Optimising information exchange between residential aged care and hospitals

The challenge

When aged care residents are transferred to and from hospital, sharing critical health information is essential for coordinated care. However, many providers face challenges with effective health information sharing due to inconsistent recording and quality of data, and inadequate technical infrastructure.

This project team has co-designed a digital health summary to improve the accurate sharing of critical resident health information during hospital transfers. This digital health summary is now being trialed in three Victorian residential aged care homes, Peninsula Health, Ambulance Victoria and general practice.

Our impact

Co-designed a digital health summary to support timely and consistent sharing of a resident’s important health information with key emergency, hospital and residential aged care staff, along with residents and their carers.
A digital health summary that includes resident health information such as usual function, medical conditions, allergies, important to know about medications, and presence/location of advance care plans to support decision-making about care during hospital transfers.
Potential to reduce avoidable hospitalisations and ambulance attendances, and improve residents’ healthcare experience.

Project leads

Professor Nadine Andrew (NCHA) leads a very experienced multidisciplinary research team from across NCHA, Monash University and LaTrobe University, supported by a broad range of stakeholder partners.

Project resources & knowledge

Our current trial – Information for participants View

Project progress summary View

Final prototype View

Conference presentations View

Project media and articles View

Optimising information exchange between residential aged care and hospitals project

Key project information

Official name:
Optimising health information exchange during aged care transfers
About the research:
By developing and testing a new co-designed digital health summary that includes key resident health information such as usual function, medical conditions, allergies, important to know about medications, and advance care plans, this project aims to reduce avoidable hospitalisations and ambulance attendances, and improve residents’ healthcare experience.
Over the course of four years, the project team has progressed through several stages of development and research and will complete Stages 3 and 4 during 2025:
- Stage 1 – Understanding the context: To understand the data requirements the research team reviewed existing research, audited information systems, and established stakeholder and end user advisory groups. The team conducted interviews to understand current practices, workflows and technical needs of end users. The Centre for Medication Use and Safety (CMUS) mapped and prioritised high-risk medication categories for the tool. Information from these processes was collated and prioritised through a consensus building (modified Delphi) process for inclusion in the digital health summary.
- Stage 2 – Designing the tool: The team held co-design workshops with aged care staff, healthcare professionals and consumers to shape the look, feel and functionality of the digital health summary.
- Stage 3 – Testing the tool: Following prototype development, the digital health summary was trialled and evaluated over a three-month period at each of the three residential aged care homes (Regis Rosebud, Regis Frankston, and Arcare Balnarring) between July 2024 to April 2025, along with Peninsula Health, Ambulance Victoria and general practice.
- Stage 4 – Implementation Package: Developing an implementation package for future scale up and adoption
To read more about project progress, please see our Project Summary for Stage 1 & 2
Project timing: 2021 – 2025
Chief Investigator
- Professor Nadine Andrew (NCHA)
Co-investigators
- Dr Katrina Long (Monash University)
- Professor Velandai Srikanth (Director, National Centre for Healthy Ageing)
- Professor Terry Haines (Monash University)
- Professor Keith Hill (Monash University)
- Professor Simon Bell (Monash University)
- Professor Patrick Olivier (Monash University)
- Associate Professor Richard Beare (National Centre for Healthy Ageing)
- Professor Karen Smith (Silverchain group)
- Professor Irene Blackberry (La Trobe University)
- Associate Professor Chris Moran (Monash University)
- Associate Professor Anna Barker (Monash University)
- Dr Jue Xie (Grace) (Monash University)
Stakeholder Steering Committee members
- Ambulance Victoria (Project Partner)
- Australian Primary Health Care Nurses Association (Project Partner)
- Australian Ageing Agenda (formerly known as Aged & Community Care Providers Association) (Project Partner)
- National Ageing Research Institute (Project Partner)
- Peninsula Health (Project Partner)
- Regis Aged Care (Project Partner & Site)
- Outcome Health (Project Partner)
- Silverchain Group (Project Partner)
- Victorian Department of Health and Human Services (Project Partner)
- Arcare (Project Site)
- Carers Australia
- Pharmaceutical Society of Australia
- Royal Australian College of General Practitioners
- South Eastern Melbourne Primary Health Network
Key funder
Medical Research Future Fund (MRFF) grant from the Australian Government, Department of Health and Aged Care.

For further information please contact Professor Nadine Andrew: nadine.andrew@monash.edu