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role of the nurse in patient transitions

Planning for our patients during times of transitions (for example: hospital to home, home to rehabilitation facility) involves collaboration with a number of healthcare professionals. Please address the following questions:
•    How does your facility promote interprofessional collaboration during times of patient transitions?
•    What is the role of the nurse in patient transitions?
•    What gaps can you identify in this process related to quality of care? (If you are not currently in practice, please use a previous role or clinical experience in your answers.)

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