Creating Connection: Digitally-derived paperwork from acute to residential aged care
Tracks
Track 2
| Wednesday, July 23, 2025 |
| 12:00 PM - 12:20 PM |
| Menzies Theatrette |
Overview
Presenters: Kate Gorell & Clare Stephenson
Speaker
Mrs Kate Gorell
Clinical Nurse Consltant
Canberra Health Services
Creating Connection: Digitally-derived paperwork from acute to residential aged care
12:00 PM - 12:20 PMAbstract
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.
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.
Biography
Kate Gorell is the Clinical Nurse Consultant for the Acute Care of the Elderly ward at the Canberra Hospital where she leads a dedicated team delivering evidence-based care to older people. Kate strongly believes healthcare should be equitable and accessible for all, despite your age or background.
With a master's degree in clinical nursing and education, Kate is equally passionate about supporting the next generation of nurses. She mentors junior staff, helping them grow into confident, capable professionals who can navigate the challenges of today’s healthcare landscape. Her work is grounded in compassion, collaboration, and a deep commitment to advancing high-quality care for older people.
Clare Stephenson is the Clinical Nurse Consultant for the Acute Care of the Elderly ward at the Canberra Hospital where she leads the nursing team to care for older people, including people with dementia, who are admitted with an acute illness. Clare’s background includes working as a Parkinson’s Advanced Practice Nurse, and she is passionate about providing excellent and equitable health care to people impacted by neurodegenerative disorders and ensuring optimal care for older people across all settings. She has a Master’s in Healthcare Leadership and is pursuing a PhD in dementia care exploring at home rehabilitation for people with dementia.
Carol Chan, Canberra Health Services
Carol Chan is currently the Lead pharmacist for the Rehabilitation, Aged and Community Services division at Canberra Health Services, with over 17 years of clinical pharmacy experience. Carol has a special interest in Aged Care, Rehabilitation and education and training. A leader in the field, Carol is a Fellow of the Australian New Zealand Collage of Pharmacy (FANZCAP) in General Medicine and Geriatric Medicine, an Advanced practice II Pharmacist (in Rehabilitation and Geriatric Medicine), a Board certified Geriatric pharmacist, a credentialled pharmacist and possesses a Masters in Clinical Pharmacy Practice, demonstrating a deep commitment to advancing healthcare for older adults. Carol has mentored multiple pharmacists in the field and has rolled out the first Geriatric Medicine pharmacy Registrar Training Program in the Australian Capital Territory.
Dr S N Fariza Nordin is a Consultant Physician in geriatric and general medicine. She received her medical degree from National University of Ireland, Galway.
She completed post-graduate training in Ireland before moving to Australia. Her specialist training in Australia were in Canberra and Newcastle.
Her clinical interests are cognitive assessment, peri-op and post op care in the geriatric population.
Kasia Bail, University of Canberra
Dr Bail’s primary interest is to improve care health delivery for older people with complex health needs. Her nursing career has always combined both research and clinical roles, with experience primarily in general medical and acute palliative care. Her peer reviewed publications are well-cited, and range in topics that include digital health systems, older people, hospitals, aged care, nurse practitioners, prognosis communication, policy analysis, dementia care, nurse care rationing, and the costs of nurse-sensitive outcomes. In identifying and researching the structures and processes which impede or enable quality patient care Dr Bail is also dedicated to sharing her learning and inquiry with nursing students, industry networks and professional groups.
Dr Aisling (Ash) Smyth is an Associate Professor of Nursing at the School of Nursing and Midwifery, University of Canberra. She graduated from Trinity College Dublin with a Bachelor of Science (Nursing) degree and is a Registered Nurse. She obtained a Master of Biomedical Science and PhD in Biomedical Science from University College Dublin, Ireland. Aislings research aims to marry biological quantifiaction data with nursing-focused research issues. Her research is centred around two main (sometimes overlapping) themes; Sleep as a modifiable lifestyle factor and Older Adults Health and Wellbeing.
Chrysta is a Director at ACT Health Digital Solutions Division. Chrysta brings together a wealth of experience from practical front line clinical care and technical electronic medical record build into the projects that she is on. Chrysta enables the use of digital tools and reporting to drive improvement in clinical areas and is a key contributor to quality improvement monitoring and evaluation of programs across ACT health.
Rebecca Heland is an Executive Branch Manager in Digital Solutions Division at the ACT Health Directorate and is responsible for the implementation of new projects across the digital health space in the ACT public health system. Rebecca was the Chief Nursing and Midwifery Information Officer during the implementation of the Digital Health Record and has been a nurse for over 15 years continuously advocating for nursing lead decision making, design and involvement in digital health systems.
