Understanding care transition notifications for chronically ill patients

Sarah Kianfar, Ann Schoofs Hundt, Peter L.T. Hoonakker, Doreen Salek, Janet Tomcavage, Abigail R. Wooldridge, Jim Walker, Pascale Carayon

Research output: Contribution to journalArticlepeer-review


Chronically ill patients may be at risk of re-hospitalization or even death if their care transitions are poorly coordinated. Transitions of care create challenges for care coordination, such as insufficient or inefficient information exchange, i.e. communication, between different care settings. This paper focuses on communication that occurs during transitions of care for chronically ill patients, specifically those with heart failure (HF) and chronic obstructive pulmonary disease (COPD). Using data from 60 interviews with healthcare professionals (care managers, nurses, physicians, social workers, administrative assistants) involved in care transitions, we identified a total of 93 communication events in which healthcare professionals notified each other about four types of patient transitions: hospital admission, hospital discharge, intra-hospital transfer and emergency department (ED) visit. Results show that healthcare professionals use a variety of media (most frequently telephone, CM software, face-to-face) to notify one another about patient transition and communicate additional information. The choice of communication medium depends on the availability of the medium to the sender and the receiver, the purpose and urgency of the message. For example, care management software is used to simply notify one another about patient transition, while telephone is used to provide additional important, time-sensitive information about the patient. We believe a central health IT with appropriate capabilities (synchronous, asynchronous, status indicator, auto-generated notifications) can make communication during care transition more efficient and potentially help reduce re-hospitalization or death among chronically ill patients.

Original languageEnglish (US)
Pages (from-to)355-363
Number of pages9
JournalIISE Transactions on Healthcare Systems Engineering
Issue number4
StatePublished - 2021
Externally publishedYes


  • care coordination; care transition notification; chronically ill patients; health IT

ASJC Scopus subject areas

  • Safety, Risk, Reliability and Quality
  • Safety Research
  • Public Health, Environmental and Occupational Health

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