Language used across boundaries is not standardized and therefore the meaning of clinical terminology (e.g. “at risk”) can differ. This can confuse treatment expectations. There is a need for standardization of language, a dictionary of terminology, and simplification of integrated care planning details so that clinicians, agencies, caregivers, and patients/clients can share a common understanding of the patient’s/client’s status and needs.

“The reality is that we just don’t speak the same languages”

• Participants recognize the value of cross­ boundary information sharing.

“I work in NY but the improved communication with the hospital in Bennington is critical for me and has improved care.”

• Some people spoke of a concern about competitiveness (e.g. “who owns the patient?”) that can inhibit improving care and communication. Reimbursement models can inadvertently reinforce this competitiveness.

“Sometimes I think we are not getting the whole story.”

• Innovation in one place may not reach out beyond the hospital and into the home after discharge.

“The Huddle has been very helpful in the hospital. But after discharge things break down…no way to really continue the approach at home for a treatment plan.”