Table 1 What’s working well with team-based discharge processes?

Collaboration with physicians makes a difference

• Regular physician engagement with team (as equal partners), including consulting with the broader team before transition decisions are made

• Consistent communication between discharge planning team, patients and families

• Relationship building between physicians and other providers

• Physically accessible physicians

• In-person communication (compared to email)

Leadership meaningfully engage with frontline providers

• Dedicated and visible senior leader who advocates on behalf of team

• Promotion of equality amongst team (ensuring members of the team treated as equals)

Partnerships across sectors are critical

• Focus on collaboration across sectors

• Discharge planning meetings (including hospital and community sectors)

• Embedded care coordinators (on hospital units)

• Physically accessible care coordinators