Introduction: High quality care transitions for older adults are paramount for safe and effective continuity of care, creating connections that promote trust and understanding. The Royal Commission into aged care recommended appropriate clinical handover and discharge summaries, including medication lists, were provided and acknowledged by the residential aged care home (RACH). In the ACT medication charts were handwritten and varied between RACH. Furthermore, there was no reconciliation process for these charts, creating an increased risk of error. Traditional discharge paperwork missed key nursing and allied health information, resulting in overlooked opportunities for compassionate care during transitions.

Methods: This study used a participatory action approach, demonstrating the courage to innovate by co-designing a standardised digital discharge paperwork-package. The package included seven-days of sachet-packed medications, a digitally-derived signing sheet, and increased nursing and allied health documentation. Ten discharges to three RACHs were followed up within 48-hours of discharge and phone surveys were used to collect descriptive characteristics of the discharge information received using semi-structured interviews and Likert scales. Interviews were recorded, transcribed verbatim, and analysed with thematic analysis.

Results: Nine out of ten transfers revealed that the new paperwork-package met the expected level for providing safe care. All ten participants confirmed that prescribed medications were accurately provided. Additionally, two out of three first-time admissions suggested that a nurse-to-nurse phone handover prior to patient arrival would foster improved connection and continuity of care.

Conclusions: The newly developed digitally derived paperwork was well-received by participants, proving to be a courageous step toward improving care transitions. It was deemed feasible and valuable for broader implementation, emphasising the importance of connection and compassion in delivering quality care. RACH nursing staff identified the need for additional information, such as behaviour support plans and end-of-life recommendations, ensuring that every individual’s unique needs are met with empathy and understanding.