Primary Care, Specialists, and Hospitals: Bridging the Gaps in Communication and Coordination

Communication and coordination between inpatient and outpatient clinical teams, patients, and caregivers are essential to effective care transitions. Frequently used strategies to promote communication include sending information, telephone calls, and asynchronous messages. Involvement of the interprofessional team, setting up postdischarge appointments prior to discharge, and navigation have been utilized to improve postdischarge care planning and execution. Most studies report single-site, pre-post interventions that as a whole have an inconsistent association with outcomes. Despite these limitations, engaging pharmacists, utilizing multicomponent approaches that can be adapted, and supporting shared understandings that enable coordinated action are key lessons for improvement.