Date of Publication


Project Team

Margaret Aitken, DNP, APRN, ANP-BC, Project Advisor; Alison Bovee, MBA, Site Advisor



In older patients with more complex and chronic health concerns, consistency and continuity of care is essential. Patients often live in assisted living residences or independently with support from programs such as Support and Services at Home (SASH), so nurses are available to address concerns and assist with certain aspects of care. Effective inter-professional communication is essential, but communication of assessments and coordinating care with participants’ primary care providers is complex.


Improve efficiency and clarity of care-related communication for patient and care team by developing a system that standardizes and streamlines workflow and addresses current concerns.


At a small primary care office in New England, a standardized communication tool was developed based on concerns voiced by community nurses and primary care staff, to be used to relay pertinent information, and request appropriate follow-up. Primary care providers and support staff were surveyed about communication efficacy with residential care sites prior to implementation of the communication tool, and utilization and outcomes of the tool were measured quantitatively.


Primary concerns at the outset were redundancy, communication by multiple methods, unclear expectation of office action, and lack of follow-up communication. During the 6 week implementation, the communication tool was utilized nine times for non-urgent issues, and resulted in reduction in back-and-forth communication and increased clarity.


Tool was used appropriately for non-urgent concerns. Initial response indicates the tool improves communication, and that this office will continue to use this tool for future communication with community based care staff.

Document Type