The Development of a National Transfer Document: for use when an older person is being transferred from residential to acute care settings

The effective management of care for older people across all sectors of healthcare is a key issue for health care policy and practice. Transitions of older adults with multiple chronic conditions are particularly vulnerable and frequently characterised by breakdowns in communication both within and between services that can lead to poorer outcomes for the older person. The provision of quality care to older adults is dependent upon clear concise and contemporary communication. However, international research suggests that documentation and handover deficiencies between age care facilities and acute services are common and in some cases absent. A variety of nursing transfer documents exist and there is a lack of consensus regarding the information considered essential for inclusion in transfer documentation. Standardised tools have demonstrated improvements in the quality of communication from aged care facilities and the acute hospital. The National Clinical Programme for Older People in Ireland, supported by Office of Nursing and Midwifery Services Director in recognition of the importance of improving communication between residential and acute care facilities, commissioned this research. To develop an evidence based and person centred national transfer document for use when an older person is being transferred from residential to acute care settings. Stages of development included: an integrated review of international literature, a stakeholder focus group study, a consultative process with an expert advisory group and an expert in person centred care. A pilot of the transfer document was then conducted, in twenty-eight residential and three acute care sites, across three geographical locations over a three-month period. Staff surveys were conducted, to ascertain their perceptions on the usability, layout and design of the document. Results: There was general agreement in the literature, the focus group study and pilot study that a standardised transfer document was required for safe and effective transfer of older people from residential to acute care and a need for a holistic, person-centred approach to this documentation. Results of the pilot were used to inform revisions to the design and layout of the national transfer document i.e. to divide the piloted document into two parts (Transfer Document and Health Profile/Passport) retaining the evidence based content and the person centred perspective. A consultation/focus group discussion with participants in the pilot study was then convened to reach consensus on the final design and layout.