Post-surgery care involves ongoing collaboration between provider teams and patients, which starts from post-surgery hospitalization through home recovery after discharge. While prior HCI research has primarily examined patients' challenges at home, less is known about how provider teams coordinate discharge preparation and care handoffs, and how breakdowns in communication and care pathways may affect patient recovery. To investigate this gap, we conducted semi-structured interviews with 13 healthcare providers and 4 patients in the context of gastrointestinal (GI) surgery. We found coordination boundaries between in- and out-patient teams, coupled with complex organizational structures within teams, impeded the "invisible work" of preparing patients' home care plans and triaging patient information. For patients, these breakdowns resulted in inadequate preparation for home transition and fragmented self-collected data, both of which undermine timely clinical decision-making. Based on these findings, we outline design opportunities to formalize task ownership and handoffs, contextualize co-temporal signals, and align care plans with home resources.

翻译：术后护理涉及医疗团队与患者之间的持续协作，这一过程从术后住院阶段延续至出院后的家庭康复。尽管先前的人机交互研究主要关注患者在家中的挑战，但对于医疗团队如何协调出院准备与护理交接，以及沟通与护理路径中的障碍如何影响患者康复，目前仍知之甚少。为探究这一空白，我们在胃肠外科背景下对13名医疗提供者和4名患者进行了半结构化访谈。研究发现，院内与院外团队间的协调边界，加之团队内部复杂的组织结构，阻碍了制定患者家庭护理计划和分诊患者信息这一"隐形工作"。对患者而言，这些障碍导致家庭过渡准备不足及自我收集数据的碎片化，二者均会损害临床决策的及时性。基于这些发现，我们提出了若干设计方向：明确任务归属与交接流程、实现共时信号的语境化解读，以及使护理计划与家庭资源相匹配。