• is timely, safe, efficient, with no loss of important information;

• incorporates the needs, knowledge, and point of view of the patient/client and primary caregiver;

• requires that all the clinical and social information needed about the patient/client be available to all providers of the patient/client when they need it, in a form that is accessible, clear, and actionable;

• ensures that the patient/client and primary caregiver are involved in decisions about the care; that the patient/client receives the right care from the right service provider; and that the result of the care is to improve the patient’s/client’s level of functioning so that she can return to her desired residence with supports that can maintain her safety and quality of life.