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ORIGINAL RESEARCH

Methods and Effectiveness of Communication

Between Hospital Allied Health and Primary Care
Practitioners: A Systematic Narrative Review
This article was published in the following Dove Press journal:
Journal of Multidisciplinary Healthcare

Jacinta Sheehan 1 Background: There is a compelling rationale that effective communication between hospi­
Kate Laver2 tal allied health and primary care practitioners may improve the quality and continuity of
Anoo Bhopti 1 patient care. It is not known which methods of communication to use, nor how effectively
Miia Rahja 2 they facilitate the transition of care when a patient is discharged home from hospital. Our
systematic review aims to investigate the methods and effectiveness of communication
Tim Usherwood 3,4
between hospital allied health and primary care practitioners.
Lindy Clemson 5
1,6,7 Methods: Systematic review of quantitative and qualitative studies with narrative synthesis.
Natasha A Lannin
Medline, CINAHL, EMBASE, PsycInfo and Proquest Nursing and Allied Health Sources
1
Department of Occupational Therapy, were searched from January 2003 until January 2020 for studies that examined hospital-
Social Work and Social Policy, School of
Allied Health, La Trobe University,
based allied health professionals communicating with community-based primary care practi­
Melbourne, Australia; 2Department of tioners. Risk of bias in the different study designs was appraised using recognized tools and
Rehabilitation, Aged and Extended Care, a content analysis conducted of the methodologies used.
Flinders University, Adelaide, Australia;
3
Westmead Clinical School, Faculty of Results: From the located 12,281 papers (duplicates removed), 24 studies met the inclusion
Medicine and Health, The University of criteria with hospital allied health communicating in some form with primary care practitioners.
Sydney, Sydney, Australia; 4The George While none of the included studies specifically investigated the methods or effectiveness of
Institute for Global Health, Sydney,
Australia; 5School of Health Sciences, communication between hospital allied health and primary care practitioners, 12 of the 24 studies
Faculty of Medicine & Health, The described processes that addressed components of their discharge communication. Four enablers
University of Sydney, Sydney, Australia;
6 to effective communication between hospital allied health and primary care practitioners were
Department of Neurosciences, Central
Clinical School, Monash University, identified: multidisciplinary care plans, patient and caregiver involvement, health information
Melbourne, Australia; 7Alfred Health technology and a designated person for follow up/care management.
(Allied Health), Melbourne, Australia
Conclusion: There is currently no “gold standard” method or measure of communication
between hospital allied health and primary care practitioners. There is an urgent need to develop
and evaluate multidisciplinary communication with enhanced information technologies to improve
collaboration across care settings and facilitate the continuity of integrated people-centered care.
Keywords: multidisciplinary, collaboration, discharge plan, continuity of care

Introduction
Discharge planning is a routine feature of healthcare, with a goal of improving the
coordination of services following discharge from hospital.1 Discharge communication
provides a vital link between hospitals and primary care and is an important determinant
Correspondence: Natasha A Lannin of positive patient outcomes following hospitalization,2 helping to facilitate seamless
Department of Neurosciences, Central transitions of care between healthcare providers. Ineffective communication and informa­
Clinical School, Monash University, Level 6,
99 Commercial Road, Melbourne, VIC, tion transfer, particularly during transitions of care,3 can have substantial implications for
3004, Australia patient safety and continuity of care,4 patient and healthcare provider comprehension and
Tel +61 3 9903 0304
Email natasha.lannin@monash.edu satisfaction,2 as well as resource use.5

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Despite the quality and economic imperatives to recovery goals and discharge needs in addition to nursing
improve discharge planning1 and facilitate transitions of and medical care.21 Variability in the way discharge infor­
care,5 no single intervention has consistently demonstrated mation is transferred2 suggests processes are not standar­
a reduction in re-hospitalization when implemented alone.6 dized and anecdotally such information rarely encompasses
The World Health Organization set global priorities in the allied health view. The multidisciplinary team should
2018 to promote integrated people-centered health services provide the necessary diversity for collaborative discharge
through collaboration and integration across sectors, set­ care planning, yet it is not known if hospital allied health
tings, providers and users,7 yet coordination and timely perspectives are sufficiently represented nor how well they
transfer of information remain great challenges to opti­ are communicated to primary care practitioners.1
mized outcomes during transitions of care.8 According to Discharge communication remains a recognized pro­
the WHO, people-centered care adopts the perspectives of blem area in spite of the international research22,23 and
individuals, caregivers, families and communities relative regulatory attention it receives.24 In the most recent review
to the comprehensive needs and social preferences of of 30 trials of discharge planning,1 none reported on the
people, rather than individual diseases.7 A person- quality of communication. Effective communication is
centered (or patient-centered) approach is less encompass­ essential for multidisciplinary collaboration within and
ing but still allows the person to be seen as a whole,9 with between healthcare settings is, thus a key indicator of
needs and goals derived from their own social determi­ quality of care, yet it has not been systematically reviewed
nants of health.7 Such an approach should allow patients to and synthesized. There is a particular gap in the knowl­
share their health information at the appropriate time with edge base regarding communication between hospital
the right person.10 allied health and primary care practitioners. Therefore,
The patient is often the only constant when healthcare this systematic review sought to answer the following
teams change during transitions of care,11 yet differences in research questions:
patient attitude12 and patient ability can compromise the
sharing of their health information.13 Mixed evaluations to 1. What are the effective methods and/or models of
date14 and persistent problems with data interoperability communication between hospital allied health and
means that personal health records are not yet primary care practitioners?
commonplace.15 Health information technology (IT) devel­ 2. What are the enablers and barriers to effective
opments have the potential to improve communication16 communication between hospital allied health and
and collaboration17 at the time of discharge. Yet despite primary care practitioners?
the increased adoption of health IT, there is very little
research that evaluates the effectiveness of these informa­ For the purpose of the review, the “3C Collaboration
tion and communication systems.10 Furthermore, evidence Model”25 is used to define “communication” as the
of system incompatibility and security issues11 suggest that exchange of information to generate commitments that
health IT solutions do not yet support sufficiently detailed or are then managed by “coordination” so that individual
timely communication to or from hospitals to enable pri­ care activities interact through shared spaces to work
mary care practitioners to coordinate patient care “cooperatively” to ensure the success of the overall care
effectively.18 Many gaps in the system remain, and one- process. These three components work together to com­
way discharge summaries from hospital medical practi­ prise healthcare collaboration.17
tioners to primary care practitioners continue to be the
mainstay of discharge communication, even when multi­ Method
disciplinary teams are internationally recognized as the The protocol for this review was developed and pro­
preferred method of healthcare delivery.19 spectively registered with PROSPERO International
Multidisciplinary teams are an integral component of Prospective Register of Systematic Reviews
improved health outcomes and collaboration between peo­ [PROSPERO CRD42019120410]. Using a systematic
ple, professions, systems and settings.20 Within the multi­ review process, the search was performed to identify
disciplinary team, allied health professionals provide both quantitative and qualitative studies published in
specialized patient support and contribute important infor­ English between January 2003 and January 2020. The
mation regarding patients’ function, social situation, “SPIDER” (Sample, Phenomenon of Interest, Design,

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Dovepress Sheehan et al

Evaluation, Research Type) tool26 was used to define the Research type
inclusion and exclusion criteria to facilitate the identifi­ There were no restrictions of research type; qualitative,
cation and selection of studies in this review. quantitative and mixed method were included, provided
publications met the design inclusion criteria.
Sample
Only studies with mention of communication between hos­ Identification and Selection of Studies
pital-based allied health professionals (including occupa­ The search was conducted in the following databases:
tional therapists, physiotherapists, dietitians, speech and MEDLINE, PsycInfo, EMBASE, CINAHL and Proquest
language pathologists, psychologists, social workers and Nursing and Allied Health Source. To identify studies
case managers) and community-based primary care practi­ relating to the communication between hospital allied
tioners (including primary care nurse practitioners, primary health and primary care practitioners, the key search
care practitioners, geriatricians and general practitioners) terms included: “communication”, “interaction”, “colla­
working with adults were included. Papers that only exam­ boration” “allied health”, “primary care” and “general
ined forms of communication between pharmacists and practice” [full search strategy available as Additional
medical practitioners were excluded to allow a review of File 1]. We excluded studies published prior to 2003 to
issues beyond medication. Papers where healthcare profes­ reflect the more recently evolved methods and models of
sionals worked only in mental health or substance abuse communication within healthcare, including electronic dis­
settings were also excluded as their transitional care com­ charge summaries. One author [JS] conducted the
monly involves the same healthcare teams (as opposed to the searches. Reference lists of included studies were also
transfer of care from one team to another). Pediatric samples screened by one author [JS] to identify relevant studies,
were similarly excluded. and authors were contacted for further information as
required. The search results from all databases were
merged and duplicate articles removed using EndNote
Phenomenon of Interest software. The Covidence platform was used for screening
The review was not restricted by communication method,
and eligibility assessment of the retrieved citations. The
and thus any type of communication was included (includ­
citations from the search, after excluding duplicates using
ing written documentation, such as discharge summaries/
EndNote, were uploaded into Covidence by one author
letters/reports, interim reports; verbal communications,
[JS]. Two authors independently assessed all retrieved
such as handovers, telephone calls; electronic communica­
citations meeting the inclusion criteria on the basis of
tions such as emails, telehealth, videoconferencing; and
title and abstract [involved authors JS, NAL, KL, AS].
face-to-face communications such as case conferences
Potentially eligible studies were then reviewed in full
and team meetings). It was essential that communication
text independently by two authors [involved authors JS,
was between hospital allied health professionals and pri­
MR, KL] and a third author was consulted in cases of
mary care practitioners.
disagreement [involved authors NAL, KL].

Design Data Extraction

We excluded protocols, abstracts, meeting summaries, the­ A standardized data extraction form based on the SPIDER
ses, letters, editorials, opinions and conference papers. tool26 was developed to collate the sample, phenomenon
Qualitative research without thematic analysis was also of interest, design, evaluation and research type of the
excluded. included studies. One author [JS] extracted all data, with
an independent review from a second author [MR].
Evaluation Extraction tool available on request.
Since the review aimed to identify, analyze and synthesize
the literature relating to all forms of communication Data Synthesis
between hospital allied health and primary care practi­ A narrative synthesis strategy was then used to organize,
tioners, we considered any types of outcomes reported in summarize and present the data, based on Guidance on the
the studies. Conduct of Narrative Synthesis in Systematic Reviews.27

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This structured process thematically summarized studies pathologists, social workers and case managers. Table 1
based on Berlo’s Model of Communication,28 which cate­ outlines the included study characteristics; Figure 1 pre­
gorized findings where possible into components of com­ sents the study PRISMA flow diagram.35
munication by “sender/source” and/or “receiver” and/or Overall study quality was rated as acceptable across all
“message/channel”. As the included studies were diverse, appraisal checklists, with all relevant studies met at least
this initial synthesis allowed a breakdown of the varied minimal standards of adequacy in accordance with their
and complex characteristics of healthcare communication. respective quality appraisal tools. The summary of the
Following this classification, one author [JS] used an results of quality appraisals for qualitative, quantitative
inductive approach to thematic analysis,29 coding the stu­ and mixed-method studies are presented in Table 2–4,
dies line-by-line to elucidate common patterns of meaning respectively. Findings were summarized to address the
and areas of potential interest.30 Data were coded by two research questions separately and narratively synthe­
collating in columns, colors and concepts to identify sized to develop the themes.
potential themes, which were then reviewed across the The characteristics of the different communication
full data set to map and further refine the specifics of methods for each study are categorized according to
each prevalent theme. Generated themes were then tabu­ Berlo’s Model of Communication28 in Table 5, highlight­
lated in word documents relative to the research questions ing the roles and processes of different healthcare profes­
to determine the effective methods and/or models of com­ sions, healthcare teams and healthcare settings. Clear
munication, as well as the barriers and enablers to effec­ categorization was not possible where study samples
tive communication, between hospital allied health and included both hospital-based and community-based health­
primary care practitioners. To further contribute to the­ care professionals but generally, hospitals were the senders
matic analysis, full texts of included studies were uploaded or source of discharge communication to primary care
to NVivo 12.2 software program,31 enabling identification practitioners, the intended receivers of patient information,
of word frequency and word mapping for further data- using various messages and/or channels.
driven exploration of conceptual relationships.
Effective Methods and/or Models of
Quality Appraisal Communication Between Hospital Allied
Given the heterogeneity of the included study designs,
Health and Primary Care Practitioners
studies were appraised for reporting quality using the
None of the included studies specifically investigated the
most appropriate tool for their design. Specifically, we
methods of communication or evaluated the effectiveness
used the Joanna Briggs Institute Critical Appraisal
of communication between hospital allied health and pri­
Checklist for Qualitative Studies,32 the McMaster Critical
mary care practitioners. However, 12 of the 24 studies did
Review Form for Quantitative Studies33 and the Mixed
describe programs or processes that indirectly addressed
Methods Appraisal Tool34 to assess the risk of bias in
components of discharge communication between hospital
qualitative, quantitative and mixed-method designs,
allied health and primary care practitioners.5,36–46
respectively. Acceptable quality was pre-defined as meet­
Narrative synthesis of each study included exploration of
ing ≥50% of applicable criteria.
these 12 interventions within the context of their relation­
ship to some guiding theoretical models of care, namely,
Results the chronic care model,47 the collaborative care model48
A total of 24 studies were included in this systematic
and the integrated care model.49 The relevance of the
review. Of these studies, 13 were qualitative, seven were
theoretical underpinnings of each model of care will be
quantitative and four used mixed-method designs. Studies
briefly discussed in relation to evolving healthcare prac­
were conducted in the United States (n=9, 38%), Australia
tice, based on our analyses of these 12 interventions from
(n=5, 21%), Sweden (n=3, 13%), The Netherlands (n=2,
the included studies.
8%), the United Kingdom (n=2, 8%), Canada (n=1, 4%),
New Zealand (n=1, 4%) and Norway (n=1, 4%). Health Chronic Care Model
professionals in these studies included nurses, nurse prac­ A descriptive paper by Allen et al in 2004 described the
titioners, doctors, medical students, occupational thera­ theoretical basis for a randomized trial of a comprehensive
pists, dieticians, physiotherapists, speech and language post-discharge care management program.36 The report

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Table 1 Summary of Included Studies Using SPIDER Tool Categories

Study Sample Phenomenon or Intervention Design/Evaluation Research

36
Allen et al, 2004 No sample described. Comprehensive, MDT post-discharge care Descriptive report of the rationale and theoretical Quantitative
(United States) management model used in an ongoing study. basis for a randomized trial.

Baker & Wellman, Hospital case managers (n=84). Identification of discharge planning concerns Survey with 86 questions and 6 case scenarios. SPSS Quantitative
200550 (United regarding patient nutrition and need for for data analysis.
States) dietician.

Bleijlevens et al, Outpatients (n=333). Primary Process evaluation of a primary care MDT Survey, structured phone/face-to-face interview and Mixed
200851 (The care staff (n=8). falls prevention program. plenary group discussion. methods
Netherlands)

Christie et al, Outpatients (n=45) and Service provider and patient experiences and A multi-center longitudinal study with qualitative semi- Quantitative
201652 (United caregivers (n=18). Primary care views about post-hospital care and PCP role. structured face-to face and phone interview. Thematic not
Kingdom) staff (n=40). analysis. provided.
Qualitative

Dossa et al, 201253 Outpatients (n=9) and Identification of patient/caregiver experience Longitudinal study using convenience sample. Thematic Qualitative
(United States) caregivers (n=9). and care transition failures from hospital to analysis.
home.

Fleiger et al, Hospital/primary care staff Exploration of payment and delivery system Case Study Design. Semi structured in-depth Qualitative
201937 (United (n=18). reform to improve coordination/ interviews. Thematic analysis.
States) communication

Hansson et al, Hospital/primary care and Healthcare professionals’ experience of Purposive sampling for three focus group interviews. Qualitative
201754 (Sweden) patient/caregivers (n=24). patient, caregiver and healthcare provider
collaboration.

Hawes et al, 20185 Outpatients (n=268) Effectiveness of a multidisciplinary Descriptive statistics to summarize patient and process Quantitative
(United States) outpatient-based transition program. characteristics.

Hesselink et al, Hospital/primary care staff, Intervention Mapping Model to improve Description of model. 26 focus groups and 321 Qualitative
201438 (The patient/caregivers (n=321). patient discharge process and reduce individual interviews.
Netherlands) readmissions.

Holmes et al, Hospital staff (n=42). Inpatients Allied Health introduced in hospital Descriptive retrospective report of a pilot study. Staff Quantitative.
201639 (New (n=51). Emergency Department, working in and consumer survey.
Zealand) interdisciplinary team.

Hsiao et al, 201840 Team leaders of Acute, Community Health Partnership to improve Description of design/implementation of a complex Qualitative.
(United States) Ambulatory, Behavioral and coordination between hospital, nursing home care coordination program.
Nursing Care (n=8). and primary care for high-risk patients.

Ivanoff et al, Hospital/primary care OT, PT, Different professionals’ views and Purposive sampling for focus group interviews. Qualitative.
201855 (Sweden) SW, nursing and medical staff experiences of a comprehensive geriatric
(n=46). assessment.

Johannessen & Unit nursing, medical, OT & PT Role of professional collaboration in patients’ Semi-structured interviews and meeting observations. Qualitative.
Steihaug, 201356 staff (n=24). Primary care staff transitions home from hospital via transition Systematic text condensation.
(Norway) (n=14). unit.

Kind et al, 201157 Inpatients (n=187). Rate of dysphagia recommendation Retrospective cohort design: SLP reports abstracted, Quantitative.
(United States) omissions in discharge summaries for high- coded, compared.
risk patients.

Massy-Westropp Hospital/primary care medical, Effectiveness of electronic data link to Staff satisfaction survey SPSS analysis. Content analysis Mixed
et al, 200541 nursing and allied health staff transfer information between hospital and of two staff focus groups with independent facilitator. methods.
(Australia) (n=82). primary care.

Mc Ainey et al, 1st 18 month of referrals to Intensive Geriatric Services Worker role and Chart audit analyzed with descriptive statistics. Mixed
201642 (Canada) Intensive Geriatric Service impact on clients, caregivers and healthcare Naturalistic inquiry approach for phone interview methods.
(n=692) system. inductive analysis.

(Continued)

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Table 1 (Continued).

Miller et al, 201943 Sample not described. Protocol for advanced care coordination Database will allow continuous audit of SW-led Quantitative
(United States) program between hospitals and primary care. longitudinal care coordination.

Rowlands et al, Hospital medical staff (n=22) Perceptions of quality, timeliness and format Grounded theory approach. In- depth interviews with Qualitative
201258 (Australia) and PCP (n=8). of patient information sent from hospital to convenience sample.
PCP.

Rydeman & Hospital/primary care nursing Experiences of the discharge process among Phenomenological approach. Data analysis from 8 Qualitative
Tornkvist, 200659 and SW (n=31). different healthcare professionals. focus-group interviews.
(Sweden)

Tang et al, 201760 Hospital/primary care medical, Gaps in care for patients with memory Semi-structured face-to-face/phone interviews. Qualitative
(United Kingdom) nursing, OT & PT staff (n=17). deficits after stroke. Thematic analysis.

Thomas & Siaki, Hospital/primary care nurses, IT, Analysis of discharge and rehospitalization ‘Healthcare Failure Model and Effects Analysis’ and Mixed
201744 (United pharmacist, case manager, unit rate to create action plans directed at ‘Project Re-engineered Discharge’ tool kits used to method
States) secretary and PCP (n=?). reducing risks. target risk priorities with stakeholder input

Trankle et al, Hospital/primary care nursing, Investigation of the effectiveness of an Qualitative evaluation using a framework analysis, with Qualitative
201945 (Australia) medical, allied health, care integrated care program. 125 in-depth interviews over 12 months.
facilitators, patient/caregivers
(n=83).

Wilson K et al, Nurse practitioners (n=9). Nurse practitioners experience of Descriptive exploratory study. Thematic analysis. Qualitative
200561 (Australia) collaboration with allied health and PCP Semi-structured interviews.

Wilson S et al, Hospital medical, SLP, SW, OT, Videoconference compared to Randomized controlled trial. Two group comparison of Mixed
200446 (Australia) PT & nursing staff (n=14). audioconference for MDT discharge two different methods of case conferencing. Staff methods
Patients (n=100) planning. satisfaction survey analysis process not described.

Abbreviations: PCP, primary care practitioner; MDT, multidisciplinary team; OT, occupational therapist; PT, physiotherapist; SLP, speech & language pathologist; SW, social
worker; IT, information technology; EMR, electronic medical record.

included details of a clinical information system allowing outpatient transition setting to support patients in the com­
hospital care plans to be communicated directly to primary munity after hospital discharge, facilitated by direct com­
care. Within the paper, the authors ascribed what they munication between social workers acting as care
termed a chronic care model to their program36 however, managers in both the hospital and primary care settings.5
has since become recognized as a proactive, person- Social workers too were described as ‘boundary spanners’
centered, evidence-based approach with features more to facilitate communication between a medical cancer
consistent with a collaborative care model.48 center and primary care in an intervention described by
Flieger et al in 2019.37 In this study, the payment and
Collaborative Care Model delivery system innovation adapted an identified chronic
Chronic care management has evolved to incorporate care management model to become a more collaborative
a collaborative care model, which includes the active model of care. The reform prompted the routine sharing of
engagement of hospital and primary care providers in the information between hospital social workers and primary
shared care of patients beyond usual discharge care chronic care coordinators, allowing improved care
summaries.48 All 12 of the interventions identified in the coordination and communication across healthcare
literature5,36–46 included features consistent with settings.37
a collaborative model of care in their initiatives to improve Improved communication between hospital and pri­
hospital discharge planning and continuity of care, even mary healthcare providers was also attributed to hospital
though they did not all reference a theoretical basis. allied health, in a 2016 retrospective report by Holmes
A collaborative care model may have formed the the­ et al describing the trial of a new allied health service in
oretical framework for the “Accountable Care in an emergency department.39 The pilot project indicated
Transitions Program”5 described by Hawes et al in 2018, that the inclusion of a combined social work and phy­
however was not specifically named. A well-coordinated, siotherapy service increased patient links to primary care
multidisciplinary team approach was used within the after hospital discharge. Stakeholder and staff feedback via

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Figure 1 PRISMA flow diagram.

Notes:PRISMA figure adapted from Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate
health care interventions: explanation and elaboration. Journal of clinical epidemiology. 2009;62(10). Creative Commons.

a questionnaire suggested communication had improved management plan than telephone conferencing.46
between the hospital and primary care,39 however, objec­ Unfortunately, both studies relied on the opinions of
tive data were not provided so the findings need to be a small sample of staff rather than finding statistically sig­
interpreted with caution. nificant measures of effect, so the findings are difficult to
Early attempts to use information technology (IT) to generalize.
improve the hospital-primary care interface were described Health IT developments have enabled more sophisti­
by two earlier studies. An electronic data linking system cated programs to measure and improve care coordina­
evaluated by Massy-Westropp et al in 200541 allowed hos­ tion such as those described by Thomas and Siaki
pital access to a primary care data base and alerted primary (2017)44 and Hsiao et al (2018).40 Both interventions
care providers to patient discharge from hospital. A study are comprehensive, multidisciplinary approaches to facil­
by Wilson et al in 200446 indicated that using videoconfer­ itate communication of hospital discharge plans with
encing between the hospital multidisciplinary team and primary care through the integration of electronic health
primary care providers provided a better patient records, promotion of patient engagement and ongoing

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Table 2 Summary of Quality of Qualitative Studies Using JBI Critical Appraisal Checklist for Qualitative Research
Study Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10

Christie et al, 201652 Yes Yes Yes Yes Yes Yes No Yes Yes Yes
Dossa et al, 201253 Yes Yes Yes Yes Yes No No Yes Yes Yes
Hansson et al, 201754 Yes Yes Yes Yes Yes No Yes Yes Yes Yes
Fleiger et al, 201937 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Hesselink et al, 201438 Yes Yes Yes Yes Yes Yes Yes N/A Yes Yes
Hsiao et al, 201840 Yes Yes Yes Yes Yes Yes Yes N/A Yes Yes
Ivanoff et al, 201855 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Johannessen & Steihaug, 201356 Yes Yes Yes Yes Yes Yes No Yes Yes Yes
Rowlands et al, 201258 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Rydeman & Tornkvist, 200659 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Tang et al, 201760 Yes Yes Yes Yes Yes No Yes Yes Yes Yes
Trankle et al, 201945 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Wilson K et al, 200561 Yes Yes Yes Yes Yes No No Yes Yes Yes

monitoring of patients to ensure timely follow up with A theoretical model was not specifically mentioned; how­
primary care. Both studies concluded that more efficient ever, the intensive geriatric service worker role was devel­
IT systems are required to support improved communi­ oped with the collaboration of a geriatric health services
cation across the healthcare continuum.40,44 Hsiao et al network and a community-based mental health service to
suggested that access to hospital medical records (inclu­ help seniors navigate a complex and disjointed healthcare
sive of allied health documentation) enhanced primary system.42
care outcomes and recognized the need for input from In another example of the extension of a collaborative
community-based organizations to address social and model of care, Trankle et al (2019)45 noted that integrated
economic issues.40 This more integrated model of care, care aims to improve communication, not just between
which they identified as a “care coordination approach”, hospitals and primary care but also between physical
was reported to strengthen relationships between the care and mental healthcare, as well as between healthcare
hospital and community healthcare providers.40 and social care. The authors evaluated a program, the
Western Sydney Integrated Care Program, which enabled
Integrated Care Model
shared patient care plans to be developed and accessed by
Hesselink et al38 used an intervention mapping framework,
hospital and community healthcare providers and patients.
commencing first with a systematic review of effective dis­
Within this broader evaluation, it was concluded that the
charge interventions, to develop a comprehensive guide to
program improved patient/caregiver experience of health­
improve communication between hospital and primary care.
care and built capacity in primary care, acknowledging
Integrated care was identified as one of the theory-based
electronic communication across healthcare sectors
methods used to identify that discharge templates, a liaison
remained difficult.45
person, reconciliation of medication and regular site visits
The “Advanced Care Coordination Program” proposed
were strategies to support high-quality discharge informa­
by Miller et al (2019)43 also seemed to be based on an
tion, well-coordinated care, and direct and timely commu­
nication with primary care.38 As mental healthcare and integrated model of care, to address the gaps in care during
social services were not mentioned in the study, it would patient care transitions, although a theoretical framework
seem that these strategies were more closely aligned with was not discussed. Their social worker-led program
a collaborative model than an integrated model of care. focused on social determinants of health in
As one component of an identified “integrated program a comprehensive and longitudinal care coordination inter­
of services”, McAiney et al (2016)42 described the role of vention. The core components of care coordination were
an intensive geriatric service worker, developed to address initial notification of patient hospital admission,
the challenges faced by seniors transitioning from hospital a comprehensive needs assessment, clinical intervention
to community care that place them at risk of poor out­ as indicated and a phone call to the primary care
comes including preventable hospital readmission. providers.43 The comprehensive needs assessment

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Dovepress Sheehan et al

addressed access to health care, economic status, housing

Conclusions
status, psychological status, and social support. The pro­
gram included the development of a shared data base, as

Yes
Yes
Yes
Yes
Yes
Yes
Yes
well as the provision of continuing education and outreach
to bridge healthcare and social care communication after
hospital discharge.43

Importance
Clinical
To summarize, while no specific methods or measures

N/A
N/A

N/A

N/A
Yes

Yes
Yes
of communication between hospital allied health profes­
sionals and primary care practitioners were evaluated, ele­
Analysis

ments of a collaborative care model48 seemed to underpin

N/A

N/A
Yes

Yes

Yes
Yes
Yes
the majority of studies describing interventions aiming to
improve discharge planning and communication between
Results

N/A
N/A
hospitals and primary care settings. The more recent stu­
Yes

Yes
No

No
No

dies suggest that the collaborative model of care can

Intervention-

evolve to become an integrated model of care, providing

a theoretical framework for interventions to facilitate col­
Detail

laboration between healthcare and community services,

Yes
Yes
Yes
Yes
Yes
Yes
Yes

including mental healthcare and social care services.

Table 3 Summary of Quality of Quantitative Studies Using McMaster Critical Review Form – Quantitative Studies

There were some common concepts and components iden­

Outcomes-

tified in the included studies which have helped and hin­

Valid

N/A

N/A

dered general communication within and between hospital

Yes
Yes

Yes
Yes
Yes

and primary care, which will be further discussed in rela­

tion to the enablers and barriers highlighted within each
Outcomes-

study.
Reliable

N/A

N/A
Yes
Yes

Yes
Yes
Yes

Enablers and Barriers to Effective

Sample-

Communication Methods Between

Size

N/A

Yes

Yes
Yes
Yes
No

No

Hospital Allied Health and Primary Care

Practitioners
Sample-
Detail

Coding of the literature allowed the identification of the

N/A
Yes
Yes
Yes
Yes
Yes
Yes

four most common themes in relation to components and

processes of communication between hospital and primary
Design

N/A
Yes
Yes
Yes
Yes
Yes
Yes

care, allowing an insight into the factors affecting dis­

charge communication between hospital allied health and
Literature

primary care practitioners. The four emerging themes of

“multidisciplinary care plans”, “patient and/or caregiver
Yes
Yes
Yes
Yes
Yes
Yes
Yes

involvement”, “information technology” and “follow up”,

are outlined in Table 6 as the enablers to communication;
Purpose
Study

however, they have their own barriers as described below

Yes
Yes
Yes
Yes
Yes
Yes
Yes

and included in Table 7.

Baker & Wellman, 200550

Multidisciplinary Care Plans

Thomas & Siaki, 201744
Holmes et al, 201639

Multidisciplinary care plans were important components

Hawes et al, 20185

Miller et al, 201943

Allen et al, 200436

Kind et al, 201157

of the 12 interventions aiming to improve communication

processes between hospitals and primary care.5,36–46 The
Study

remaining 12 studies50–61 assumed or suggested that multi­

disciplinary care plans were a means of facilitating

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Table 4 Summary of Quality of Mixed Methods Studies Using Mixed Method Appraisal Tool (MMAT) Version 2018
Study Criteria 5.1 Criteria 5.2 Criteria 5.3 Criteria 5.4 Criteria 5.5

Bleijlevens et al, 200851 Yes Yes Yes Cannot tell Cannot tell
Massy-Westropp et al, 200541 Yes Yes Yes Yes Yes
McAiney et al, 201642 Yes Yes Yes Cannot tell Yes
Wilson S et al, 200446 Cannot tell Yes Yes Cannot tell Yes

healthcare communication, as outlined in Table 6. There too medically unstable to contribute to discharge planning.54
were, however, multiple barriers to the practice and pro­ Furthermore, healthcare professionals may not feel equipped
cess of multidisciplinary care plans mentioned in the 24 to broach certain topics with patients and caregivers.60
included studies, including ineffective relationships Insufficient time and knowledge to allow effective commu­
between health professions,50–56,61 junior doctors respon­ nication with patients50,54 could be further barriers to invol­
sible for the discharge summary54 and allied health reports ving patients and caregivers in the planning of the transition
and recommendations omitted from the care plan.50,57 from hospital to home.
Multidisciplinary care plans that are collaborative and
person-centered may be a common goal, however, there Health Information Technology
is little evidence in the literature to determine their quality, There was a general consensus in the literature with 18
consistency or whether they support or are supported by (75%) of the 24 included studies suggesting that
effective communication between hospital allied health advances in health IT may offer a promising
and primary care practitioners. A word frequency search solution to the inconsistency of healthcare
across all of the included studies using NVivo software31 communication,5,36–38,40,41,43–46,52–59 as seen in
revealed that the term “communication” was not one of the Table 6, but multiple barriers to its implementation
ten most frequent words, only appearing in the 50 most were identified. Logistical barriers to health IT include
frequent words [see Figure 2], despite the accepted under­ the lack of staff access and training,41,46 lack of appro­
standing that communication is one of the cornerstones of priate technology36,40 and system incomp
37,38,43,45
collaborative healthcare.62 atibility.

Patient and Caregiver Involvement Follow-Up

According to the World Health Organization, person- In the absence of consistent, compatible health IT systems to
centered care takes into account the patient’s values, share care plans and standardize communication across health­
beliefs and preferences while encouraging them to actively care settings, the importance of a designated person to support
participate in their own individualized care plan.7 the transition of care was highlighted by 20 (83%) of the 24
Involving the patient and caregiver in discharge planning included studies5,36–40,42–45,50,51,53–55,57–61 as seen in Table 6.
and encouraging self-management was incorporated in 18 “Care manager” and “case manager” were the most common
(75%) of the 24 included studies5,36–40,42–45,51–56,59,60 as titles attributed to the healthcare professional identified to
seen in Table 6. Several of the studies reported negative follow up patients after hospital discharge;5,36,44,50,55 however,
patient experiences of the discharge process where they they were also referred to as ‘chronic care coordinator,37
did not feel sufficiently involved or informed.38,42,52,53 “transition guide”,40 “care facilitator”,45 “health coach”,54
Despite theoretical models, healthcare policies and hos­ and “intensive geriatric service worker”.42 One study recom­
pital guidelines, it seems barriers remain to the involvement mended that an occupational therapist and a geriatrician
of patients in their own care planning, preventing healthcare should provide post-discharge follow-up and communicate
practice from being truly person-centered and compromising with primary care practitioner.51 Other studies recommended
initiatives to become more people-centered. Two studies various healthcare professionals could provide such follow-up
focused specifically on the unmet communication needs of and communication with primary care: a liaison nurse or
patients and their caregivers, leading to issues with continuity pharmacist,38 nurse practitioner,61 advanced practice nurse53
of care.52,53 Other studies found some patients do not dare to or social worker.39 Of the four studies that did not refer to
speak up,38 are unable to comprehend information or may be a designated person to provide follow up, all four studies

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Table 5 Categorization of Studies Based on Berlo’s Model of Communication

Study and Intervention Sender/Source Receiver Message/Channel
or Phenomenon (Communication Skills, Attitudes, (Communication Skills, Attitudes, (Content/Process/Format or General
Knowledge, System and Culture) Knowledge, System and Culture) Method of Communication)

Allen et al, 200436 Poststroke consultation core team made up of hospital/primary care PT, geriatrician, care manager, primary care general internist & stroke
A comprehensive post- unit clinical nurse specialist. Post stroke consultation extended team includes neurologist, pharmacist, physiatrist, SLP, SW, OT,
discharge stroke care psychologist & dietitian. Care manager home assessment & 6-month follow up to implement or adjust care plan, provides frequent phone
management model: follow up & home visit if needed. Copy of MDT care plans, guidelines & patient specifics to PCP by letter/phone.
STEPS CARE (All team members participate in care plan development & implementation as needed so all act as sender, receiver & channel)

Baker & Wellman, 200550 Case managers identified medical, Not addressed Not addressed
Discharge planning for nursing, SW & PT as important in
nutrition needs. discharge planning, not dietitians.

51
Bleijlevens et al, 2008 Medical risks and other fall-risk factors Patients told to contact PCP for details Geriatrician & OT sent written patient
Multidisciplinary falls such as home hazards & behavior not recommendations & referrals to PCP.
prevention program. systematically addressed by hospital
medical staff.

Christie et al, 201652 Not addressed PCP had limited options & not always able to Not described
Post discharge care & role provide patient information/support. PCP
of PCP. want prognostic information from hospital to
help manage patient recovery &
expectations.

Dossa et al, 201253 Patients not satisfied with hospital Despite common electronic medical record Hospital phones patient 1–2 days post
Patient and caregiver provision of safety information & shared by facilities, patients did not feel that discharge. EMR between hospital & PCP.
discharge experience potential adverse events. the hospital had communicated with their
PCP.

37
Fleiger et al, 2019 Person-to-person communication There remains a lack of clarity about exactly Chronic care coordinators faxed PCP visit
A Chronic Care between hospital SW & chronic care what information each PCP wants and needs, notes to hospital SW, where it was scanned
Management Model: the coordinators for treatment regime & for what purpose. into EMR.
Vermont Oncology Pilot. changes and admission information.

Hansson et al, 201754 Hospital had insufficient time to talk to PCP may take over care of patients without Hospital nurse checks IT system, contacts
Health professionals’ patients/families. Medical staff with least full patient information. hospital OT, PT & care planning nurse then
collaboration in the care experience handled discharge. Hospital sends nursing report to primary care
of frail elderly patients. did not discuss patient with PCP. assistance officer who contacts primary care
Ingrained culture & professional OT, PT, care planning unit, hospital & PCP.
boundaries hamper communication
initiatives.

Hawes et al, 20185 Care manager met with patient to The post-discharge MDT visit scheduled Hospital nurse phone patient to assess
Accountable Care in discuss psychosocial concerns, within 7 days post discharge with PCP, medication adherence/adverse event, review
Transitions Program in behavioral health needs, barriers to structured and coordinated using symptoms, identify care barriers & provided
a patient-centered medical care, medical equipment, potential a standardized checklist to address new appointment reminder. Hospital & primary
home. palliative care, community resources & diagnoses, care plans & goals, follow-up tests, care pharmacist & care managers
continuity of care plan. symptom management, care coordination & communicate via EMR.
self-management strategies.

Hesselink et al, 201438 Hospital writing complete, accurate & The relationships between providers are Patients are expected to participate in
Intervention Mapping. timely discharge letter resulted in lacking (no formal meeting between hospital discharge, giving letter to PCP & knowing
a step-by-step checklist of follow up. & PCP). medical history & care plan.

Holmes et al, 201639 Hospital SW linked patients with PCP, Hospital allied health team (PT and SW) SW facilitated MDT meetings/care plan.
Allied health team in facilitated hospital MDT meetings & received referrals from hospital triage nurse.
Emergency department. developed care plans.

(Continued)

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Table 5 (Continued).

Hsiao et al, 201840 Hospital risk screen, MDT care plan, Transition Guides met regularly with hospital Personal post-discharge care & follow-up
John Hopkins Community patient/caregiver education, pharmacist- MDT to discuss moderate to high-risk phone call with care coordination protocols
Health Partnership driven medication management. patients. & patient access phone line.

Ivanoff et al, 201855 Experience-based knowledge used more than standardized tests. Professions reluctant to Not addressed
Comprehensive Geriatric encroach on other’s territory so questions. Resources & organizational conditions set
Assessment agenda more than person’s needs (related to both senders and receivers).

Johannessen & Steihaug, Hospital PT & OT sought collaboration whereas nurses were unsuccessful, due to Healthcare providers from hospital &
201356 pervading “us and them” attitude. Medical staff satisfied with collaboration. primary care attend MDT discharge
Profession collaboration. (above factors related to both senders and receivers of communication) meetings with patient.

Kind et al, 201157 SLP recommendations not included in Not addressed. Average 3.6-page discharge summary
Omission of dysphagia discharge summaries. dictated by medical resident but 96% with
therapies senior medical review, edit & sign.

Massy-Westropp et al, Upon admission, automated check if Primary care staff advised of existence of Automated email alert sent to primary care
200541 patient under primary care service and hospital report system, given access at discharge with admission details to
Electronic data link from report provided of current issues for instructions and a short cut icon placed on prompt the primary care case coordinator
hospital to primary care. hospital staff to access with password. desktop of each personal computer. to contact hospital.

42
McAiney et al, 2016 Intensive Geriatric Service Worker used an integrated and collaborative manner to work Intensive Geriatric Service Worker support
Intensive Geriatric Service with primary care services and geriatric emergency management nurses in hospitals. post discharge PCP visits by reviewing
Worker. (Intensive Geriatric Service Worker as sender, receiver and channel) patient questions to ensure asked, answered
& understood.

Miller et al, 201943 Hospital emergency department to A survey will assess perceived frequency, SW will make a phone call to the primary
Protocol for the notify program SW of patient admission. timeliness & accuracy of communication, care team. A one-page fact sheet will inform
Advanced Care SW will do biopsychosocial assessments, extent of problem-solving & mutual respect healthcare facilities of the program & the
Coordination Program. then connect patient with primary care between & among program providers. referral process.

Rowlands et al, 201258 Often only hospital medical staff communicated with PCP. Nurses had little/no contact MDT meeting was main process of
Perceptions of the quality, with PCP as they thought not their job. Care coordinator communicated on MDT behalf. communication.
format and timeliness of Hospital allied health had no communication with PCPs and did not know if medical staff One PCP had to make phone call to have
patient information from communicated information about their interventions to PCPs but if so, it would be information faxed during a patient
hospital to primary care. limited (eg ‘patient seen by dietitian’). Most hospital medical staff did not know if hospital consultation.
allied health communicated with PCP and had varying views about necessity.

Rydeman & Tornkvist, 200659 Mainly geriatric Primary care nurses were seldom involved in Patient care management plan developed in
Different professionals’ experience of discharge care unit nurses discharge process. weekly MDT meeting.
and hospital SW PCPs often lacked necessary patient
discussed patient information when assumed responsibility.
discharge.

Tang et al, 201760 Not addressed Not addressed Not addressed

Gaps in patient care

Thomas & Siaki, 201744 Evaluation Not addressed Electronic reports, interprofessional huddles,
Re-Engineered Discharge and Health Care identified need to post discharge phone calls and
Failure Mode Effects Analysis. improve care plan documentation
communication
with primary care
and care
management for
high-risk patients.

45
Trankle et al, 2019 Specialist action plans provided at hospital discharge to inform PCP support phone line allowed faster
Evaluation of Western Sydney Integrated Care patients and PCP about complex and changing care needs. Care access to hospital specialists.
Program. facilitator communicates with hospital MDT, patient and PCP. Care plan shared electronically with patients,
(Care facilitator is sender, receiver and channel of communication) hospitals, PCP & primary care

(Continued)

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Table 5 (Continued).

Wilson K et al, 200561 Nurse practitioners considered that successful quality health care Telephone call to PCP
Nurse practitioners’ collaboration with allied environments were influenced by collaborative practices among
health and PCP. MDT members.
(Nurse practitioner as sender, receiver, and channel of
communication)

46
Wilson S et al, 2004 All but one of 14 healthcare providers found videoconference Videoconference to replace thrice weekly
Audio versus video-case conference better for patient care management plan than audio (telephone) audio conference between hospital and
conference primary care.
(attitude of senders and receivers in mixed MDT).

Abbreviations: PCP, primary care practitioner; MDT, multidisciplinary team; OT, occupational therapist; PT, physiotherapist; SLP, speech & language pathologist; SW, social
worker; IT, information technology; EMR, electronic medical record.

suggested an alternative process to encourage patient follow- studies41,46,52,56 did not seem to include a process to ensure
up by primary care; two of them recommended primary care follow up had occurred after hospital discharge.
providers be involved in hospital discharge planning The main barrier to a designated person to follow up
meetings,46,56 another relied on an automated hospital dis­ and ensure continuity of care appears to be ineffective
charge alert system41 and one recommended patient provision relationships between healthcare organizations, due to
of follow-up service information, including whom to call if and resulting in a lack of collaboration between health­
follow up does not occur.52 Unlike the interventions recom­ care providers50 and between healthcare
38,53–55,57–59
mending a designated person to provide follow up, these four settings. Siloed healthcare is clearly

Table 6 Enablers to Communication Between Hospital Allied Health and Primary Care
Study MDT Follow- Involve Health Other Enablers
Care Plan Up Patient and IT
Caregiver

36
Allen et al, 2004 Yes Yes Yes Yes MDT decision support and evidence-based protocols for PCP.
Baker & Wellman, 200550 Yes Yes No No Dietician as care managers, contributing to discharge planning.
Bleijlevens et al, 200851 Yes Yes Yes No Check if PCP agrees with hospital plan, check patient calls PCP.
Christie et al, 201652 Yes No Yes Yes Provide PCP a range of ‘normal’ post-surgical consequences.
Dossa et al, 201253 Yes Yes Yes Yes Primary care allied health support patient & PCP communication.
Fleiger et al, 201937 Yes Yes Yes Yes SW as ‘boundary spanners’ across healthcare organizations.
Hansson et al, 201754 Yes Yes Yes Yes ‘Project leader’ to direct care plan.
Hawes et al, 20185 Yes Yes Yes Yes MDT outpatient transition program based in primary care practice.
Hesselink et al, 201438 Yes Yes Yes Yes Patient coaching to assert a more active role in own care plan.
Holmes et al, 201639 Yes Yes Yes No Allied health service (SW and PT) in an Emergency Department.
Hsiao et al, 201840 Yes Yes Yes Yes Telephone call from hospital to PCP. Patient access phone line.
Ivanoff et al, 201855 Yes Yes Yes Yes Clear care plans built by MDT, family and all involved caregivers.
Johannessen & Steihaug, 201356 Yes No Yes Yes Patients and PCP attend hospital discharge meetings
Kind et al, 201157 Yes Yes No Yes Shift in the medical focus of discharge summary.
Massy-Westropp et al, 200541 Yes No No Yes Automated staff access to EMR patient information, alert system.
Mc Ainey et al, 201642 Yes Yes Yes No Supported PCP appointment so patient understands care plan.
Miller et al, 201943 Yes Yes Yes Yes SW care coordinator with focus on social determinants of health.
Rowlands et al, 201258 Yes Yes No Yes Guidelines for how, when & by whom communication happens.
Rydeman & Tonkvist, 200659 Yes Yes Yes Yes Identification of shared care team values and purpose.
Tang et al, 201760 Yes Yes Yes No PCP education regarding memory deficits after stroke.
Thomas & Siaki, 201744 Yes Yes Yes Yes Script and algorithm to frame follow up phone calls to patient.
Trankle et al, 201945 Yes Yes Yes Yes Guidelines & support phone line for PCP. IT training.
Wilson K et al, 200561 Yes Yes No No Nurse practitioner collaborating with PCP and allied health.
Wilson S et al, 200446 Yes No No Yes Shared hospital & community MDT by videoconference.

Total agreement 100% 83% 75% 75%

Abbreviations: PCP, primary Ccare practitioner; MDT, multidisciplinary team; OT, occupational therapist; PT, physiotherapist; SLP, speech & language pathologist; SW,
social worker; IT, information technology; EMR, electronic medical record.

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Table 7 Barriers to Communication Between Inpatient Allied Health and Primary Care
Study Barriers

Allen et al, 200436 Few health systems have one IT system storing all patient encounters which is the main communication hurdle.

Baker & Wellman, Case managers did not have sufficient knowledge of community services. Nurses rarely detailed patient’s previous prior
200550 level of function or home circumstances, so decisions about post-discharge requirements are more difficult.

Bleijlevens et al, 200851 Poor compliance with PCP follow-up and data not collected directly from PCPs (one-way communication).

Christie et al, 201652 Patients experience gaps in support, services and information post hospital discharge.

Dossa et al, 201253 Poor communication between patients and hospital regarding ongoing care; poor hospital response to PCP phone calls.

Fleiger et al, 201937 Inability to create a technologically feasible electronic care plan.
54
Hansson et al, 2017 Short length of stay so patient too unstable to comprehend information. Insufficient collaboration with patients/
caregivers. Absence of person responsible across organizations. Obstacles are societal (political ambitions &
government actions), organizational (managerial procedures & economics) & individual (professional/personal
interests).

Hesselink et al, 201438 Attitudinal and behavioral factors (lack of relationship/collaborative attitude between hospital & PCP), organizational
factors (lack of guidelines), technical factors (no shared IT system) or patient factors (patients less skilled or unwilling).

Hsiao et al, 201840 Siloed health system and the lack of appropriate technology to collect, standardize and track data so not possible to
share data with other community hospitals. Laws and regulations restricted availability of potentially sensitive patient
data.

Ivanoff et al, 201855 Ineffective collaboration between health professionals and people working closely with the older person so can be
difficult to assess hidden need. Communication and structural barriers within and between each organization. Health
and social care are complex organizations.

Johannessen & Steihaug, The hospital PT, OT and medical practitioner had no formal collaboration with primary care. Healthcare providers have
201356 different understandings of interprofessional collaboration with some considering it an inappropriate working method

Kind et al, 201157 Hospital allied health recommendations omitted from medically focused discharge summaries, so PCP not informed.

Massy-Westropp et al, Staff lacked access to integration tools for EMR and needed more training.
200541

Miller et al, 201943 The program will rely upon notifications from other hospitals - not guaranteed that their staff will incorporate this
process.
No access to admission utilization readmission data at non-veteran hospitals could limit evaluation of adverse
outcomes
58
Rowlands et al, 2012 Communication influenced by length of MDT treatment time, change in treatment modality, delayed specialist letter.

Rydeman & Tonkvist, Professionals often lacked necessary patient information when assumed care. Ambiguity in who responsible for what.
200659

Tang et al, 201760 Gaps, either in structure or communication between hospital & primary care. Reduced PCP consultation time.
44
Thomas & Siaki, 2017 No process for post discharge. No identified staff member identified to conduct the call-backs & no standard script
used

Trankle et al, 201945 Poor functionality of shared health records and minimal IT between hospitals and PCP. IT services & training
inadequate.

Wilson K et al, 200561 Ineffective collaborative relationships between healthcare providers.

Wilson S et al 200446 Staff not knowing how to take advantage of available technology.
Abbreviations: IT, information technology; COVID-19, coronavirus disease of 2019; PCP, primary care practitioner; MDT, multidisciplinary team; OT, occupational
therapist; PT, physiotherapist; SLP, speech & language pathologist; SW, social worker; EMR, electronic medical record.

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Figure 2 Word cloud of 50 most frequent words.

a contributing factor,38,51,54,55 resulting in one-way Discussion

communication,51 with hospital discharge summaries Despite the wide-held assertion that hospital discharge
often not received in time to be relevant to primary processes and care transitions are improved through timely
care practitioners53,59 and/or without establishing and accurate communication,1,63 this narrative systematic
a shared understanding by determining if the informa­ review is the first to synthesize data on communication
tion is according to need and/or understood.54 specifically between hospital allied health professionals
In summary, enablers to effective communication and primary care practitioners. Given the paucity of
between hospital allied health and primary care practi­ research in the field, the review took a broad and inclusive
tioners are multidisciplinary care plans, made in collabora­ approach to study across qualitative and quantitative
tion with patient and caregivers, electronically research. In doing so, we have identified the lack of well-
communicated to primary care, with a designated person designed, intervention-based research related to communi­
to follow up to ensure that there is continuity of care in the cation between these key healthcare provider groups,
community after hospital discharge. The barriers to such which potentially suggests that hospital allied health pro­
communication include that discharge communication can fessionals do not communicate at all with primary care
remain medically focused and may not include allied practitioners.
health recommendations or the preferences of patients Previous systematic reviews investigating healthcare
and/or their caregivers. Even when multidisciplinary care collaboration have highlighted the importance of effective
plans aimed to be collaborative and person-centered or multidisciplinary communication.17,64 While important to
ideally based on a people-centered integrated model of collaboration, there has been little recognition of the role
care,7 health IT systems do not consistently support effec­ of hospital allied health from the perspective of primary
tive communication between hospitals and primary care. care practitioners. The terms “multidisciplinary” and

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“interdisciplinary” are used interchangeably to denote the COVID-19 pandemic has placed increased pressure on
a healthcare team working together; however, it has been health and social systems, affecting hospital to home tran­
suggested that the terms are conceptually different, with sitions on many levels and highlighting the particular
only the latter allowing the coordination of a common and vulnerability of older adults with complex health and
coherent approach to the care required for collaboration.65 social care needs.68 Public health measures such as social
The teams mentioned in the included studies were com­ distancing, as well as shorter hospital stays to minimize
prised of various healthcare professionals, acknowledged infection, may have negative consequences for the man­
at times to be poorly described, with some relying on agement of chronic conditions including mental health
a social worker as the only mentioned hospital allied issues however they have also accelerated some develop­
health representative. The World Health Organization ments in virtual care.67 Health IT developments such as
recommends an interdisciplinary approach to healthcare;7 telemonitoring, telehealth and web-based portals could
however, differences in culture, resources and expectations facilitate communication between healthcare providers,69
of healthcare professionals, systems and populations may patients and caregivers.15 Findings from this review can be
result in different interpretations of definitions, theoretical integrated into clinical practice: multidisciplinary care
models and guidelines. Similarly, patient-, person-, and plans with input from hospital allied health made in con­
people-centered care are not interchangeable nor universal junction with patients (and their caregivers) need to be
terms. The goal of patient-centered communication is to routinely included in electronic discharge summaries.
provide care concordant with patient’s values, needs and Also, including the details of a designated follow-up per­
preferences, allowing patients to actively participate in son/process would facilitate discharge communication and
decisions about their health and care.66 The core values similarly could be done electronically or virtually. While
of patient-centered communication are shared with the health IT has the potential to improve the quality and
World Health Organization’s definition of person- continuity of care,70 research findings on the impact of
centered care, which they recommend extending to people- electronic communication on clinical practice and out­
centered care by adopting the perspectives of individuals, comes have been mixed71 hence further development is
caregivers, families and communities relative to people’s needed to be able to leverage this potential.
comprehensive needs and social preferences.7 The hetero­ Heterogeneity of the included studies prevented
geneity of the included studies within this review, although a meta-analytic synthesis of studies, and this remains
deliberate to capture the scope of the issue, may be reflec­ a limitation of the review. In addition, the reliance of
tive of these ambiguities in terminology, suggesting a need this review on qualitative and mixed-method studies
to establish what constitutes effective multidisciplinary may reduce the representativeness of our findings. The
and/or interdisciplinary, patient/person/people-centered majority of included studies originated from the United
care and/or communication before they can be further States and Australia, so the generalizability of their find­
evaluated. ings beyond these healthcare systems may be limited. We
Despite the limitations in the breadth of the literature, have also excluded relevant manuscripts in languages
a number of key observations may be drawn from our data other than English, and by restricting our systematic
synthesis. Firstly, multi-component interventions using an evaluation to peer-reviewed literature we may have
integrated model of care could improve the success of omitted additional publications of interest. Excluding
communicating the multidisciplinary, person-centered studies from mental health and substance abuse settings
care plan from the hospital setting to the primary care prevented the narrative synthesis of the integrated care
setting. Secondly, a designated person to provide follow- model used in these settings despite their relevance to
up such as a case/care manager working across healthcare WHO recommendations.7 Truly person-centered and peo­
settings may be required to support care plans.67 Thirdly, ple-centered care cannot exclude mental health or the
standardization of health IT processes to include hospital social determinants of health; however, many healthcare
allied health input regarding patient function, social situa­ systems do not yet integrate physical and mental health­
tion and recovery goals could facilitate more multidisci­ care with social care, hence the exclusion criteria for the
plinary collaboration with greater consideration of purposes of this literature review. We also acknowledge
individual needs and preferences, especially during transi­ that we excluded studies involving children. Pediatric
tions of care. These findings are particularly relevant since healthcare also incorporates an integrated care model;

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Dovepress Sheehan et al

however, it draws from other theoretical frameworks, Funding

most notably family-centered care; hence, the associated This work was supported by an Australian Government
research would not necessarily be applicable to an adult Research Training Program Scholarship (JS). JS was sup­
population. ported by La Trobe University (PhD scholarship); KL was
supported by an Australian Research Council Discovery
Conclusion Early Career Research Award (DECRA) Fellowship; NAL
In conclusion, despite the paucity of research investigating was supported by a Future Leader Fellowship (102055)
communication between hospital allied health profes­ from the National Heart Foundation of Australia.
sionals and primary care practitioners, our findings do
offer a way forward. Further research is needed to under­ Disclosure
stand how healthcare providers can collaborate across The authors declare that they have no competing interests.
healthcare settings and in partnership with patients to
improve continuity and strive for integrated people-
centered care. Importantly, research must involve allied References
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