Connecting Care for Patients: Interdisciplinary Care Transitions and Collaboration

Book excerpt: Connecting Care for Patients: Interdisciplinary Care Transitions and Collaboration addresses practical strategies for creating connected, seamless, and transparent health care for patients in settings outside of the hospital. It presents antidotes to healthcare fragmentation caused by inefficient care, patient safety problems, patient dissatisfaction, and higher costs. The text focuses on clinical case management, interdisciplinary referrals and conferencing, cross functional team meetings, tracking patients in value-based purchasing programs, inpatient liaison visits, structured collaboration with physician groups, and referral sources and development of clinical community networking groups. Further, it explores tools for patient self-management support, effective integration of technology, family caregiver engagement, and techniques for addressing health disparities and other high-risk care gaps.