U.S. Department of Health and Human Services

National Diabetes Education Program

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Improve Communications

To improve communication teams could:

  • Develop structured, standardized expectations for referrals within the medical neighborhood. For example, when a primary care provider refers a patient to a specialist, certain information should accompany the referral such as: reason for the referral, patient demographics, background labs, copy of the last progress note, and any other relevant information.
  • Increase use of provider to provider communication interfaces for electronic health records.
  • Increase clarity over who will bill for transition fees post discharge.
  • Develop care managers that interface with transition nursing care providers post-hospitalization.


1. American College of Physicians resource In the Clinic: Transitions of Care
Kim CS, Flanders SA: Transitions of care. Ann Intern Med 2013; 158(5 Pt 1): ITC3-1.

This resource focuses on the transition of care involved in hospital discharge. It was developed to address identified gaps in quality of hospital discharge transitions that may contribute to post-discharge complications.

The 8Ps Risk Assessment Tool

  • Problem medications (e.g. warfarin, insulin, digoxin)
  • Polypharmacy
  • Psychological conditions (e.g. depression)
  • Principal diagnosis (e.g. cancer, stroke, diabetes, COPD, congestive heart failure)
  • Poor health literacy
  • Patient support (the absence of social support, either formal or informal)
  • Prior hospitalizations (in the past 6 months)
  • Palliative care

The resource includes a risk assessment tool, the “8Ps” (see Box) that identifies patient factors linked to high rates of adverse events after discharge. “Each of the risk categories requires a different set of interventions —some may be implemented by the hospital staff, and others require ongoing supportive care after hospital discharge.”

The resource includes this Clinical Bottom Line:

  • “Hospital Discharge... An interdisciplinary group of care providers along with the patient and family should communicate and coordinate the care needs for the discharged patient. Each discipline can offer specific risk-mitigating interventions that should be discussed with the patient and family to ensure that care is coordinated and follow-up is established.
  • While most patient-centered interventions should be started in the hospital, ongoing assessment and adjustments to the care plan can and should take place in the home with home care service providers and the outpatient team.
  • Communication of information about the patient’s health condition and treatments should incorporate appropriate health literacy tools and utilize such methods as “teach-back” to enable providers to assess knowledge and skill gaps requiring additional and ongoing reinforcement.
  • Interventions aimed at reducing risk for adverse post-discharge events are often not effective in isolation but need to be bundled in a consistent manner by the health system.”

2. View more resources in section on Address Health Literacy and Numeracy Issues.