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13 Dec 2018

Appropriate and effective transfer of care arrangements between general practitioners and hospitals when patients are admitted to and discharged from hospitals can reduce patient readmissions in the days and weeks following their treatment.

The AMA has released an updated Position Statement on General Practice/Hospitals Transfer of Care Arrangements – 2018, outlining the steps required from both GPs and hospital doctors to ensure the best health outcomes when admitting and discharging patients.

“Appropriate and effective transfer of care arrangements are more than just a GP sending a referral letter to the hospital and, in return, the hospital sending on a discharge summary when the patient leaves hospital,” AMA President, Dr Tony Bartone, said today.

“While some policy and resourcing has been put in place between general practice and hospital to improve transfer of care arrangements, the AMA remains concerned that efforts are inconsistent, with too many transfers not meeting best practice.

“Where appropriate and effective transfer of care practices are undertaken, readmissions are reduced, and adverse events minimised.

“Unfortunately, missing discharge summaries and slow – or no – communication too often leads to poor patient outcomes.

“This is despite research showing that the absence of a discharge summary was associated with a 79 per cent increase in the risk of readmission within seven days, and a 37 per cent increase in risk of readmission within 28 days.

“A patient’s GP is their main provider of ongoing health care. They have a critical role in coordinating care and providing continuity for their patient throughout the system.

“GPs also work in tandem with medical specialists, allied health providers, and other support services that manage and treat the patient across a variety of settings.

“GPs are strongly encouraged to visit their patient in hospital, and should be able to obtain progress reports, including when their patient is likely to need a post-discharge appointment.

“Maintaining strong GP involvement in the patient’s care will provide the best outcomes for the patient.

“Digital technology, including My Health Record, has the potential to improve transfer of care arrangements, but it cannot replace direct communication with a patient’s GP.

“GPs should consider uploading a Shared Health Summary into My Health Record for patients with serious or complex medical conditions, and who are more likely to require unanticipated hospital admissions.

“Alternatively, these patients should be provided with a paper-based medical summary to carry with them, or store in a readily accessible place at home, particularly if the patient has opted out of My Health Record.

The Position Statement advises that:

  • GPs should provide hospitals with all relevant information about the patient, including knowledge of any treatment the patient is receiving from another doctor, whether the patient needs interpreter or cultural support, and the reason for the referral.
  • At the hospital, the name and contact details of the patient’s GP and/or practice must be verified and updated each time.
  • If the patient is admitted directly to hospital via the Emergency Department or outpatient clinic, the practice should be contacted to obtain the patient’s relevant medical history.
  • The hospital should advise the GP within 24 hours if a patient presents at the Emergency Department or is an unplanned admission, and within 24 hours of their discharge from hospital, or if the patient dies or any other sentinel event.
  • The hospital should notify the GP within seven days of the patient’s initial specialist outpatient consultation, of any changes in health status or medication at a specialist outpatient service, and of their discharge from a specialist outpatient clinic.
  • The patient should be given a handheld, paper-based clinical summary, particularly if they are seeing their GP for immediate follow-up, and adequate supplies of medication to last until they can see their GP.

The AMA Position Statement on General Practice/Hospitals Transfer of Care Arrangements – 2018 is at  https://ama.com.au/position-statement/general-practicehospitals-transfer-care-arrangement-2018


13 December 2018

CONTACT:        John Flannery            02 6270 5477 / 0419 494 761
                            Maria Hawthorne       02 6270 5478 / 0427 209 753

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Published: 13 Dec 2018