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  • Explore challenges related to information sharing

  • Identify potential areas of resistance from interdisciplinary teams

  • Describe the development of four clinical initiatives that addressed the needs of a primary care practice


The transitional care team was now poised to implement a program we believed could transform care delivery and meet the Triple Aim in our community. Village Primary Care staff members had embraced our first transitional care nurse (TCN) as a member of their team and expressed appreciation for the difference she was making in the care of their patients. We were ready to expand our program and make a positive difference in our community. However, there were more unanticipated challenges to overcome every step of the way.


We quickly realized that having access to information from the primary care patient record as well as the hospital records for admission to the hospital meant that we would be able to provide more complete information from one setting to another. Despite the integration of medical records from one setting to another, providers did not have time to seek out the information that may be helpful in the care of their patients. We wanted to help improve this issue, but first we were met with resistance.

Certainly in any busy hospital setting, providers are on a tight timeline to assess, evaluate, and treat patients. We expected our information would be invaluable to bridge the gap from primary care to emergency department (ED)/hospital care. We found out quickly this was not the case. One by one, the TCNs would approach a provider with information they expected could be useful and were brushed aside. Finally, when one TCN asked why it was not helpful, she was told that the doctor wished to evaluate the patient himself and did not want to be influenced by the primary care provider (PCP) information. At first, we thought that may be an isolated point of view but quickly found that was not the case. Looking at this from a physician's/associate provider's point of view, there are so much data and information to assimilate that perhaps more information is not welcome or appreciated. Are there other ways this information could be useful? Would the nurse, physical therapist, or clinical pharmacist appreciate some of the data?

On the other hand, we did find that often the PCPs were appreciating the information we shared with them from the hospitalization. We were able to scan information into the primary care medical record and learned over time how best to communicate effectively with the primary care team.


When implementing any change in clinical practice, there can be an expected level of resistance (Hader, 2013). This was no less true in our case as we pioneered our new ...

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