Digital health breakthrough targets hospital transfer risks for aged care residents

A new digital health summary developed by Monash University’s National Centre for Healthy Ageing is being hailed as a breakthrough for aged care, tackling the long-standing risks residents face when transferred between facilities and hospitals without complete medical records.

Every year, thousands of aged care residents are moved to and from hospitals without accurate records. Advance care directives, baseline health details and even routine medications are often missing, leaving paramedics and clinicians to treat patients with incomplete knowledge.

The NCHA project, led by Professor Nadine Andrew, has created a Digital Health Summary designed and tested with input from aged care staff, hospital clinicians, paramedics, GPs, residents and families. It identifies 33 pieces of critical information that all stakeholders agreed must be available during transfers.

The prototype has been trialled across three residential aged care homes in Frankston and the Mornington Peninsula with partners including Peninsula Health, South Eastern Melbourne Primary Health Network, Ambulance Victoria, Outcome Health, Regis Aged Care and Arcare Aged Care.

Professor Andrew said the need was clear.

“Many providers face challenges with effective health information sharing due to inconsistent recording and quality of data, and inadequate technical infrastructure. It varies from centre to centre,” she said.

“So, we knew that overcoming technical and implementation barriers to the digital sharing of health information was a key priority if this new tool was going to improve health care outcomes. This project is a first step towards providing the foundations for shared communication and greater transparency in the residential aged care sector.”

The system works by creating a digital summary populated with aged care resident records. Hospitals can upload discharge information, GPs are automatically notified of transfers, and paramedics receive alerts that a summary is available. Families and residents can also access the information directly on personal devices.

The tool was designed using a co-design process involving interviews, audits and workshops. More than 300 clinicians, aged care staff, residents and family members were consulted to identify what information mattered most.

The project, funded by the Commonwealth’s Medical Research Future Fund, is now looking at broader feasibility trials across more homes. NCHA researchers say scaling the tool nationally could reduce avoidable hospitalisations, improve resident experiences, and strengthen data linkages across primary and acute care.

Professor Andrew and her team — including Dr Long, Associate Professor Beare and Dr Xie — are optimistic. “We are excited about exploring future scale-up opportunities for this unique Digital Health Summary infrastructure,” she said.