Table 5.

Categorization of Studies Based on Berlo’s Model of Communication

Study and Intervention or Phenomenon	Sender/Source (Communication Skills, Attitudes, Knowledge, System and Culture)		Receiver (Communication Skills, Attitudes, Knowledge, System and Culture)			Message/Channel (Content/Process/Format or General Method of Communication)
Allen et al, 200436 A comprehensive post-discharge stroke care management model: STEPS CARE	Poststroke consultation core team made up of hospital/primary care PT, geriatrician, care manager, primary care general internist & stroke unit clinical nurse specialist. Post stroke consultation extended team includes neurologist, pharmacist, physiatrist, SLP, SW, OT, psychologist & dietitian. Care manager home assessment & 6-month follow up to implement or adjust care plan, provides frequent phone follow up & home visit if needed. Copy of MDT care plans, guidelines & patient specifics to PCP by letter/phone. (All team members participate in care plan development & implementation as needed so all act as sender, receiver & channel)
Baker & Wellman, 200550 Discharge planning for nutrition needs.	Case managers identified medical, nursing, SW & PT as important in discharge planning, not dietitians.		Not addressed			Not addressed
Bleijlevens et al, 200851 Multidisciplinary falls prevention program.	Medical risks and other fall-risk factors such as home hazards & behavior not systematically addressed by hospital medical staff.		Patients told to contact PCP for details			Geriatrician & OT sent written patient recommendations & referrals to PCP.
Christie et al, 201652 Post discharge care & role of PCP.	Not addressed		PCP had limited options & not always able to provide patient information/support. PCP want prognostic information from hospital to help manage patient recovery & expectations.			Not described
Dossa et al, 201253 Patient and caregiver discharge experience	Patients not satisfied with hospital provision of safety information & potential adverse events.		Despite common electronic medical record shared by facilities, patients did not feel that the hospital had communicated with their PCP.			Hospital phones patient 1–2 days post discharge. EMR between hospital & PCP.
Fleiger et al, 201937 A Chronic Care Management Model: the Vermont Oncology Pilot.	Person-to-person communication between hospital SW & chronic care coordinators for treatment regime changes and admission information.		There remains a lack of clarity about exactly what information each PCP wants and needs, & for what purpose.			Chronic care coordinators faxed PCP visit notes to hospital SW, where it was scanned into EMR.
Hansson et al, 201754 Health professionals’ collaboration in the care of frail elderly patients.	Hospital had insufficient time to talk to patients/families. Medical staff with least experience handled discharge. Hospital did not discuss patient with PCP. Ingrained culture & professional boundaries hamper communication initiatives.		PCP may take over care of patients without full patient information.			Hospital nurse checks IT system, contacts hospital OT, PT & care planning nurse then sends nursing report to primary care assistance officer who contacts primary care OT, PT, care planning unit, hospital & PCP.
Hawes et al, 20185 Accountable Care in Transitions Program in a patient-centered medical home.	Care manager met with patient to discuss psychosocial concerns, behavioral health needs, barriers to care, medical equipment, potential palliative care, community resources & continuity of care plan.		The post-discharge MDT visit scheduled within 7 days post discharge with PCP, structured and coordinated using a standardized checklist to address new diagnoses, care plans & goals, follow-up tests, symptom management, care coordination & self-management strategies.			Hospital nurse phone patient to assess medication adherence/adverse event, review symptoms, identify care barriers & provided appointment reminder. Hospital & primary care pharmacist & care managers communicate via EMR.
Hesselink et al, 201438 Intervention Mapping.	Hospital writing complete, accurate & timely discharge letter resulted in a step-by-step checklist of follow up.		The relationships between providers are lacking (no formal meeting between hospital & PCP).			Patients are expected to participate in discharge, giving letter to PCP & knowing medical history & care plan.
Holmes et al, 201639 Allied health team in Emergency department.	Hospital SW linked patients with PCP, facilitated hospital MDT meetings & developed care plans.		Hospital allied health team (PT and SW) received referrals from hospital triage nurse.			SW facilitated MDT meetings/care plan.
Hsiao et al, 201840 John Hopkins Community Health Partnership	Hospital risk screen, MDT care plan, patient/caregiver education, pharmacist-driven medication management.		Transition Guides met regularly with hospital MDT to discuss moderate to high-risk patients.			Personal post-discharge care & follow-up phone call with care coordination protocols & patient access phone line.
Ivanoff et al, 201855 Comprehensive Geriatric Assessment	Experience-based knowledge used more than standardized tests. Professions reluctant to encroach on other’s territory so questions. Resources & organizational conditions set agenda more than person’s needs (related to both senders and receivers).					Not addressed
Johannessen & Steihaug, 201356 Profession collaboration.	Hospital PT & OT sought collaboration whereas nurses were unsuccessful, due to pervading “us and them” attitude. Medical staff satisfied with collaboration. (above factors related to both senders and receivers of communication)					Healthcare providers from hospital & primary care attend MDT discharge meetings with patient.
Kind et al, 201157 Omission of dysphagia therapies	SLP recommendations not included in discharge summaries.			Not addressed.		Average 3.6-page discharge summary dictated by medical resident but 96% with senior medical review, edit & sign.
Massy-Westropp et al, 200541 Electronic data link from hospital to primary care.	Upon admission, automated check if patient under primary care service and report provided of current issues for hospital staff to access with password.			Primary care staff advised of existence of hospital report system, given access instructions and a short cut icon placed on desktop of each personal computer.		Automated email alert sent to primary care at discharge with admission details to prompt the primary care case coordinator to contact hospital.
McAiney et al, 201642 Intensive Geriatric Service Worker.	Intensive Geriatric Service Worker used an integrated and collaborative manner to work with primary care services and geriatric emergency management nurses in hospitals. (Intensive Geriatric Service Worker as sender, receiver and channel)					Intensive Geriatric Service Worker support post discharge PCP visits by reviewing patient questions to ensure asked, answered & understood.
Miller et al, 201943 Protocol for the Advanced Care Coordination Program.	Hospital emergency department to notify program SW of patient admission. SW will do biopsychosocial assessments, then connect patient with primary care				A survey will assess perceived frequency, timeliness & accuracy of communication, extent of problem-solving & mutual respect between & among program providers.	SW will make a phone call to the primary care team. A one-page fact sheet will inform healthcare facilities of the program & the referral process.
Rowlands et al, 201258 Perceptions of the quality, format and timeliness of patient information from hospital to primary care.	Often only hospital medical staff communicated with PCP. Nurses had little/no contact with PCP as they thought not their job. Care coordinator communicated on MDT behalf. Hospital allied health had no communication with PCPs and did not know if medical staff communicated information about their interventions to PCPs but if so, it would be limited (eg ‘patient seen by dietitian’). Most hospital medical staff did not know if hospital allied health communicated with PCP and had varying views about necessity.					MDT meeting was main process of communication. One PCP had to make phone call to have information faxed during a patient consultation.
Rydeman & Tornkvist, 200659 Different professionals’ experience of discharge		Mainly geriatric care unit nurses and hospital SW discussed patient discharge.			Primary care nurses were seldom involved in discharge process. PCPs often lacked necessary patient information when assumed responsibility.	Patient care management plan developed in weekly MDT meeting.
Tang et al, 201760 Gaps in patient care		Not addressed			Not addressed	Not addressed
Thomas & Siaki, 201744 Re-Engineered Discharge and Health Care Failure Mode Effects Analysis.		Evaluation identified need to improve care plan communication with primary care and care management for high-risk patients.			Not addressed	Electronic reports, interprofessional huddles, post discharge phone calls and documentation
Trankle et al, 201945 Evaluation of Western Sydney Integrated Care Program.		Specialist action plans provided at hospital discharge to inform patients and PCP about complex and changing care needs. Care facilitator communicates with hospital MDT, patient and PCP. (Care facilitator is sender, receiver and channel of communication)				PCP support phone line allowed faster access to hospital specialists. Care plan shared electronically with patients, hospitals, PCP & primary care
Wilson K et al, 200561 Nurse practitioners’ collaboration with allied health and PCP.		Nurse practitioners considered that successful quality health care environments were influenced by collaborative practices among MDT members. (Nurse practitioner as sender, receiver, and channel of communication)				Telephone call to PCP
Wilson S et al, 200446 Audio versus video-case conference		All but one of 14 healthcare providers found videoconference better for patient care management plan than audio (telephone) conference (attitude of senders and receivers in mixed MDT).				Videoconference to replace thrice weekly audio conference between hospital and primary care.

Abbreviations: PCP, primary care practitioner; MDT, multidisciplinary team; OT, occupational therapist; PT, physiotherapist; SLP, speech & language pathologist; SW, social worker; IT, information technology; EMR, electronic medical record.