Care Coordination and Team Communication

The Handoff That Almost Failed

In the previous lesson, we explored research review and literature synthesis. Now let’s build on that foundation. A night-shift nurse received handoff for a post-surgical patient. The outgoing nurse mentioned the patient was “doing fine” and had “some pain.” What wasn’t communicated clearly: the patient’s pain had been escalating over the last two hours, the surgical site had new drainage, and the surgeon had asked to be called if pain reached 7/10.

The night nurse didn’t call the surgeon until the patient was in severe distress three hours later.

Care transitions are where patients fall through the cracks. AI can’t fix communication culture, but it can ensure the right information is structured and transmitted every single time.

What You’ll Learn

By the end of this lesson, you’ll know how to create standardized handoff summaries, write effective referral letters, draft interdisciplinary care updates, and build communication templates that keep information from getting lost in transitions.

The Cost of Poor Handoffs

Before building the AI tools, let’s understand why this matters:

• An estimated 80% of serious medical errors involve miscommunication during care transitions
• The average clinician performs dozens of handoffs per week
• Each handoff is an opportunity for information to be lost, distorted, or delayed
• As care becomes more complex and team-based, the coordination burden increases

Your clinical knowledge doesn’t help your patient if it doesn’t reach the next provider in their chain of care.

Structured Handoff Summaries

The SBAR (Situation, Background, Assessment, Recommendation) framework works. The problem isn’t the framework – it’s consistently applying it under time pressure. AI helps by making structured handoffs faster:

AI: "Create an SBAR handoff summary template for a [unit type]
nurse handing off [number] patients.

For each patient slot, include:
S - SITUATION:
  - Room, name, age, attending physician
  - Why they're here (admission diagnosis, day of stay)
  - Current status in one sentence

B - BACKGROUND:
  - Relevant medical history (brief)
  - Key medications and recent changes
  - Allergies (highlight critical ones)
  - Recent procedures or significant events this shift

A - ASSESSMENT:
  - Current vital sign trends (not just last set)
  - Pain level and management
  - Key assessment findings this shift
  - Changes from previous shift

R - RECOMMENDATION:
  - Pending tasks for incoming shift
  - Anticipated needs (meds due, labs expected, procedures)
  - Potential concerns to watch for
  - Outstanding orders or calls needed

Keep each patient to one half-page maximum.
Include a 'SAFETY FLAGS' line at the top: fall risk,
isolation, allergies, code status."

Quick Check

Think about the last handoff you received. Was there something you wish the outgoing provider had told you? That gap is exactly what structured templates prevent.

Shift Change Documentation

For nursing and allied health, shift summaries need to capture what happened and what’s next:

AI: "Create a shift summary template for a [your role]
completing a [length] shift on a [unit type].

Include:
1. PATIENT STATUS OVERVIEW (table format):
   - Room | Patient | Diagnosis | Key changes this shift | Priority for next shift

2. SHIFT HIGHLIGHTS:
   - Admissions and discharges this shift
   - Significant events or changes
   - Incidents or near-misses
   - Equipment or supply issues

3. PENDING ITEMS:
   - Tasks started but not completed
   - Expected results (labs, imaging)
   - Pending physician callbacks
   - Family communications needed

4. SAFETY NOTES:
   - Patients requiring increased monitoring
   - New precautions initiated
   - Staffing concerns affecting coverage

Format for quick verbal delivery (under 5 minutes for
the unit overview) plus written documentation."

Writing Effective Referral Letters

A good referral letter saves everyone time – the specialist gets context, the patient doesn’t repeat their story, and you get a focused consultation back.

What specialists actually want:

Surveys of specialists consistently identify these priorities:

1. A clear clinical question
2. Relevant history (not everything, just what matters)
3. What’s already been tried or ruled out
4. Current medications
5. Patient’s functional context and goals

AI: "Write a referral letter from a [your specialty/role] to
a [receiving specialty].

Patient context (DE-IDENTIFIED):
- [Age/sex]: [relevant demographics]
- [Presenting issue]: [description]
- [Duration]: [how long this has been going on]
- [What's been tried]: [treatments, tests, interventions]
- [Results so far]: [what worked, what didn't, test results]

Clinical question: [What specifically do I need the specialist
to evaluate or recommend?]

Relevant history: [Only the history pertinent to this referral]
Current medications: [List]
Allergies: [List]

Format:
- Professional but concise
- Lead with the clinical question
- Organize supporting information logically
- Include urgency level
- Close with your contact information for questions"

Example referral question formats:

• “Requesting evaluation for persistent knee pain despite 8 weeks of PT – is surgical intervention warranted?”
• “Patient with refractory migraines on maximal prophylactic therapy – requesting neurology guidance on alternative management.”
• “Abnormal liver enzymes trending up over 3 months with negative viral panel – requesting GI evaluation for hepatic workup.”

Notice how each one tells the specialist exactly what you need. The specialist doesn’t have to guess why the patient was sent.

Interdisciplinary Care Plans

Complex patients often involve multiple disciplines. AI helps create a shared care summary everyone can use:

AI: "Create an interdisciplinary care plan summary for a
complex patient.

Patient context (DE-IDENTIFIED):
- [Age/sex/diagnosis]
- [Key issues requiring multiple disciplines]

Disciplines involved:
- [Medicine: focus areas]
- [Nursing: focus areas]
- [PT/OT/SLP: focus areas]
- [Social work: focus areas]
- [Nutrition: focus areas]
- [Other: focus areas]

Create a document with:
1. SHARED GOALS (what we're all working toward)
2. DISCIPLINE-SPECIFIC PLANS (each team's role, clearly outlined)
3. COORDINATION POINTS (where disciplines need to communicate)
4. PATIENT/FAMILY COMMUNICATION (who tells the patient what)
5. DISCHARGE CRITERIA (what needs to happen before discharge)
6. NEXT TEAM MEETING DATE AND AGENDA

Keep each discipline's section brief. The value is seeing
how the pieces fit together."

Family Communication Templates

Families need updates that are clear, compassionate, and consistent:

AI: "Create a family update template for a patient in
[setting].

Include:
- Current condition (plain language, avoid medical jargon)
- What's happened since last update
- What's planned next
- Expected timeline (realistic ranges, not promises)
- How the patient is responding (functional description)
- What the family can do to help
- Questions to ask the care team
- Next update timing

Tone: Warm, honest, respectful of family anxiety.
Reading level: 6th grade.
Assume the family has no medical background."

This template ensures every family gets consistent, clear communication regardless of which team member provides the update.

Transitions of Care

Moving between settings – hospital to rehab, acute care to home, ED to inpatient – is high-risk. AI helps structure these transitions:

AI: "Create a care transition summary for a patient moving
from [current setting] to [receiving setting].

Include:
1. CLINICAL SUMMARY: Why they were here, what was done, current status
2. ACTIVE PROBLEMS: Listed with current management
3. MEDICATIONS: Complete list with recent changes highlighted
4. ALLERGIES AND ALERTS: Including behavioral and environmental
5. FUNCTIONAL STATUS: What can the patient do independently?
6. ONGOING NEEDS: Tests pending, follow-up required, therapies needed
7. ADVANCE DIRECTIVES: Code status, healthcare proxy, wishes
8. PATIENT/FAMILY PREFERENCES: Goals, concerns, cultural considerations
9. OUTSTANDING ISSUES: Anything the receiving team needs to address
10. CONTACT INFORMATION: Who to call with questions

Make this comprehensive enough that the receiving team
has everything they need, but organized enough that they
can find information quickly."

Quick Check

When was the last time a patient arrived at your facility with an incomplete transfer summary? What was missing? That gap tells you what to prioritize in your own transition documents.

Building a Communication Protocol Library

Create standardized communication templates for your recurring scenarios:

Build these templates once with AI, refine through use, and share with your team.

Exercise: Improve One Communication Workflow

Choose the care coordination scenario that causes the most problems in your setting:

1. Identify what information gets lost or delayed
2. Use the appropriate template from this lesson to create a standardized format
3. Test it on three actual handoffs or communications this week
4. Ask the receiving provider: “Did you get everything you needed?”
5. Refine based on feedback

Key Takeaways

• Care transitions are where patients are most vulnerable – structured communication prevents errors
• SBAR works; the challenge is consistent application under time pressure. AI makes it faster
• Referral letters should lead with a clear clinical question – specialists need direction, not data dumps
• Interdisciplinary care plans help complex patients by showing how each discipline’s work connects
• Family communication should be consistent, compassionate, and jargon-free
• Build a template library for your recurring communication scenarios and share it with your team

Next lesson: Administrative efficiency – tackling the SOPs, compliance docs, scheduling, and paperwork that steal time from patient care.