How does your facility promote interprofessional collaboration during times of 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.)