Care_Coordination_Patient_Experience_Gaps.xlsx

	A	B	C	D	E
1	Category	Observable Issue	Who Is Affected	Hidden Risk	Internal Process Gap

2	Continuity & Information	Patient repeats trauma history to each new provider	Patient	Patient starts under-disclosing or sanitizing their story over time	No shared, real-time record accessible across all roles
3	Continuity & Information	Different providers give conflicting instructions	Patient, family	Patient loses trust in clinical guidance altogether, not just one provider	No single owner of the "plan of record"
4	Continuity & Information	Stated triggers or boundaries don't carry over between staff	Patient	Re-traumatization goes unaddressed and undocumented	No structured handoff protocol capturing patient-specific context
5	Communication & Transparency	No way to reach anyone between sessions	Patient	Concerns escalate to crisis level before anyone hears them	No defined between-visit communication channel or owner
6	Communication & Transparency	Appointments rescheduled with no explanation	Patient, family	Patient interprets the silence as being deprioritized and disengages	No accountability line for proactive patient communication
7	Communication & Transparency	Patient unsure who's coordinating their care after staff turnover	Patient	Care plan quietly stalls with no one noticing	No ownership continuity when staff change
8	Role & Therapeutic Alliance	Patient treats case manager as their therapist, feels rejected when redirected	Patient	Patient avoids future disclosure or drops out of care entirely	Role scope never explicitly set with the patient upfront
9	Role & Therapeutic Alliance	Patient over-discloses to staff not equipped to hold it	Patient, staff	Disclosure is mishandled, patient feels exposed rather than supported	No boundary-setting protocol built into intake
10	Role & Therapeutic Alliance	Patient handed off to a new case manager with no warning	Patient	Therapeutic alliance ruptures, engagement drops off	No warm-handoff process for staff transitions
11	Access & Referral	Long wait between referral and first specialist contact	Patient	Symptoms worsen during the window where intervention was possible	No referral tracking or follow-up ownership
12	Access & Referral	Referral quietly drops if patient doesn't chase it	Patient	Patient believes their care is complete when it isn't	Referral treated as a one-time event, not a closed loop
13	Access & Referral	No fallback offered when a patient declines a referral	Patient	Patient exits the care system entirely, invisibly	Referral pathway has no built-in alternative or retry step
14	Crisis Escalation	Early warning signs missed in infrequent check-ins	Patient	Crisis reaches an acute stage before anyone intervenes	No structured, ongoing risk-monitoring cadence
15	Crisis Escalation	Delayed response from on-call clinician	Patient, family	Irreversible harm occurs during the response gap	No tested escalation protocol with clear accountability
16	Crisis Escalation	No follow-up immediately after a crisis event	Patient	Relapse or repeat crisis within days	Crisis response ends at stabilization, not at safety-net handoff
17	Post-Discharge & Transition	Patient disengages after discharge with no outreach	Patient	Silent relapse that's only caught at re-admission	No proactive post-discharge check-in system
18	Post-Discharge & Transition	No warm handoff to outpatient or community provider	Patient	Care gap widens long enough for total disengagement	Discharge treated as an endpoint, not a transition
19	Post-Discharge & Transition	Medication continuity breaks at the inpatient-outpatient handoff	Patient	Non-adherence gets blamed on the patient instead of the system	No medication reconciliation step built into the transition
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100