Patient-centred care and multidisciplinary issues - collaboration with general practitioners, allied health, and other medical specialists to achieve the best outcomes for patients

Why it matters

Effective collaboration between hospital/specialist geriatric services and general practitioners is essential given the GP's role as the coordinating point for an older patient's ongoing, longitudinal, multi-specialty care
Older patients with multimorbidity frequently see multiple specialists in parallel - without active coordination, this risks conflicting advice, duplicated investigation, and medication conflicts that no single clinician has full visibility over

Fragmented communication between hospital, specialists, and the GP is a recognised contributor to adverse events at transitions of care, particularly medication errors and gaps in follow-up

Timely, clear discharge summaries and specialist letters (including explicit medication changes and the reasoning behind them) allow the GP to maintain an accurate, current overall picture
Proactive communication before, not only after, a major management change (e.g. a new diagnosis, a significant medication change, a goals-of-care shift) allows the GP to reinforce and support the plan in ongoing community care

Shared care models and structured communication pathways (rather than ad hoc contact) improve continuity - particularly important around hospital discharge, when the risk of information loss is highest
The GP is often best placed to know the patient's baseline function, social context, and previously expressed wishes - specialist input should draw on this knowledge, not simply provide instructions without it

Care coordination, discharge planning, shared decision-making, chronic disease management in the community

The GP-specialist relationship works best as a genuine two-way partnership - the GP provides longitudinal context the specialist lacks, and the specialist provides condition-specific expertise the GP lacks - rather than a one-directional referral and report relationship

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