ABSTRACT
This article discusses the potential for shared mental models to improve teamwork during discharge planning and follow-up care. A 58-year-old inpatient on the hematology care unit of an academic medical center was discharged to his community after initial treatment of acute myeloid leukemia, without a clear plan for either discharge or follow-up. This case highlights the challenges faced by the primary oncology care team, the patient's community health-care team, the patient, and his caregiver, because a formal plan for follow-up care after discharge was not in place. The lack of communication within the oncology care team and between the medical center and community care teams that leads to the gap in continuity of care between inpatient and outpatient oncology settings could be addressed at least in part by establishing a shared mental model. This model would require all individuals involved in patient care to recognize they are part of a team. Furthermore, all members of the interdisciplinary discharge team need to understand their own roles and responsibilities as well as those of the other team members, including the need for communication and how their roles and activities affect those of other team members. Tools such as huddles, checklists, and patient education could be used to help the team recognize and achieve its goals. Ideally, this shared mental model could be extended to include the community health-care team, leading to a more fluid transition between inpatient and outpatient care, improving patient satisfaction, and likely improving patient outcomes.