Comprehensive effective care

Despite our efforts to provide comprehensive effective care during transitions, gaps do occur from time to time-based on many of the issues you mention.  Patient transition times are some of the most critical times and some of the most vulnerable times for patients.  Having all of the details about a patient’s status and needs is complex, and many areas of responsibility within the team overlap based on a number of factors, including the patient’s perspectives.  How do you think all of the ‘pieces’ of these experiences, such as discharge planning, are best tracked, including the work of case management, in communicating to the team what information or actions are still pending during a transition?  How might a structured tracking system increase accountability?