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.
A unique resource, this text blends conceptual information with practical tools and strategies for connecting care for patients by describing research and evidence-based techniques while translating them into actionable tools. Also included are chapter objectives, review questions, explanations of key terms, case studies, self-assessments, scripts, trigger questions, and detailed descriptions of each tool and technique.
Chapter 1 Connected Care - Closing the Gaps and Filling the Cracks in Health Care
Chapter 2 Integrated Delivery Systems - The Connected Care Ideal
Chapter 3 Care Transitions - Fractured or Flowing?
Chapter 4 Leading for Connected Care - The Senior Management Role
Chapter 5 Middle Managers and Connected Care
Chapter 6 Care Coordination and Communication on the Front Lines - The Clinician Role
Chapter 7 Experiencing Connected Care - The Patient Role
Chapter 8 Pulling Together for the Patient - Teamwork in Healthcare
Chapter 9 Digital Connections, Communication and Collaboration
Chapter 10 High Risk Gaps and Cracks I: Social Determinants of Health, Health Disparities and Mental Health
Chapter 11 High Risk Gaps and Cracks II: Caregivers, Dementia and End-of-Life Care