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With strengthened standards now in place, organisations have the mandate and the tools to treat transitions of care as a core unit of safety in aged care.
If a medication list changes three times in 48 hours, whose list is the truth? For many older Australians, the riskiest moment is not the diagnosis or the procedure. It is the transition of care. The Australian Commission on Safety and Quality in Health Care (ACSQHC) defines a transition of care as the temporary or permanent transfer of some or all responsibility for a person’s health care between providers.
For aged care residents and their families, successful transition of care means clarity about what has changed and who to contact if required. For general practitioners (GPs), it’s a current medicines list and a timely, meaningful discharge summary. For aged care homes, it is the resident’s medication charted, packed and delivered against the same live chart that prescribers see. For hospitals, it is a clean clinical handover and a safe landing in the community. Yet gaps persist. National experts highlight inaccurate discharge lists, out‑of‑date GP records and low uptake of pharmacist shared medicines lists as critical vulnerabilities.
Why this matters now
Hospital presentations are highest at the point of entry into aged care and in the early weeks following discharge from hospital. The risk is highest where medication lists change and communication lags. InSight+ reporting on residential medication management reviews (rMMRs) shows under-use of early review to reconcile medicines and prevent duplication.
Globally, medication harm accounts for nearly half of preventable patient harm, and the WHO identifies transitions of care as a key action area.
In addition, the strengthened Aged Care Quality Standards (effective November 2025) now make safe transitions a compliance requirement. Under Outcome 7.2: Transitions, providers must have structured processes for moves to and from hospital, timely and accurate information sharing with GPs, pharmacists, the individual and their families, and reassessment of care plans after discharge. They must also ensure access to specialist support when needs change. For clinicians and aged care teams, this means embedding safe handover practices into everyday workflows.
What’s happening and how it helps
Here’s what’s changing now, and how to make it work on the floor.
1) Make eNRMC the single source of truth for medicines
The Department of Health, Disability and Ageing has set clear expectations and timeframes for the transition to electronic medication platforms. Aged care homes are expected to retire hybrid and paper systems and move to compliant electronic national residential medication charts (eNRMC) that support electronic prescribing and administration. This removes transcription errors, eliminates discrepancies between charts and packs, making things more streamlined.
GPs play a central role. When the resident’s usual GP prescribes from the live chart and reviews changes after a hospital stay, it helps ensure the medicines list stays accurate and doesn’t drift across systems. Boards and executives can reinforce this by adopting a single chart in use policy and requiring vendors to demonstrate prescribing conformance and interoperability.
2) Use My Health Record as the continuity layer
Clinicians report usability issues and incomplete information in My Health Record (MHR) and interoperability remains patchy across hospitals, primary care and residential aged care. Even so, when teams upload discharge summaries and pharmacist medicines lists promptly, MHR becomes the continuity layer that lets the medicines story follow the person.
3) GPs and on-site pharmacists, one multidisciplinary team
Since 1 July 2024, aged care homes can employ onsite pharmacists with funding scaled to bed numbers. These pharmacists work alongside GPs, nurses and community pharmacies to improve medication safety. At the same time, the General Practice in Aged Care Incentive supports GPs and practices to provide regular visits and proactive care planning. Regular GP involvement plus a pharmacist enables timely medication reconciliation after a transition, supports deprescribing of high-risk medicines and optimises communication.
4) Medication safety rounds
A new MRFF funded study is testing monthly medication safety rounds in residential aged care homes. This is to identify drug interactions, potentially inappropriate medicines and deprescribing opportunities that commonly arise at transitions. The model adapts the successful Palliative Care needs rounds approach to medication safety and uses a multidisciplinary team within aged care.
5) After hours care and virtual care that prevent transfers
Australian studies show that after hours telehealth can resolve most medication related calls within the residential aged care home when clinicians can access the live chart and recent handover documents. This reduces unnecessary transfers and supports GPs covering large sites. When a GP isn’t available after hours and locums are scarce, the Victorian Virtual Emergency Department (VVED) provides a statewide 24/7 video emergency pathway with dedicated aged care workflows, helping prevent avoidable transfers.
The opportunity
Australia now has the foundation for safer transitions of care. These include national transition of care principles, eNRMC timelines, My Health Record integration and on-site pharmacists. With strengthened standards now in place, organisations have both the mandate and the tools to treat transitions as a core unit of safety. If this happens, avoidable transfers, medication errors and harm can be significantly reduced.
Dr Simon Grof is a geriatrician and clinical director with Eastern Health, and also chief medical officer at Jewish Care Victoria.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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The South Australian public system has (for at least 5 years) the capability based on the excellent practice and medication reconciliation reviews done by clinical pharmacists to populate the discharge summary with this more accurate and up to date information however this improvement has not been progressed despite the obvious advantages to patient safety. Many of the changes in workflows and processes are well within our capacity if endorsed and sponsored at the appropriate level.