Aged Care Coordination
CAREFUL is a coordination platform for clinical teams, used in aged care. Older patients move between facilities, GPs, hospitals and family carers — and at every transition, three questions need clear answers: what's happening now, what's happening next, and who is responsible.
CAREFUL is a coordination platform for clinical teams, used in aged care. Older patients move between facilities, GPs, hospitals and family carers — and at every transition, three questions need clear answers: what's happening now, what's happening next, and who is responsible. CAREFUL connects all parties in one shared plan that answers all three.
Aged care coordination is one of the most demanding applications of the post-EMR coordination layer — where patients move across the most organisational boundaries and the gaps between them are widest. Aged care cohorts are also frequently the focus of real-world evidence studies — CAREFUL supports both.
The problem
Aged care coordination in most countries relies on phone calls, faxes and fragmented messaging. A medication change in hospital may not reach the care home for days. A GP managing dozens of residents across multiple facilities has no single view of who needs what.
Medication errors are the most dangerous consequence. When prescribing teams and dispensing pharmacies cannot communicate in real time, errors accumulate. Older patients are the most vulnerable to the consequences.
How CAREFUL solves it
CAREFUL connects every clinician involved in a patient's care — regardless of which organisation they work for. The GP, the care home nursing team, the community pharmacy and the hospital geriatrician share one patient record with tracked actions, referral history and team messaging.
The GP gets real-time oversight of all their residents, across all facilities, from one screen. Medication changes are communicated immediately. Urgent concerns are flagged, discussed and actioned — not left as voicemails.
CAREFUL is a partner platform to Leecare Solutions, an aged care management system used across Australian residential aged care facilities. The partnership connects facility-level care records with CAREFUL's cross-organisational coordination layer.
Results
At Abberfield aged care facility in Melbourne, one GP used CAREFUL to manage 100 elderly patients across five healthcare organisations for 12 months:
- 91% of staff reported improved safety
- 97% reported improved nurse-doctor communication
- Significant reduction in serious medication errors
- More clinician time redirected to face-to-face patient care
These results were presented at the BMJ/IHI International Forum in Brisbane in 2024. Read the Brisbane evidence →
"If I lost CAREFUL, I would have to reconsider whether I would continue with my clinical work. There is no going back."
— Dr Henry Konopnicki, General Practitioner, Melbourne
Frequently asked questions
What is aged care coordination software?
Aged care coordination software connects every clinician involved in an older patient's care — regardless of organisation — in a shared plan with tracked actions, referral history and team messaging. CAREFUL gives the GP real-time oversight of all their residents across all facilities, from one screen.
How does CAREFUL work with Leecare?
CAREFUL is a partner platform to Leecare Solutions, an aged care management system used across Australian residential aged care facilities. The integration connects facility-level care records with CAREFUL's cross-organisational coordination layer.
Can CAREFUL connect aged care to hospitals?
Yes. CAREFUL works across organisational boundaries. When an aged care resident is admitted to hospital, the GP, care home nursing team and hospital clinicians can share a single patient plan — eliminating the communication failures that occur at hospital transitions.
Is CAREFUL used in Australian aged care?
Yes. CAREFUL was piloted at Abberfield aged care facility in Melbourne, where one GP used it to coordinate 100 elderly patients across five healthcare organisations. Results — including a significant reduction in serious medication errors and 97% improved nurse-doctor communication — were presented at the BMJ/IHI International Forum in Brisbane in 2024.
How does CAREFUL handle escalations from RACFs?
CAREFUL allows care home nurses to create urgent actions and referrals that notify the GP immediately, with patient context attached. The GP can respond, triage and coordinate from any device — without a phone call that may go unanswered.