Recognizing and Responding to Acute Deterioration in Older People in Viet Nam: Building Safe Escalation Pathways Across Home, Community and Long-Term Care

INTEGRATED CARE & CARE TRANSITIONS · LONG-TERM CARE QUALITY

Last reviewed: October 2026

An older man in Viet Nam usually gets up early, prepares his own breakfast and walks around the house without assistance. One morning, his daughter notices that he is unusually quiet. He has barely eaten, seems less steady on his feet and takes longer than usual to answer simple questions. He does not complain of pain or appear to have a high fever. She wonders whether he is simply tired or whether something more serious is happening.

At a community-based day care point, a volunteer notices that an older woman who normally enjoys group activities has become withdrawn. She remains seated during an exercise session and needs help standing, although she usually moves around independently. The volunteer recognizes that something has changed but is uncertain whether to contact the woman's family, the commune health station or an emergency service.

In a long-term care setting, an older resident with several chronic illnesses develops new breathing difficulties during the evening. The care worker knows the resident's usual condition but does not have the authority to diagnose the problem. The responsible healthcare professional is not on site, and the family has previously expressed concerns about repeated hospital admissions.

These situations differ in severity and setting, but they share an important challenge. Someone close to an older person notices a change before a clinician has assessed it. What happens next may determine whether the person receives timely care or experiences an avoidable delay.

For older people, acute deterioration does not always begin with an obvious emergency. A sudden change in mobility, alertness, breathing, appetite or behavior may be the first indication of a significant health problem. Some changes require immediate emergency assistance. Others need prompt clinical assessment, while selected situations may be monitored safely under an existing professional care plan.

The difficulty is deciding which response is appropriate without expecting family members, volunteers or nonclinical care workers to make medical judgments beyond their competence.

As Viet Nam develops community-based older-person care and responds to growing long-term care needs, this becomes an important patient safety and service coordination issue.

The central question is: How can caregivers and community-based services recognize an older person's acute deterioration and activate the right clinical response without unnecessary delay?

Answering this question requires more than teaching people to recognize warning signs. Homes, community services and long-term care providers need practical arrangements for documenting changes, communicating concerns, reaching qualified healthcare professionals, obtaining emergency assistance and ensuring that relevant information follows the older person between care settings.

Acute Deterioration Often Begins Before a Healthcare Professional Is Present

In hospitals, clinical deterioration may be recognized through nursing observations, physiological measurements and established escalation procedures. At home or in a community care setting, the first indication is often less formal. A family member notices that someone is behaving differently. A volunteer realizes that a regular participant needs more assistance than usual. A care worker observes that a resident has become unusually sleepy or less responsive.

These observations matter because people providing everyday support often know what is normal for that individual. A person who usually walks to the dining area independently but suddenly cannot stand presents a different concern from someone who has required assistance with walking for several years. Similarly, confusion that develops over a few hours should not automatically be attributed to dementia or considered a normal feature of aging.

A meaningful change is best understood in relation to the person's usual condition, the speed at which it developed and whether it is progressing. The same symptom can have different implications depending on the circumstances, and a change that appears minor in isolation may be important when considered alongside other observations.

Acute deterioration can have many causes. Infection, cardiovascular or neurological events, dehydration, medication-related problems, metabolic disturbances, injury and other conditions may produce changes that are initially difficult to distinguish without professional assessment. The purpose of early recognition is not to determine which diagnosis is responsible. It is to identify that something has changed in a way that may require medical attention.

International guidance reinforces the importance of changes that may not initially appear dramatic. The National Institute for Health and Care Excellence (NICE) guideline on suspected sepsis in people aged 16 years and older, published in November 2025 and updated in September 2026, emphasizes that serious infection may present with nonspecific symptoms and that concerns raised by patients, families and caregivers deserve attention.

A person with serious infection may not have a high temperature or be able to describe symptoms clearly. This is particularly relevant when an older person has cognitive impairment, communication difficulties or limited ability to explain how they feel.

However, acute deterioration is not always caused by infection. Guidance developed specifically for suspected sepsis should not be used as a universal diagnostic or escalation protocol for every health problem.

Not every change indicates a life-threatening condition. The appropriate response depends on its nature, severity and progression, the person's circumstances and, when clinical assessment is needed, the judgment of an appropriately qualified healthcare professional.

What matters is that a potentially important observation does not disappear between the person who notices it and the person responsible for deciding what happens next.

Viet Nam's Legal Framework Requires Clear Boundaries Between Care and Medical Treatment

The distinction between noticing deterioration and making clinical decisions is particularly important in Viet Nam, where older people receive support through several different arrangements.

Some live with relatives or receive assistance from domestic caregivers. Others participate in community activities, attend daytime care points or live in residential facilities providing varying levels of personal support and healthcare. These settings do not necessarily have the same legal status, professional workforce or authorized activities.

The Law on Medical Examination and Treatment No. 15/2023/QH15, effective from 1 January 2024, provides the principal legal framework for professional medical examination, treatment and emergency care.

Article 61 addresses emergency care within and outside healthcare facilities. It requires emergency care to be based on assessment, classification and appropriate professional measures. It also distinguishes first aid provided by people with relevant knowledge or training from prehospital emergency medical care performed by authorized professionals.

Article 62 addresses medical examination, decisions about treatment methods and prescribing. It requires assigned healthcare practitioners to comply with applicable professional requirements and take responsibility for their clinical decisions.

These provisions support an important distinction: recognizing a concerning change and requesting help is not equivalent to diagnosing the cause or deciding on medical treatment.

For community-based older-person care, Government Decree No. 168/2026/NĐ-CP, issued on 15 May 2026 and effective from 1 July 2026, provides a further relevant legal foundation.

Article 5 defines the điểm chăm sóc người cao tuổi ban ngày tại cộng đồng, or community-based day care point for older people, as a specific model under the commune-level health station. The point has no separate legal personality and does not conduct medical examination or treatment activities.

Article 7 identifies activities involving guidance on care and disease prevention, early recognition of disease risks, health-promoting activities and assistance with daily living. These provisions support health-related education and community assistance, but they do not independently authorize the day care point to diagnose acute illness, prescribe medication or undertake treatment requiring separate professional authorization.

The Ministry of Health's Decision No. 1976/QĐ-BYT, issued on 1 July 2026, provides professional guidance on caring for older people at home and in the community. Its application must remain consistent with the responsibilities, competence and lawful scope of those involved.

Long-term care facilities also require careful legal distinction. A residential care establishment, social assistance facility, privately operated care service and licensed medical examination and treatment provider may have different organizational structures and professional requirements. The name of a service does not establish its clinical authority.

A care worker may appropriately recognize a change, document observations and request help. A qualified healthcare professional working within an authorized service may undertake clinical assessment and determine the required response.

A safe escalation pathway must preserve these boundaries without allowing uncertainty about professional authority to delay necessary care.

Recognizing What Is Different From an Older Person's Usual Condition

An effective recognition process begins with knowing the individual.

Families and care personnel often understand an older person's daily routine, usual mobility, appetite, communication and level of independence. These details provide a practical reference point when something changes.

For a person who normally walks independently, suddenly needing help to reach the bathroom may be important. For someone who usually enjoys conversation, becoming unusually withdrawn or difficult to engage may deserve attention. A noticeable change in breathing, alertness or ability to eat and drink may also signal deterioration.

Such changes are sometimes described in international practice as soft signs of deterioration. They may be visible before formal physiological measurements are available or before the person can clearly describe a symptom.

Soft signs are not diagnoses. Their value lies in prompting closer attention and timely communication.

The observation should be specific whenever possible. Saying that someone is "not themselves" may alert others to a concern, but describing what has changed gives the receiving healthcare professional more useful information. A caregiver might explain that the person normally walks to the kitchen independently but has needed assistance since that morning, has eaten very little and is unusually sleepy.

The timing of the change matters. A problem developing suddenly over minutes or hours may require a different response from a gradual decline observed over several weeks. A change that is progressing rapidly deserves particular concern, even when its cause is not yet known.

Cognitive impairment can make recognition more difficult. Someone living with dementia may already have memory problems or require support with communication. However, a sudden change in alertness, attention, behavior or ability to perform familiar tasks should not automatically be considered part of the existing diagnosis.

The same principle applies to people with longstanding mobility limitations, chronic breathlessness or other medical conditions. What matters is whether the current presentation differs meaningfully from their established baseline.

A simple description of usual functioning can therefore be valuable. This might include how the person normally communicates, moves around, eats, drinks and responds to others.

For people receiving regular home care or attending community services, this baseline can be documented as part of ordinary support planning. It need not become an extensive clinical assessment, but it should be sufficiently clear for personnel to recognize meaningful changes.

Where an older person has difficulty communicating, information from someone who knows them well may be especially useful. At the same time, caregivers should avoid assuming that they understand every symptom or preference without involving the person whenever possible.

Baseline information does not replace clinical assessment. It helps the healthcare professional interpret observations made by people who know the older person well.

A Safe Escalation Pathway Needs Different Responses for Different Levels of Urgency

Recognizing a change is only the beginning. Caregivers also need to know what kind of response should follow.

A practical escalation pathway can distinguish between situations requiring immediate emergency assistance, changes requiring prompt assessment by a qualified healthcare professional and concerns that may be monitored under an existing professional plan.

These are proposed operational categories for organizing care. They are not a nationally mandated Vietnamese triage classification, and caregivers should not be expected to perform clinical risk stratification beyond their competence.

The first category involves an immediate or potentially life-threatening emergency.

Examples include sudden severe breathing difficulty, loss of consciousness, suspected stroke, severe chest pain suggesting an acute cardiac problem, uncontrolled serious bleeding, prolonged seizures, severe choking or another rapidly developing condition that may threaten life.

Sudden one-sided weakness, facial drooping or difficulty speaking may indicate stroke and should trigger emergency assistance. A marked sudden change in mental status, particularly when accompanied by reduced responsiveness or other danger signs, may also represent a medical emergency.

In these circumstances, the appropriate response is to seek emergency medical assistance immediately. In Viet Nam, 115 is the medical emergency number, although the availability and organization of prehospital emergency services can vary between localities.

The person making the call should provide the location, describe the observed problem and follow instructions from the emergency service. Appropriate first aid may be provided by someone with the necessary knowledge and training.

Gathering additional observations, completing paperwork or waiting for a routine appointment should not delay the emergency call. Notifying family members is important, but it should not take priority over obtaining urgent assistance.

The second category includes changes that may not appear immediately life-threatening but still require prompt clinical evaluation.

An older person may become unusually weak, eat or drink substantially less than usual, experience a new decline in mobility or develop other signs of acute illness without an obvious emergency presentation.

These changes can represent important health problems. The caregiver should contact an appropriately qualified healthcare professional through an agreed pathway and describe the situation clearly. The receiving professional should determine whether immediate transfer, urgent face-to-face assessment or another clinically appropriate response is necessary.

This distinction must remain flexible. New confusion, weakness or difficulty walking can also be associated with serious emergencies, including stroke or severe infection. If the change is sudden, severe, rapidly progressing or accompanied by other danger signs, emergency assistance should be sought rather than waiting for a routine clinical response.

The third category involves monitoring under a plan that has already been established by an authorized healthcare professional.

Some older people have fluctuating symptoms or known conditions for which a clinician has provided clear instructions. Continued observation may be reasonable when the current presentation remains within the agreed plan, the person is sufficiently stable and caregivers understand when to seek further help.

Such a plan should identify what to observe, when to reassess, whom to contact and which changes require a higher level of response.

Monitoring should not become a default alternative to medical assessment merely because a caregiver is uncertain, a clinician is difficult to reach or transportation is inconvenient.

Nor should a new significant deterioration be placed into a lower-urgency category simply because the person has advanced age, dementia or several chronic conditions.

If the situation becomes more concerning, the response must change accordingly. When immediate danger is suspected, emergency assistance should not be delayed while waiting for a non-emergency clinician to return a call.

The purpose of distinguishing these responses is to help caregivers activate the appropriate level of assistance without creating a false expectation that they can independently determine the medical severity of every change.

Early Warning Scores Can Help, but They Cannot Replace Clinical Judgment

International healthcare systems have developed structured tools to recognize deterioration and communicate concerns.

The Royal College of Physicians' National Early Warning Score 2 (NEWS2), published in 2017, uses physiological measurements including respiratory rate, oxygen saturation, systolic blood pressure, pulse, temperature and level of consciousness or new confusion. It also takes account of supplemental oxygen.

In suitable clinical settings, NEWS2 supports standardized assessment of acute illness severity and helps guide escalation through established procedures.

RESTORE2, developed in England for care and nursing homes, combines recognition of soft signs, physiological observations, escalation arrangements and structured communication with healthcare professionals.

These approaches offer useful lessons because they connect recognition with action rather than treating measurement as an end in itself.

However, their use depends on the setting, workforce, equipment and clinical support available.

NEWS2 requires reliable physiological observations, appropriate interpretation and a response process capable of acting on the findings. RESTORE2 similarly requires relevant training, competence in measuring physiological parameters and arrangements for obtaining clinical assistance.

The Hampshire and Isle of Wight NHS guidance distinguishes the full RESTORE2 tool from RESTORE2 Mini. The simplified version focuses on recognizing soft signs and supporting structured communication in settings where personnel may not be able to obtain a complete set of physiological observations.

For Viet Nam, these distinctions are important.

A family caring for an older person at home may not have a blood pressure monitor or pulse oximeter. A community day care point may rely on volunteers whose training focuses on everyday assistance. Some long-term care facilities may employ nurses and have suitable equipment, while others may not.

Applying the same numerical thresholds or requiring the same observations in all these settings would be difficult to justify.

A normal-looking measurement should not automatically override a serious concern about a person's condition. Conversely, an isolated abnormal reading obtained incorrectly or without clinical context may lead to an inappropriate conclusion.

Clinical interpretation requires attention to the entire presentation, relevant history and the individual's usual condition.

The NICE guideline NG253, updated in September 2026, distinguishes approaches used in community settings from those used in acute hospitals and ambulances. Its recommendations concerning NEWS2 and suspected sepsis should not be converted into a universal numerical escalation rule for all Vietnamese community services.

Evidence about deterioration tools in long-term care also requires careful interpretation.

A scoping review by Barker and colleagues, published in BMC Health Services Research in 2025, examined 26 studies of tools used to recognize and respond to acute deterioration in long-term care facilities. The review found that structured approaches, particularly communication tools such as SBAR, may help staff feel more confident and communicate concerns with healthcare professionals.

However, the studies were heterogeneous, and robust evidence of direct improvements in residents' health outcomes was lacking. The findings therefore do not establish that adopting a particular scoring system will necessarily reduce mortality, hospital transfers or other adverse outcomes.

For Vietnamese services, the useful principle is to build a recognition and response process that matches actual capabilities.

Where an organization wishes to introduce a formal early warning tool, it should first determine whether personnel can obtain reliable measurements, whether equipment and supervision are available and whether qualified healthcare professionals can respond to the resulting alerts.

There are also conditions governing the reproduction and use of international tools. The Royal College of Physicians allows NEWS2 material to be reproduced under specified conditions, including acknowledgment, color reproduction of charts and restrictions on modification. RESTORE2 is a trademarked and copyrighted tool whose components must not be altered without appropriate authorization.

Organizations developing locally adapted processes should respect those conditions rather than reproduce or modify the original tools and present them as approved versions.

HLVN or a Vietnamese provider may develop an original observation and communication process informed by general international principles without claiming that it is an officially adapted or validated version of NEWS2 or RESTORE2.

A score without a dependable response pathway may create documentation without improving safety.

Family Caregivers Need Practical Guidance, Not Diagnostic Responsibilities

For older people living at home, family members may be the first and sometimes the only people to observe a change.

They may know the person's ordinary behavior better than any healthcare professional, yet have limited experience deciding whether an unfamiliar symptom requires urgent attention.

Education should therefore focus on recognizing meaningful changes and knowing how to obtain help. Families can benefit from understanding common warning situations, the importance of new confusion or functional decline, and the practical information needed when contacting a healthcare service.

A simple written record may be useful. It can identify when the change began, what was observed, how the person differs from usual and whether any professional advice has already been obtained.

Families should also know how to contact the regular healthcare provider, what emergency options exist locally and what to do if the usual clinician cannot be reached. This is particularly relevant for older people who live alone or depend on relatives who work outside the home.

Where paid home caregivers are involved, their responsibilities should be discussed explicitly. Recognizing a concerning change, contacting the designated person and following an established emergency procedure are different from independently diagnosing an illness or modifying prescribed treatment.

Family members should not be expected to interpret complex clinical measurements or make treatment decisions that require professional qualifications.

At the same time, a caregiver's observation should not be dismissed merely because they lack medical training. Someone who knows an older person well may recognize a significant change before it becomes obvious during a brief clinical encounter.

The healthcare professional receiving the concern should take this information seriously, ask relevant questions and determine what assessment or intervention is needed.

A practical home escalation plan can make the process less uncertain. It should identify emergency contacts, regular healthcare contacts, relevant medical information and arrangements for obtaining assistance when the primary caregiver is unavailable.

The plan should be understandable to the people expected to use it. If an older person lives with several relatives, responsibilities should be sufficiently clear that a serious concern is not delayed because everyone assumes someone else has already requested help.

For households with limited transportation, unreliable communication or long distances to healthcare facilities, the plan also needs a realistic alternative when the preferred route cannot be used.

The objective is to make it easier for families to request the right help without requiring them to become clinicians.

Community Day Care Points Need a Clear Route to Professional Assistance

The development of community-based day care points creates another setting in which deterioration may first be noticed outside a medical consultation.

An older person may arrive looking well and become unwell during an activity. A volunteer may notice a sudden change in mobility, alertness or breathing. Someone may fall, experience difficulty eating or become unusually distressed.

The response must reflect the legal identity and capabilities of the day care point.

Under Decree No. 168/2026/NĐ-CP, community-based day care points are a specific model under commune-level health stations and do not independently conduct medical examination or treatment.

This does not prevent personnel from recognizing warning signs, providing assistance within their competence, contacting emergency services or requesting professional evaluation. It does mean that the point should not operate as though it were an independently licensed medical facility.

The day care point should have agreed arrangements with the commune health station and relevant emergency services before an incident occurs.

Personnel need to know whom to contact during operating hours, who coordinates the immediate response and what to do when the usual contact is unavailable.

For a potentially life-threatening emergency, activating emergency assistance should take priority. A caregiver or volunteer should not wait for routine administrative approval before making an emergency call.

For other significant changes, communication with the commune health station or another authorized healthcare provider can support timely clinical assessment and decisions about referral.

Where the day care point is located within a commune health station, the distinction between the point's activities and the station's authorized clinical services should remain clear.

A healthcare professional may provide care through an appropriately authorized service within their professional scope. That does not automatically extend the day care point's activities to independent diagnosis or treatment.

Staffing arrangements also matter. A volunteer trained to assist with daily living may recognize that a participant has become unwell but should not be expected to determine the cause or independently change medication.

The point needs practical arrangements for remaining with the participant while assistance is being obtained, communicating with the appropriate family contact and documenting relevant observations.

After a significant incident, the team should review whether the concern was recognized, whether assistance was requested promptly and whether responsibilities were clear.

These arrangements allow a day care point to contribute to early recognition and continuity of care while respecting the boundaries of its legal and professional role.

Long-Term Care Settings Need Reliable Escalation Across Every Shift

Long-term care environments may provide opportunities for more consistent observation because care personnel see residents regularly. However, regular contact does not automatically ensure timely recognition or response.

A resident's condition may change at night, during a weekend or when experienced personnel are absent. Information recorded by one worker may not reach the next shift. A concern may be reported to a supervisor without a clear decision about whether clinical assessment is required.

The risk is not only failure to notice deterioration. It is also failure to connect an observation with the person who can act on it.

A long-term care provider should therefore establish responsibilities appropriate to its actual legal status, staffing and authorized activities.

Where nursing personnel are employed, clinical observations and professional responsibilities should reflect their qualifications and applicable scope. Where the service provides primarily personal care, personnel should have clear arrangements for obtaining assessment from an authorized healthcare provider.

Staff should understand which changes require immediate emergency assistance, which concerns must be reported promptly and which situations can be managed under a clinician-established plan.

Handover between shifts is especially important. A worker beginning an evening shift should know whether a resident has recently become less mobile, eaten poorly, experienced a fall or developed new symptoms.

A brief, useful record of the concern and the response may prevent the same information from being rediscovered repeatedly.

The provider should also maintain arrangements for accessing healthcare outside ordinary working hours. A pathway that works only when the regular doctor is available may fail precisely when the resident needs assistance most.

International experience offers relevant organizational lessons. NHS England's Enhanced Health in Care Homes Framework, updated in March 2026, emphasizes collaboration between care homes, primary care and community healthcare services.

Its arrangements reflect the United Kingdom's health and social care system and should not be treated as mandatory requirements for Vietnamese long-term care providers. However, the underlying principle of reliable access to professional support is relevant.

Long-term care staff should not be placed in the position of making unsupported decisions about whether a resident needs hospital treatment.

A well-organized service enables them to recognize concerning changes, communicate effectively and obtain an accountable professional response regardless of when the deterioration occurs.

Structured Communication Must Lead to an Accountable Clinical Decision

When an older person deteriorates, the information communicated during the first call can influence what happens next.

A caregiver may describe the person as "very weak" or "not feeling well." These concerns are legitimate, but the receiving healthcare professional may need more detail to understand the situation.

A useful communication process should establish who the person is, what has changed, when the change began, how the current condition differs from usual and what help is being requested.

Relevant medical information may include known major conditions, recent illness or hospitalization, important medications, allergies and an existing care plan, where available and appropriate to share.

The information should be concise enough for urgent communication while retaining the details needed for a clinical decision.

International approaches such as SBAR or SBARD can help organize these conversations. They emphasize communicating the current situation, relevant background, observations and the request for further action.

For nonclinical caregivers, the emphasis should remain on describing what they have seen rather than assigning a medical diagnosis.

For example, reporting that an older person normally walks independently but has been unable to stand since the morning, is unusually sleepy and has eaten very little provides useful information without claiming to know the cause.

A structured format may help, but no international communication template should be presented as mandatory for all Vietnamese homes or care services.

The process also needs to be two-way.

The receiving healthcare professional should clarify important information, explain the recommended next step and ensure that the caregiver understands what to do.

If urgent assessment is required, the responsible person should know where the patient should be seen and how the assessment will be arranged. If monitoring is recommended, the caregiver should understand what to observe, when further contact is required and which changes would make the plan unsafe to continue.

This is sometimes described as closed-loop communication. Its practical value is that a message does not end simply because it has been sent.

A concern has not been adequately escalated merely because someone has made a phone call. The pathway must establish that an appropriate recipient has received the information and that a clear next action has been agreed upon.

The distinction becomes particularly important when advice is provided remotely.

A telephone or digital consultation may help a clinician gather information and determine the next step. However, remote communication does not always provide enough information for a safe decision.

The professional must consider whether a face-to-face examination or emergency assessment is necessary and whether the person can safely remain in the current setting.

Where a clinical decision is made, the caregiver or care team should understand who made it, what information informed it and what follow-up arrangements apply.

A general instruction to "monitor closely" is insufficient if the caregiver has not been told what to monitor, when reassessment is required or when to contact the clinician again.

Similarly, a recommendation for urgent hospital assessment is incomplete if nobody has established how the older person will reach the receiving service.

A reliable system should identify the responsible clinical contact and an alternative when that person is unavailable. It should also clarify who organizes transportation, communicates with the family and documents the decision.

Where the expected response cannot be obtained, the caregiver needs an alternative route. Repeated unanswered calls or messages should not result in a potentially serious condition being left without assessment.

Local arrangements may differ between urban and rural communities, public and private providers, and services with different workforce capabilities. Such variation is reasonable, but uncertainty about responsibility should not be allowed to delay access to necessary care.

Emergency Transfer and Referral Should Match the Older Person's Condition

Once a clinical concern requires transfer, another set of practical decisions begins.

The receiving service must be appropriate to the person's condition, and transportation should reflect the severity of the problem and the assistance required during travel.

For a suspected life-threatening emergency, contacting the local emergency medical system should occur promptly. In Viet Nam, 115 is the medical emergency number, although the availability and operational capacity of prehospital services can differ between localities.

Services caring for older people should therefore understand the actual emergency arrangements in their area, including what to do when the usual service cannot be reached.

An older person with severe breathing difficulty, reduced consciousness or another potentially life-threatening condition may require professional support during transportation. Arranging ordinary transport without considering clinical risk may expose the person to additional harm.

The decision about transportation and the receiving facility should involve the emergency service or an appropriately qualified healthcare professional whenever possible. Suspected immediate danger should not be left unattended while waiting for routine referral arrangements.

For non-emergency referrals, the appropriate route may involve a commune health station, outpatient service, hospital or another authorized provider, depending on clinical advice and local availability.

The handover should include the information needed for the receiving team to understand what happened before arrival. This may include the person's usual condition, the observed change, the time it began, relevant medical history, any available observations, professional advice already received and assistance provided before transfer.

Caregivers should not be expected to produce a clinical referral document when they lack the authority or information to do so. However, a concise record of what was observed and communicated can be valuable.

The purpose of referral is not simply to move someone from one location to another. It is to connect the older person with a service capable of providing the assessment and care required.

An effective pathway reduces avoidable delays while preserving the continuity of information needed for safe treatment.

Goals of Care and Palliative Care Require an Individualized Response

Not every older person experiencing acute deterioration has the same treatment goals or would benefit from the same response.

Some live with advanced, progressive illnesses and are receiving palliative care. Others have previously discussed their preferences concerning hospitalization, intensive treatment or the burden of repeated transfers.

These preferences should be taken seriously.

Viet Nam's Ministry of Health Decision No. 183/QĐ-BYT of 25 January 2022 provides professional guidance on palliative care. It recognizes the importance of relieving suffering and addressing physical, psychological, social and spiritual needs in people with serious illness.

Palliative care can be provided alongside other appropriate treatment. It should not automatically be equated with the final days of life or with a decision to avoid hospital care.

For an older person with advanced illness, a new deterioration may require discussion of the expected benefits and burdens of available treatment options. In some circumstances, hospital transfer may be appropriate. In others, a professionally established plan for care in the current setting may better reflect the patient's condition and goals.

These decisions require appropriate clinical assessment, communication with the patient whenever possible and the lawful involvement of representatives where applicable.

A care plan may identify the preferred place of care, the professionals responsible for follow-up, arrangements for managing anticipated symptoms and circumstances in which emergency services should be contacted.

However, such plans must be sufficiently clear and practical for caregivers to follow.

A general statement that someone is receiving palliative care does not tell a care worker what to do when the person suddenly develops severe breathlessness or becomes unresponsive.

Similarly, an older person's advanced age, frailty or residence in a long-term care facility is not a reason to assume that emergency treatment would be inappropriate.

Decisions about treatment limitations, consent and representation must remain consistent with Vietnamese law and applicable professional requirements. Foreign treatment-escalation, advance directive or resuscitation forms should not be assumed to have automatic legal status in Viet Nam.

A goals-of-care plan should guide an appropriate response, not justify neglect, failure to assess a significant change or avoidable delay in obtaining necessary help.

Where an individualized and legally appropriate clinical plan exists, caregivers should understand its instructions and know how to contact the responsible healthcare professional when deterioration occurs.

Where the situation is unexpected, the plan is unclear or the person appears to be in immediate danger without a suitable alternative response arrangement, appropriate urgent or emergency assistance should be sought.

Respecting patient goals and responding safely to acute deterioration are not competing objectives. A well-designed pathway should support both.

Information Must Follow the Older Person Back to Their Usual Care Setting

The escalation pathway does not end when an older person reaches a hospital or another healthcare provider.

Following assessment or treatment, the individual may return home, resume attendance at a community care point or return to a long-term care facility.

The people providing everyday support need to understand what has changed and whether the previous care arrangements remain appropriate.

A hospital may determine that the person has a new condition, requires changes in medication, needs additional assistance or should receive further monitoring. These decisions may affect the safety of care after the person returns.

Relevant information should therefore be communicated through an appropriate and lawful handover process.

Families may need to understand the treatment plan, warning signs, follow-up appointments and when to request further medical help. Care personnel may need instructions concerning mobility, eating, medication support within their lawful responsibilities or other changes in daily assistance.

A community day care point may need to reconsider whether the person can safely participate with its available personnel and facilities. A long-term care service may need to update its records, communicate changes to staff working different shifts or arrange further professional review.

An updated baseline may also be necessary. Someone who has returned from hospital may not immediately function at the same level as before the acute illness. Care personnel need to understand whether this change is expected, what assistance is appropriate and which new concerns require reassessment.

This is particularly important when an older person has experienced a significant change in mobility, cognition or daily care needs.

The return-home or return-to-care process also provides an opportunity to examine what happened before the initial deterioration.

Was the change recognized promptly? Did the caregiver know whom to contact? Was the information communicated clearly? Were there difficulties obtaining a professional response or arranging transfer?

These questions should be considered without assuming that every adverse outcome reflects an avoidable error.

The purpose is to identify weaknesses that can be corrected and improve readiness for future events.

A successful escalation pathway supports safe movement in both directions: from the usual care setting to professional assessment and from professional care back to the support environment.

Protecting Personal Information While Sharing What Is Necessary

Recognizing and responding to deterioration often requires sharing personal health information.

A caregiver may need to communicate relevant medical history, medication information, emergency contacts and observations concerning changes in functioning or behavior. Such information can be important for timely care, but it should be handled responsibly.

Viet Nam's Law on Personal Data Protection No. 91/2025/QH15, effective from 1 January 2026, and Government Decree No. 356/2025/NĐ-CP establish an important legal framework for personal data processing.

The responsibilities of the organizations and individuals involved depend on their roles, purposes and applicable legal arrangements.

Care services should collect and communicate information relevant to their responsibilities, provide access only to appropriately authorized persons and avoid unnecessary disclosure.

Digital messaging groups and electronic records may make communication more convenient, but they also create risks when sensitive information is shared too broadly.

The need to protect personal information should be incorporated into the design of routine communication and referral processes.

At the same time, privacy requirements should not be interpreted as a reason to withhold information necessary for an appropriate emergency response when a lawful basis for disclosure applies.

A practical escalation system should identify what information may be shared, with whom and through which channels.

The objective is to support timely care while respecting the older person's rights, dignity and confidentiality.

Implementing an Early Recognition and Escalation Pathway in Viet Nam

A comprehensive deterioration management system may be difficult to introduce across every home, community service and long-term care provider at once.

A more feasible starting point is a clearly defined service or population in which the pathway can be tested and improved.

For example, a community-based day care point could work with its commune health station to develop a recognition and escalation process for participants who experience significant changes during attendance.

A long-term care facility might begin with one residential unit, while a home care organization could start with a defined group of older people who require regular assistance.

The initial work should focus on understanding what currently happens when someone becomes unwell.

The team should examine who usually recognizes changes, how concerns are communicated, which healthcare professionals can be contacted, what happens outside normal working hours and how emergency transfer is organized.

This review may reveal that caregivers already notice concerning changes but lack a clear route to professional advice. It may show that contact information is outdated, decisions are not communicated across shifts or nobody is responsible for confirming whether an urgent referral has occurred.

These gaps should inform the design of a manageable response pathway.

One practical approach is to develop an original, locally appropriate set of working documents. These may include a concise baseline health and functioning record, a change-of-condition observation form, an escalation contact and responsibility plan, and a communication record for referrals and professional advice.

The documents should be designed around information that caregivers can reasonably obtain, rather than require clinical measurements or judgments beyond their competence.

The escalation procedure should identify examples of situations requiring immediate emergency assistance, arrangements for prompt professional assessment and the circumstances in which monitoring may continue under an existing clinical plan.

Responsibilities should be explicit. Personnel need to know who makes the first call, who remains with the older person, who communicates with the family and who records the response.

Where the service has no clinical personnel, the process should focus on recognition, safe assistance within competence and timely access to authorized healthcare providers.

Training should use realistic situations rather than rely only on written instructions.

Staff and volunteers can practice describing a sudden change, making an emergency call, communicating with the commune health station and responding when the designated contact cannot be reached.

Exercises should also include changes that occur outside ordinary working hours and situations in which the older person has an existing palliative or individualized care plan.

The pathway should be tested with the personnel, equipment and communication systems actually available.

Introducing a sophisticated scoring tool should not be the first priority if basic responsibilities, emergency contacts or referral arrangements are still unclear.

Once the process is operating, the team can review whether it is being used consistently and whether problems are being resolved.

Expansion should follow practical experience and demonstrated readiness rather than assume that one model will work identically across all locations.

Measuring Quality Should Focus on Timeliness, Communication and Appropriate Response

A community-based deterioration pathway needs a manageable approach to evaluation.

Counting emergency calls or hospital transfers alone does not establish whether the pathway is safe or effective.

A service supporting people with more complex health needs may experience more acute events. Better recognition may also increase the number of concerns reported, particularly during early implementation.

The more meaningful questions concern whether changes were recognized, whether the appropriate person was contacted and whether the response occurred without avoidable delay.

One area for measurement is the completeness of baseline information. The service may examine whether participants have a useful record of their usual functioning, emergency contacts and relevant care arrangements.

Another is recognition and communication. Records may indicate when a concerning change was first observed, when assistance was requested, whom the caregiver contacted and whether the concern reached an appropriate healthcare professional.

The response itself should also be reviewed. Did the receiving professional provide a clear decision? Was urgent assessment or transfer arranged when required? Did the caregiver understand what to do if the person deteriorated further?

Where a monitoring plan was agreed upon, the service may examine whether the plan specified the required observations, review arrangements and escalation conditions.

Transport-related difficulties and delays in accessing care may provide further information about system performance.

However, timing measures require careful interpretation. Rural distance, emergency service availability, communication limitations and differences in clinical severity can affect response times.

A local improvement program should not present arbitrary time targets as nationally mandated requirements or assume that every situation needs the same response interval.

Quality review may also consider the experiences of older people, families and caregivers. They may report whether instructions were understandable, whether appropriate help was available and whether communication reduced uncertainty during a stressful event.

Clinical outcomes such as hospitalization, complications or mortality may be relevant to broader evaluation, but they should not be attributed to the escalation pathway without considering illness severity, baseline health and other influences.

An increase in hospital transfers is not necessarily evidence that the pathway has failed. Some transfers may represent appropriate recognition of serious conditions that might otherwise have gone untreated.

Equally, fewer transfers do not automatically indicate better care if important deterioration is being missed or if people cannot access appropriate services.

The purpose of measurement is to understand whether the pathway consistently connects concerning changes with timely, clinically appropriate decisions.

These are proposed indicators for local implementation and quality improvement, not a nationally mandated Vietnamese accreditation framework for community deterioration management.

Learning From Events Can Make the Next Response Safer

Every significant deterioration event offers an opportunity to examine how the system worked.

A review does not need to become a lengthy investigation of every minor change. However, events involving delayed recognition, communication failure, difficulty accessing emergency assistance or unexpected harm deserve appropriate attention.

The review should consider what caregivers observed, what information was available and how decisions were communicated.

Sometimes the problem may be a lack of training. In other cases, personnel may have recognized the concern but been unable to reach a healthcare professional.

A family may have delayed requesting help because it was uncertain which symptoms were serious. A volunteer may have believed that a supervisor had already contacted the commune health station when no call had been made.

These examples show why improving individual knowledge is not always sufficient. The pathway also needs clear responsibilities, reliable communication and workable alternatives when normal arrangements fail.

Learning should be supportive rather than focused only on assigning blame. Personnel need to feel able to report concerns and uncertainty, particularly when they are working without immediate professional supervision.

Where a problem is identified, the organization should agree on a practical improvement and review whether the change has been implemented.

This might involve updating contact details, clarifying emergency responsibilities, simplifying the observation record or improving the way information is handed over between caregivers.

The value of an early recognition system becomes apparent when lessons from one event make the response to the next event more dependable.

From Recognizing a Change to Securing the Right Clinical Response

An older person's acute deterioration may begin quietly. A family member notices that a parent is unusually sleepy. A volunteer realizes that a regular participant cannot stand as usual. A care worker observes a change in breathing or behavior during an evening shift.

At that moment, no one may know the diagnosis. What matters is that the change is recognized and that the person observing it knows how to obtain appropriate help.

For Viet Nam, the challenge is to connect care provided at home, in community services and in long-term care settings with authorized healthcare professionals and emergency services.

This requires realistic arrangements suited to the capabilities of each setting. Families should not be expected to make complex medical decisions. Community volunteers should not be treated as independent clinical providers. Long-term care workers need clear supervision and access to professional assessment.

At the same time, valuable observations should not be dismissed simply because they come from people without medical qualifications.

The pathway must make it possible to act on those observations, distinguish different levels of urgency, communicate concerns effectively and arrange appropriate care without unnecessary delay.

For people with advanced illness or established goals of care, the response should also remain individualized and legally appropriate, without treating palliative care as a reason to overlook significant deterioration.

The central question remains: How can caregivers and community-based services recognize an older person's acute deterioration and activate the right clinical response without unnecessary delay?

The answer lies in building a practical connection between everyday observation and accountable clinical decision-making. Caregivers need to know what has changed, whom to contact and what to do next. Healthcare professionals need sufficiently clear information to make timely decisions, and services need arrangements that ensure those decisions lead to action.

Early recognition is valuable only when it leads to an appropriate response. A safe escalation pathway turns a caregiver's concern into timely clinical attention while protecting the older person's dignity, preferences and access to necessary care.

As Viet Nam develops community-based and long-term care services, strengthening these pathways offers a practical opportunity to improve patient safety, professional coordination and continuity of care before deterioration becomes a hospital emergency.

References

1. National Assembly of Viet Nam. Law on Medical Examination and Treatment No. 15/2023/QH15. Adopted 9 January 2023; effective 1 January 2024.

2. Government of Viet Nam. Decree No. 168/2026/NĐ-CP detailing certain provisions and measures for implementing the Law on Population. Issued 15 May 2026; effective 1 July 2026.

3. Ministry of Health of Viet Nam. Decision No. 1976/QĐ-BYT issuing professional guidance on care for older people at home and in the community. 1 July 2026.

4. Ministry of Health of Viet Nam. Decision No. 183/QĐ-BYT issuing the Guidelines on Palliative Care. 25 January 2022.

5. National Assembly of Viet Nam. Law on Personal Data Protection No. 91/2025/QH15. Adopted 26 June 2025; effective 1 January 2026.

6. Government of Viet Nam. Decree No. 356/2025/NĐ-CP detailing certain provisions and measures for implementing the Law on Personal Data Protection. Issued 31 December 2025; effective 1 January 2026.

7. Royal College of Physicians. National Early Warning Score (NEWS) 2: Standardising the Assessment of Acute-Illness Severity in the NHS. Updated report of a working party. London: RCP; 2017.

8. Hampshire and Isle of Wight Integrated Care Board. RESTORE2: Recognise Early Soft Signs, Take Observations, Respond, Escalate. Official tool guidance, training resources and RESTORE2 Mini.

9. NHS England. Providing Proactive Care for People Living in Care Homes: Enhanced Health in Care Homes Framework. Version 4. March 2026.

10. National Institute for Health and Care Excellence. Suspected Sepsis in People Aged 16 or Over: Recognition, Assessment and Early Management. NICE Guideline NG253. Published 19 November 2025; updated 23 September 2026.

11. Barker RO, Eastaugh CH, Searle B, Wallace SA, Craig D, Hanratty B. Which acute deterioration tools are used in long-term care facilities and how have they been evaluated? A scoping review. BMC Health Services Research. 2025;25:765. DOI: 10.1186/s12913-025-12534-x.

12. World Health Organization. Integrated Care for Older People (ICOPE): Guidance for Person-Centred Assessment and Pathways in Primary Care. 2nd edition. Geneva: WHO; 2025.

13. World Health Organization. Long-Term Care for Older People: Package for Universal Health Coverage. Geneva: WHO; 2024.