Melisa Kelly, a 57-year-old patient hospitalized with pneumonia, is being discharged to home. The nurse care coordinator

Melisa Kelly, a 57-year-old patient hospitalized with pneumonia, is being discharged to home. The nurse care coordinator has identified Ms. Kelly as high risk for readmission and sent a message to her primary care provider’s nurse care coordinator. The nurse care coordinator is looking for the social worker’s notes from Ms. Kelly’s inpatient stay. The nurse care coordinator cannot find them in the medical record and calls the unit from which Ms. Kelly was discharged. The nurse care coordinator is told social workers do not document on the same platform as the rest of the inpatient documentation. What can health systems do to prevent this type of barrier?

Melisa Kelly, a 57-year-old patient hospitalized with pneumonia, is being discharged to home. The nurse care coordinator

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