Minding the gap: Interprofessional communication during inpatient and post discharge chasm care

•Patients and their parents were very satisfied and engaged communicating via telehealth.•Patient readmission rates have declined compared to patients not participating.•Major benefit is the ability to follow the patient and continue care post discharge.•Use of telehealth technology, unlike a phone, allows real-time view of home life.

ObjectivePoor communication is cited as a main cause of poor patient outcomes and errors in healthcare, and clear communication can be especially critical during transitions such as discharge. In this project, communication was standardized for clarity, and techniques were implemented to continue care from inpatient, to discharge, across the post-discharge chasm, to hand-off with the primary care provider (PCP).MethodsThe interprofessional (IP) quality improvement initiative included: (1) evidence-based teamwork system; (2) in situ simulation; (3) creation of an IP model of care; and (4) innovations in use of telehealth technology to continue care post-discharge.ResultsMeasures inpatient/parent satisfaction and the attitudes of the care team have improved.ConclusionsTraditional methods of communication and transition do not meet patient or healthcare provider needs. Communication must be standardized to be understandable and be used by the IP team. Care must continue post-discharge by utilizing technology to increase quality and continuity of care.Practice implicationsImproving and practicing communication skills may lead to reductions in healthcare errors and readmissions, and may decrease the length of stay and improve satisfaction of care teams.