Communicating with other services

Good communication and sharing information between all health professionals involved in the care of people with co-occurring conditions is essential to adequate care. Ensure that:

• You obtain the client’s consent before sharing any information.
• The client is kept informed during this process.
• Confidentiality is maintained (e.g., obtain client’s written permission for release of case notes and avoid faxing confidential information).

When consulting with or referring clients to other services, assessment reports are often requested by those services. When writing an assessment report for an external party, the following should be considered [389]:

• Include only relevant and important information, including reasons for referral.
• Write in a clear, simple, and objective writing style.
• Include mental state examination report if necessary.
• Be concise.
• Always cite the source of the information. For example, ‘Andrew stated that…; Andrew’s parents revealed that…’
• Consider all sources of information in your conclusions.
• Avoid jargon.
• Eliminate any ambiguous, biased, or judgemental wording.
• Mark all reports ‘STRICTLY CONFIDENTIAL’.
• Avoid faxing confidential information.

A pro forma which may be useful in the referral process is included in Appendix BB.

In an attempt to increase communication, teamwork, and safety, a model of standardised communication has been introduced in various healthcare settings, modelled on aviation approaches to standardised safety processes [644]. The model, ISBAR, is a standardised cross-professional tool for enhancing communication, organised in a clear and concise format (see Figure 17) [645]. Although commonly used in clinical handover, ISBAR may also be useful in referral and discharge, with clinicians communicating with other services and agencies about client care.

Adapted from Scotten et al. [646] and SA Health [647].

South Australia Health has developed an ISBAR toolkit to assist with the safe transfer of client information in handover and discharge. They recommend that ISBAR be adapted for use to fit within each clinical practice and is an opportunity for different health care teams to determine which client information is always handed over and discussed as routine practice [647].

Some examples of how to modify ISBAR to your clinical practice include [647]:

• Identify: Include client’s medical record number if available, their full name and date of birth.
• Situation: What was the reason for the client’s initial presentation? What is their diagnosis? Are they on current pharmacotherapy? What other treatments have they had, and when?
• Background: Include relevant previous history (e.g., homeless, unemployed, living with abusive ex-partner).
• Assessment: When was their last clinical assessment/investigation? What do you think they may be at risk for?
• Recommendation: Actions required after handover/discharge.

The NSW Ministry of Health have made ISBAR a mandatory component of referring patients to hospital drug and alcohol clinical liaison services [648, 649].