Table 2.

System-based solutions to gaps in care transition.

Theme	Quotes
Inadequate discharge planning	“. . .discharge is the one place where all of these disparate pieces of information can be summed up and woven together in a manner that is sensible to the patient.”
Cohesive discharge plan	“. . .Communicating this information to the health care teams ‘downstream’ (eg, inpatient, sub-acute rehabilitation facility, etc.) would also be paramount. This information could be a multi-disciplinary summary of a patient’s information and specific, and potentially unmet, needs.”
Care team communication	“. . .to communicate more deliberately and effectively with nursing staff, I hope to better share discharge responsibilities and employ our strengths in a more coordinated effort.”
Patient engagement at discharge	“. . .education is necessary for a safe transition from the hospital to home for someone with a severe medical disease, new or otherwise.”
	“‘teach back’ methodology, which can be vital in assessing patient understanding.”
Silos in discharge planning	“. . .when a primary care doctor gets the chance to observe and help in decision making, provide education, and share in a patient’s life trajectory; that there is great strength in the relationship of caring and connection.”
Role of primary care doctor in transitions	“Repetition, clear communication, time and space for contemplation, and reaching out from beyond the clinic and hospital wards will serve our patients well in each of their transitions. . .”
	“. . .how critical the role of the primary care physician is when it comes to care transitions, and how crucial it is for physicians to communicate with each other.”
Goals of care discussions	“. . .get all essential parties (family members, caregivers, etc.) to attend goals of care meeting with medical team.”
	“. . .to assess general goals of care along with code status and healthcare surrogates when possible on admission.”
Access to care	“. . .more care needs to happen in the home where the majority of health maintenance really happens.”
	“. . .multi-disciplinary approach to patient education will facilitate improved patient education and self-management as patients transition from the hospital to their homes.”