Care coordinators can help hospitals better manage care through an integrated system that provides best practices in the handover process.

For example, Trinity Health in Livonia, MI, created a care coordination tool to ensure the most effective care. It is adapted from the Agency for Healthcare Research and Quality (AHRQ) TeamSTEPPS 2.0. (Find out more about TeamSTEPPS at:

The following are some sample items from Trinity Health’s two-page handover process SBAR (situation, background, assessment, recommendation/request) guidance:

• Situation:

The guidance suggests questions to consider in one column, and their descriptions in an adjoining column. Here are a few examples:

- What are the current situation and overarching concerns? “Describe specific situation. Include code status. Be concise and concrete,” according to the guidance.

- What are key, recent changes to the patient’s health status? “Determine the current opportunities and/or challenges.”

- What is the patient’s level of risk for poor outcomes? “Utilize standard risk stratification methodology.”

• Background:

- What are the relevant comorbid conditions? “Highlight the comorbid conditions that place patients at risk.”

- How does the family history impact the plan of care? “Share applicable family history.”

- Does the patient have a support network? “Include family and caregiver dynamics.”

• Assessment:

- What are the pertinent biometrics — the pertinent, critical, and pending labs, diagnostics, or medications? “Communicate clinical information, as applicable.”

- What are the safety concerns? “Highlight allergens, falls, isolation, socioeconomic factors.”

- Is the patient able to self-manage? “Consider health literacy, cultural factors, social determinants (food insecurity, transportation, housing, medications).”

• Recommendation and Request:

- What is the recommended plan or the next steps? “Respect patients’ preferences and goals of care.”

- What actions will be taken to ensure a safe transition? “Clarify expectations. Ensure there is adequate time allowed in handover process to ask/answer questions.”

- How will the next site of care connect with the previous site of care if further questions arise? “Communicate follow-up contact information.”