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Use Cases Care Continuity

Care Transition Management

When patients move between units, facilities, or levels of care, critical information travels by phone or memory. The receiving team often doesn't have what they need — and the transferring team has no confirmation the handoff actually landed.

The Scenario

A patient is transferring from the ICU to a step-down unit. The ICU nurse calls and reads through 20 minutes of notes. The step-down nurse takes handwritten notes. An hour later, she has a question — but the ICU nurse is already with another patient. Two key medication instructions were never confirmed received.

Handoffs are conversations, not workflows. There's no structured record of what was communicated, no confirmation of receipt, and no accountability if something wasn't transferred correctly.

What's Actually Breaking

  • Verbal handoffs are inconsistent — what's shared depends on who's doing the handoff and how busy they are.
  • Receiving team confirmation is informal — there's no required acknowledgment that the handoff was received and understood.
  • No structured record — if something goes wrong post-transfer, there's no clear documentation of what was communicated.

How Pathways Handles It

A standardized digital handoff that's required, confirmed, and fully documented.

Transfer Event Triggers
Patient transfer order in EHR fires the Pathways workflow
Structured Handoff Form
EHR patient context surfaces into the form — clinicians confirm and add notes, not re-enter data
Receiving Team Notified
Handoff packet delivered to the receiving team with full patient context
Required Fields Validated
Workflow ensures all mandatory information is complete before proceeding
Acknowledgment Required
Receiving clinician must confirm receipt of handoff
SLA: 30 min · configurable
Handoff Complete + Logged
Transfer record closed; full documentation retained for compliance
Powered by Pathways capabilities:
Patient Transfer Trigger Form Requests Required Field Validation Acknowledgment Signal Audit Trail EHR Integration

Every workflow is configurable to your protocols, team structure, and EHR environment — no custom development required.

The Outcome

What changes when transfers are structured, not improvised.

100%
Structured Handoffs
Every transition follows the same required fields — no more variable verbal reports
Fewer
Post-Transfer Incidents
Structured confirmation reduces information gaps that cause adverse events
Full
Transfer Documentation
Complete record of what was communicated and confirmed at every transition

More Workflows Like This

See how Pathways handles adjacent coordination challenges.

Discharge Coordination
Parallel tasks, real-time visibility, and automatic escalation to move patients out faster.
See workflow
Structured Shift Handoffs
Standardized digital handoff forms that ensure every patient gets a complete, confirmed report at shift change.
See workflow
Medication Alert Management
Critical alerts assigned, tracked, and escalated — never lost in a message thread.
See workflow

See Care Transition Management in Your Environment

We'll map your current transfer process, identify where handoff information breaks down, and show you exactly how Pathways would structure it.

Schedule a Workflow Assessment