The Handoff Problem: Why Continuity of Care Requires More Than Sharing Records

When we talk about continuity of care, we usually focus on whether information moved with the person.

Did the new provider receive the medication list? Was the discharge summary sent? Can the receiving organization access the record?

Those questions matter enormously. But they leave out another kind of continuity.

Suppose a woman living with dementia moves from her home into memory care. Her clinical record follows her. The system is designed to ensure the receiving team knows her diagnoses, medications, allergies, and medical history.

But do they know she becomes frightened when someone touches her without first explaining what is happening? Do they know she spent 40 years as a teacher and responds warmly when asked for her help? Do they know she has recently started refusing dinner, but her daughter has noticed that she will eat when someone sits beside her?

The record may arrive. Understanding often does not.

Healthcare has long recognized transitions as vulnerable moments. An Agency for Healthcare Research and Quality review cites a study in which 70% of observed hospital-to-home health transitions across five U.S. agencies included at least one safety issue. Those issues included incomplete information, medication concerns, unsafe home environments, and a lack of understanding of the care plan.

The study focused on patient safety, but some transition failures are quieter. A routine that prevented distress is not shared. A new behavior noticed at home is interpreted differently in the new setting. An approach the family already knows will fail is tried again.

In practice, families often become the continuity system.

A daughter explains her mother’s routines to the home care aide. She tells the emergency department what her mother means when she says she wants to “go home.” She repeats the same information to the rehabilitation center, the memory care community, the hospice team, and whoever comes next.

At every transition, she must decide which details matter most, remember what has changed, and hope she has not forgotten something important. Often, she is doing this in the midst of a crisis, while managing a career and other family members, or living hundreds of miles away.

Families hold essential knowledge, but relying on them as the only bridge between care settings is neither reliable nor equitable. Not everyone has a family member who can be present. Not every family knows which information the next provider will need. Even the most involved family cannot be available for every appointment, emergency, or transition.

This is especially important during the first days after a move. The person is adjusting to unfamiliar faces, routines, and surroundings at the same time the receiving team is trying to learn how she communicates, what causes distress, and which approaches help. Small gaps in understanding can quickly become larger problems.

The Centers for Medicare & Medicaid Services describes person-centered care as care guided by an individual’s goals, preferences, and values and coordinated across providers and settings. Meeting that standard should not depend on whether a family member is present to reconstruct what others have already learned.

SeeInMe was designed to give the person a stable source of human context that can travel with them rather than remain behind with a family member, caregiver, or organization. With that context, a new care team does not have to wait for a crisis, repeated refusal, or distressed family call to begin understanding the person in front of them.

When someone moves, the record should not be the only thing that follows.