroduction of the TCRS tool into the nursing admission process.
  • Tested use of TCRS and discharge checklist tool in the Acute Assessment Unit (AAU).
  • Met with service managers to support the development of tools and procedures that streamlined referral processes. 
  • Developed clear processes and procedures for the transfer of patient information. 
  • Presented findings of the project to the executive managers of RNSH, HCC and P&CH services to ensure a high level of engagement and a commitment to the organisation.

Implementation site

  • Royal North Shore Hospital, Northern Sydney Local Health District


  • Centre for Healthcare Redesign


  • TCRS and discharge checklist tools tested in AAU indicated 81% patients were screened for primary and community health service requirements.  
  • 100% patients completed a discharge checklist.
  • Staff surveys indicated that satisfaction improved 33%.
  • Patient surveys indicated that satisfaction improved 26%.
  • Early signs of increased APAC referral numbers are encouraging.
  • By June 2015, there was 100% compliance with the Transfer of Care Risk Assessment for all admissions to the AAU. A revised modified Blaylock Transfer of Care Risk Assessment will be rolled out and tested in five inpatient wards.
  • A revised electronic APAC referral form is being developed for referrals via the HCC. This will go a long way in reducing confusion on the modes of referral to APAC.

Lessons learnt

Given the broad scope of our project, change would not have been possible or sustainable if undertaken in isolation. Fortunately, during the course of our project we were able to proactively capitalise on a number of relevant concurrent initiatives. These included:

  • accreditation at RNSH, driving best practice in transfer of care processes
  • the Whole of Hospital Journey Board Program, to ensure effective communication within the inpatient multidisciplinary teams
  • the APAC emergency department trial, to identify patients who may be better managed at home.

Seamless transitions are only possible when there is a shared commitment between acute and P&CH services for a robust, coordinated and flexible approach to the transfer of care process. While the positive trends evident across all our objectives are very encouraging, the greatest achievement has undoubtedly been the overarching recognition by executive teams of the need to work collaboratively in all transfer of care initiatives.

Further reading

Project team

  • Paula Harman, Clinical Nurse Coordinator Discharge Planning, RNSH
  • Melissa Christiansen, APAC, Hospital Liaison, RNSH 
  • Louise Bayliffe, Occupational Therapist, RNSH


Paula Harman
Clinical Nurse Coordinator (CNC) Discharge Planning
Royal North Shore Hospital
Northern Sydney Local Health District
Phone: 0422 006 571

Melissa Christiansen
APAC Hospital Liaison
Royal North Shore Hospital
Northern Sydney Local Health District
Phone: 0430 126 261

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