Journal article
“This was a good transition”: Piloting a standardised, comprehensive discharge documentation and medication package for hospital-to-nursing home
Geriatric Nursing, Vol.73, pp.1-12
2026
PMID: 42570557
Abstract
Introduction
In Australia, nearly 400,000 people live in residential aged care, of those, 40% experience a hospital admission annually. High-quality care transitions are crucial for ensuring safe and effective continuity of care. Ineffective information sharing increases risks of harm for already vulnerable consumers, contributing to adverse health outcomes, creating care delays and causing distress to individuals moving between care settings.
Aim
This study aimed to co-design, pilot and evaluate the implementation of a comprehensive discharge documentation and medication package aligned with the electronic medical record to support quality care transitions between hospital and residential aged care.
Methods
Mixed-methods, participatory action approach, incorporating workshops, surveys, and interviews. Ten RNs from four residential aged care sites participated, and ten hospital-to-residential aged care transitions were evaluated.
Results
80% (n = 8) stated the discharge package met the standard for providing comprehensive care, and 100% (n = 10) identified improved medication safety. Three themes were identified from the interviews: 1) Enhancing system improvements supports more effective care transitions; 2) Effective cross-sector information sharing depends on well-defined and replicable processes; 3) Historical standards drive lower expectations.
Conclusion
This participatory action research co-designed an effective discharge package for hospital-to-residential aged care. Developed by a nurse-led multidisciplinary team, this work established a strategy that supports patient safety, quality information sharing, and is aligned with hospital and residential aged care standards. Based on the difficulties of effective communication, the use of the documentation package demonstrates an effective tool to support information sharing processes between hospital and residential aged care.
Details
- Title
- “This was a good transition”: Piloting a standardised, comprehensive discharge documentation and medication package for hospital-to-nursing home
- Authors
- Kate Gorell (Corresponding Author) - Canberra Health Services (Australia)Clare Stephenson - Canberra Health Services (Australia)Ash Smyth - University of CanberraChrysta Bridge - Digital Canberra (Australia)Carol Chan - Canberra Health Services (Australia)Shrijana Gautam - Warrigal Aged Care (Australia)Fariza BINTI Nordin - Canberra Health Services (Australia)Victoria Traynor - University of the Sunshine CoastKasia Bail - University of Canberra
- Publication details
- Geriatric Nursing, Vol.73, pp.1-12
- Publisher
- Elsevier Inc.
- Date published
- 2026
- DOI
- 10.1016/j.gerinurse.2026.104206
- ISSN
- 1528-3984
- PMID
- 42570557
- Copyright note
- © 2026 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
- Organisation Unit
- Healthy Ageing Research Cluster; School of Health - Nursing
- Language
- English
- Record Identifier
- 991250587902621
- Output Type
- Journal article
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