Overview and Summary: Care Coordination: Benefits of Interprofessional Collaboration

Care transitions are recognized as a time of significant vulnerability for children and adults with multiple chronic illnesses and complex health and social needs. Moving between settings or between providers requires comprehensive preparation and education of patients and families and accurate and timely flow of essential information. Lack of effective coordination on both sides of the transition leaves patients at risk for serious adverse outcomes influencing quality of life and function and substantial cost.This OJIN topic captures several important steps in the evolution of knowledge and practice of transitional care and care coordination. Together, the articles included in this topic reflect where we have been and where we still need to go to assure that patients and their families have safe and effective transitional care experiences. The articles range from a summary of over two decades of research on the nurse-led Transitional Care Model (TCM) to recent pilot studies developing new models and tools to expand transitional care and care coordination interventions to new settings and populations.In Continuity of Care: The Transitional Care Model, Hirschman and members of the multiprofessional Transitional Care Model (TCM) team at the University of Pennsylvania detail the evidence supporting the impact of their nurse-led transitional care model on quality and cost outcomes for older adults with multiple chronic illnesses. The TCM has undergone rigorous testing over the past two decades and has consistently demonstrated reductions in hospitalizations and costs for Medicare beneficiaries at high risk for adverse outcomes. This well-recognized model has been implemented in hospitals and health systems including patientcentered medical homes across the United States. The nine core TCM interventions and tools developed to measure them are described in the paper. This latest summary of the body of TCM research and its translation into "real-world" health care systems is a testament to the importance of rigorous and continuous programs of research for defining and improving care coordination for vulnerable populations with complex care needs.DelBoccio and colleagues describe one hospital's experience in becoming a top performer in transitional care in Successes and Challenges in Patient Care Transition Programming. Spurred to improve transitional care by changes in the Affordable Care Act, Indiana University Health North Hospital launched new programs to enhance patient activation and health team performance in medication management and communication with post-acute providers. Their experience reinforces the importance of effective teamwork and continuous quality improvement in making meaningful improvements in the care transition experience and subsequent performance outcomes.Nurses across academic and clinical settings in Minnesota describe the implementation of two models of care coordination for children with medical complexity (CMC) in their article Pediatric Care Coordination: Lessons Learned and Future Priorities. Cady and colleagues designed the TeleFamilies Model and PRoSPer models of pediatric care coordination to overcome current challenges of integrating complex care for children in healthcare homes (HCH) and to address key components of their state's healthcare reform legislation. Examining the implementation of new care coordination models within the context of unfolding state healthcare reform is a critical aspect of this article. Both the TeleFamilies and PRoSPer models incorporate nurses as drivers of care coordination processes in concert with members of interprofessional teams. They involve different team members and the use of different technologies according to the needs of children and families in rural and urban HCHs. The results of initial model tests show improved family perceptions of their health care experience and provider communication. The authors suggest several opportunities for further evaluation of In their article Registered Nurse Care Coordination: Creating a Preferred Future for Older Adults with Muitimorbiditv. …