Bridging the gaps in communication and coordination

In the recently published article, “Primary Care, Specialists, and Hospitals: Bridging the Gaps in Communication and Coordination” in Medical Clinics of North America, Dawn M. Bravata, M.D., a research scientist at Regenstrief Institute, professor of neurology at Indiana University School of Medicine and physician at the Richard L. Roudebush VA Medical Center, explores why effective communication across primary care, specialty care and hospitals is essential to improving patient outcomes.

Why are transitions between primary care, specialists and hospitals such a critical part of patient care?

The transition from hospital discharge to home is a critical moment in a patient’s health care journey. For many patients, it is a period of change both in their overall health status (having just spent time in the hospital) and health care (e.g., medication changes, need for follow-up tests or visits). To avoid needing to return to the emergency department or hospital, transitional care programs seek to support patients and their caregivers during this high-risk period. The transitional period has been described as a “white space” because the patient has left the hospital and is therefore no longer under the direct care of the hospital medicine team but has not yet been seen by their primary care team.

Your article highlights persistent communication and coordination gaps across care settings. Where do these breakdowns most commonly occur, and how do they affect patients and caregivers?

A fundamental component of transitional care programs is communication, which is necessarily complex because it involves sharing timely information between patients, caregivers and health care providers, as well as communication across settings (inpatient to outpatient) and across specialties (hospitalists, primary care providers and specialists). For patients who receive care across multiple health care systems, especially when the electronic medical records between the health care systems are not integrated, transitional-period communication challenges may be even more complex. Patients transitioning from hospital to home may require additional caregiving support in the post-discharge period—which can place strain on caregivers.

Many interventions have been developed to improve care transitions, yet the evidence remains mixed. What have we learned about what works—and what doesn’t?

A variety of effective transitional care programs have been developed and evaluated. Some focus on certain high-risk patients, like those with congestive heart failure. Others are more general and focus on older patients or those at the end of life. Evaluations of these programs have identified certain critical components (e.g., the importance of ensuring that patients know what medications they should be taking and have access to any new medications that were prescribed). In addition, the local context is critical to consider. For example, programs that serve rural patients may have to solve transportation and access issues that are less relevant to urban-dwelling patients.

What role can health systems, clinicians and patients themselves play in improving communication and coordination during transitions of care?

The transitional period is widely recognized as a high-risk period during which patients and their caregivers require additional support. Health care systems should invest in transitional care programs that support patients and their caregivers—for example, by providing a single telephone number for patients to call with questions or symptoms and facilitating needed follow-up appointments for tests or doctor visits.

Looking ahead, what opportunities are you most excited about for improving care coordination and creating smoother transitions for patients?

Within the Department of Veterans Affairs (VA)—the largest integrated health care system in the country—there are several key initiatives focused on supporting Veterans and their caregivers during the transition from hospital to home. Some focus on provider education, others on rural-dwelling Veterans, patients after a mental health admission or the complex needs of Veterans who obtain care in both VA and community settings.

Who’s behind this story?

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Lisa Lock

BA art history, MA material culture. Former museum editor, paramedic, and transplant coordinator. Editing for Science X since 2021.

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Andrew Zinin

Master’s in physics with research experience. Long-time science news enthusiast. Plays key role in Science X’s editorial success.

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