Apanajan Aya Centre , Kolkata Home health nurses experience inadequate communication of basic patient information between the hospital, primary care, and home care after hospital discharge . Home care nurses receive either too much information (i.e., all clinical documentation associated with an admission) or too little information (i.e., just the patient’s demographic information, primary discharge diagnosis, and reason for the home care referral). Nurses who are not provided with actionable information must rely on patients and caregivers to share information that is hopefully relevant, appropriate, and accurate. However, patients and caregivers often cannot provide accurate information due to miscommunication, misunderstanding, and/or poor memory . Discharge instructions are given to all patients following a hospitalization, but this paperwork might be lost or discarded, hard to understand, or inappropriately focused on the primary discharge diagnosi...