Learning Outcomes
By the end of this section, you should be able to:
- 30.3.1 Describe key responsibilities and competencies of community health nurses in care coordination.
- 30.3.2 Incorporate evidence-based intervention to improve outcomes and safety during the transition of care between care areas.
- 30.3.3 Discuss strategies to improve safety and continuity of care for vulnerable clients.
- 30.3.4 Describe how the nurse can contribute to enhanced quality through care coordination and transition management.
- 30.3.5 Explain the role electronic health, mobile health, and telehealth systems play in the coordination and transition of care.
- 30.3.6 Describe a collaborative approach in coordinating care with other health care professionals and community partners.
The role of the community health nurse (CHN) in transitional care is integral to supporting clients through the often-complex process of moving between care settings, ensuring continuity of care, and promoting optimal health outcomes (see Table 30.5). While nurses do not often complete all the roles in this process, they are often the central person with the most client contact. This allows them to be sure all the areas are covered for the client.
| Role | Description | Client Example |
|---|---|---|
| Discharge Planning | CHNs assist in developing comprehensive discharge plans, ensuring clients have the resources and support they need when transitioning from a hospital to home or another health care facility. They coordinate with physicians, social workers, and family members to ensure that the client’s needs will be met after discharge. | Mr. Aguilar has been discharged from the hospital following a stroke. The CHN coordinates with the hospital team, Mr. Aguilar, and his family to create a comprehensive discharge plan that includes physical therapy appointments, home care assistance, and regular medical checkups. |
| Client Education | CHNs educate clients and their families about the client’s condition, medications, necessary lifestyle changes, and self-care techniques. They also help them understand the care plan and what to expect during the transition. | The CHN educates Mr. Aguilar and his family about stroke recovery, including lifestyle modifications such as diet, exercise, and stress management, and taking prescribed medications. |
| Medication Reconciliation | CHNs play a vital role in reviewing and reconciling medications when clients move between care settings, ensuring they understand their medication regimen, and reducing the risk of medication errors or adverse events. | The CHN reviews all of Mr. Aguilar’s prescribed medications, checking for potential drug interactions and ensuring Mr. Aguilar and his family understand the dosages and timing for each. |
| Coordination of Care | CHNs help facilitate communication among the care team, the client, and their family, which is crucial for a smooth transition. | The CHN coordinates Mr. Aguilar’s care, communicating with his primary care doctor, physical therapist, and home care aide to ensure a holistic approach and seamless transition to home. |
| Follow-Up Care | CHNs often conduct follow-up visits or calls to monitor the client’s health status, ensure they’re adhering to their care plan, and address any health concerns or changes in condition. These follow-ups can help prevent unnecessary hospital readmissions. | The CHN visits Mr. Aguilar at his home a week after his discharge to assess his recovery progress, ensure his adherence to the care plan, and address any new health concerns. |
| Home Safety Evaluations | CHNs can perform home safety evaluations, identifying potential hazards and recommending modifications to support the client’s health, safety, and independence. | Upon Mr. Aguilar’s return home, the CHN assesses his living environment for potential hazards like loose rugs or poor lighting that could increase his risk of falls and suggests necessary modifications. |
| Linkage to Community Resources | CHNs connect clients with community resources that can support their health and well-being, such as meal delivery services, transportation assistance, support groups, and rehabilitation services (Figure 30.4). | The CHN connects Mr. Aguilar with a local meal delivery service, a transportation service for his therapy appointments, and a local support group for stroke survivors. |
| Advocacy | CHNs advocate for clients’ needs and rights during transitions, ensuring they receive the care they need, and their preferences are respected. | The CHN advocates for Mr. Aguilar’s needs and preferences, such as his wish to have a family member present at medical appointments, ensuring these are communicated to and respected by the rest of his care team. |
| Documentation | CHNs ensure all aspects of the transition care process are documented to keep all involved parties informed and facilitate communication among health care professionals. | The CHN documents all aspects of Mr. Aguilar’s transition care process, including his medical history, care plan, medication regimen, changes in health status, and interactions with other care providers, ensuring all information is up-to-date and accessible to the entire care team. |
Case Reflection
The Role of the Community Health Nurse in Transitional Care
The following scenario continues following Mrs. Johnson. Read the scenario, and then respond to the questions that follow.
Before discharge, Mrs. Johnson received education on her condition and her care plan. She also received a follow-up call from a registered nurse two days after her discharge, during which she reported feeling well and having no health or other concerns.
One week later, Mrs. Johnson’s community health nurse visited her home for a follow-up visit. The nurse found that Mrs. Johnson had been experiencing shortness of breath and fatigue, which she had not reported during her follow-up call. Upon further assessment, the nurse found that Mrs. Johnson’s blood pressure was elevated, and there were changes in her lung sounds. The nurse discovered that Mrs. Johnson had not been following her prescribed diet and medication regimen. The nurse notified Mrs. Johnson’s physician, who readjusted the medication regimen and referred Mrs. Johnson to a registered dietitian. With appropriate care and follow-up, Mrs. Johnson’s condition improved, and she was able to maintain her health and avoid readmission.
- How might a lack of communication, such as Mrs. Johnson’s failure to report her symptoms, affect the effectiveness of the transitional care plan?
- What are some of the challenges that the community health nurse may face when conducting a home visit for clients like Mrs. Johnson? How can these challenges be addressed to ensure optimal client outcomes?
- What strategies could be implemented to encourage client adherence to their prescribed medication and diet regimen? How can the community health nurse support clients in adjusting to their new care routines?
Community Health Nurses’ Role in Care Coordination
CHNs play a vital role in care coordination. They provide health care services to individuals, families, and groups within the community, often focusing on prevention, promotion, and maintenance of health. Table 30.6 summarizes their key responsibilities and competencies in care coordination. These responsibilities require a range of competencies, including strong communication skills, leadership abilities, critical thinking, problem-solving, adaptability, and a solid understanding of public health principles and nursing best practices.
| Client Assessment | CHNs assess the health needs of individuals, families, or communities. They identify potential health risks and work toward mitigating these risks through education and direct care. |
| Health Education and Promotion | CHNs educate clients and community members on healthy behaviors and self-care skills, with the goal of promoting a healthy lifestyle and preventing disease. They also provide information about local resources and health services. |
| Care Planning and Case Management | CHNs develop and implement care plans based on assessments. They manage cases, coordinating services across different health care providers and community resources, to ensure clients receive comprehensive care that addresses their unique health needs. |
| Advocacy | CHNs advocate for individual and community health needs, helping clients navigate the health care system, understand their rights, and access necessary resources and services. |
| Collaboration | CHNs work collaboratively with other health care providers, social workers, educators, and community organizations to improve the overall health of the community. This includes attending multidisciplinary team meetings and contributing to community health strategies. |
| Monitoring and Evaluation | CHNs monitor the health status of clients and communities, evaluate the effectiveness of interventions, and adjust care plans as needed. They also identify trends and potential gaps in care and work to address them. |
| Cultural Competency | CHNs must understand and respect the diverse cultural backgrounds, beliefs, and values of their clients. They incorporate cultural considerations into care planning and delivery, fostering a more individualized and effective approach to care. |
| Research and Evidence-Based Practice | CHNs apply evidence-based practices and use research to inform their care strategies. They may also participate in community health research to further knowledge and improve care services. |
| Ethical Practice | CHNs must adhere to professional nursing ethics and maintain client privacy and confidentiality at all times. |
Evidence-Based Interventions
Transition of care between different care areas is a critical time for clients, and evidence-based nursing interventions can help improve outcomes and enhance client safety during this process. Here are some interventions supported by evidence:
- Effective provider communication (universal transfer tool)
- Health information technology (continue work on interoperability and compatibility)
- Medication reconciliation
- Ensuring access to care after discharge
- Communication of health care information
- Follow-up telephone calls
- Post-discharge home visits
Effective Provider Communication
Effective communication between health care providers plays a vital role in ensuring a seamless transition for clients between different health care settings. Unfortunately, challenges arise due to incomplete health information and the absence of a universally accessible electronic health record (EHR). These limitations impede the ability of acute care providers to access records from ambulatory care and community pharmacy settings, especially when the inpatient provider differs from the primary care provider. Consequently, miscommunication can persist following discharge from the acute care setting, as the primary care provider may not receive comprehensive documentation of the client’s diagnostic tests, procedures, and medication changes during hospitalization.
It is crucial to acknowledge that hospital discharge summaries have been identified as primary sources of communication errors, underscoring the need for improvements in this area (Mansukhani et al., 2015). Without adequate information during transfers, it is difficult to maintain continuity of care. The National Transitions of Care Coalition (NTOCC) has recognized the barriers to direct communication between health care providers during client transitions and supports the use of a universal transfer tool to facilitate the movement of clients.
A universal transfer tool can be instrumental in supporting care coordination by standardizing the exchange of client information during care transitions. This tool or form helps ensure that essential information, such as client medical history, current medications, diagnoses, and care instructions, is accurately and comprehensively communicated between different health care settings and providers (Mansukhani et al., 2015). It can facilitate efficient and effective handoffs, reducing the risk of miscommunication, medical errors, and adverse events.
Moreover, a universal transfer tool enables health care professionals to have a standardized format for documenting and transmitting critical client information, making it more accessible and understandable across different health care personnel and settings. This enhances continuity of care, enables prompt decision-making, and promotes collaborative care planning.
Medication Reconciliation
Making sure medications are reconciled accurately is crucial to the transition process. The Institute for Health Care Improvement explains that medication reconciliation involves creating a precise list of all the medications a client is taking, including the names of the drugs, their strengths, how often they are taken, and how they are administered. This list is then compared to the orders given by the health care provider during admission, transfer, or discharge.
Throughout a client’s care, clinicians may stop, pause, or adjust medications that were previously prescribed to manage or optimize treatment. This makes medication reconciliation during discharge necessary to prevent errors and ensure effective communication for post-acute care. This process involves repeating the initial reconciliation done at admission right before the client is discharged or transferred to another health care setting. The medication list is checked again for accuracy and completeness, and it is shared with the next level of care along with any new prescriptions and written instructions.
The accuracy and completeness of the discharge medication list largely depend on how accurately and completely the medication reconciliation was done at the time of admission. If the list of medications taken at home is incomplete or inaccurate, discrepancies will arise after discharge. For example, studies have found that clients’ discharge medication lists frequently contain at least one discrepancy (Caleres et al., 2020; Lalonde, 2008; Mueller et al., 2023). Tomlinson et al. (2020) noted that interventions that best support older clients’ medication continuity are those that bridge transitions; these also have the greatest impact on reducing hospital readmission. Interventions that included self-management, telephone follow-up, and medication reconciliation activities were most likely to be effective. Medication reconciliation activities are particularly important as having incorrect information can lead to inappropriate transitions of care and is a significant cause of rehospitalizations among older adults (Figure 30.5).
Access to Care after Discharge
Caregivers must ensure that clients have access to necessary medications and durable medical equipment such as nebulizers, walkers, wheelchairs, and home oxygen. It’s also crucial for clients to properly fill, pick up, and take their medications. Weir et al. (2020) found that almost half of all clients did not adhere to some or all changes made to their medications at hospital discharge and that clients who did not adhere to any of their medication changes had a significantly higher risk of adverse events compared to those who did.
Access to a pharmacy is also important for clients to adhere to their medication regimen after discharge. Research has shown that fewer clients obtained their medications when given a prescription compared to when they were given the medications directly during a hospital visit. There are programs that aim to improve medication access and reduce readmission rates. For example, the Medication REACH program provided uninsured clients with free medications for the first 30 days after discharge. A study conducted at Einstein Medical Center in Philadelphia found that clients in the program had a lower readmission rate compared to those in the control group (American Society of Health-System Pharmacists and American Pharmacists Association, 2013).
Some health care facilities have started delivering medications to clients at their bedside before discharge (Katz et al., 2020). This approach, along with follow-up phone calls a few days later, has been found to significantly reduce readmission rates compared to standard care (Katz et al., 2020). Bedside medication delivery can help overcome initial barriers to medication access and address any insurance or medication-related issues before the client leaves the hospital.
Communication of Health Care Information
Sharing health care information with clients and their families can be challenging due to various factors like physical limitations (e.g., hearing, vision, or cognitive impairments) and low health literacy. It’s important to note that only around 12 percent of Americans have a high level of health literacy, and more than one-third struggle with basic health tasks, such as understanding prescription labels (Lopez et al., 2022). Individuals with poor health literacy or cognitive impairments may have difficulty reading and comprehending written health information. This can lead to problems like not following discharge instructions or medication regimens as well as failing to follow up with health care providers after leaving the hospital.
To address these challenges, health care providers and CHNs should allocate sufficient time to interact with clients and identify any barriers they may face, such as low health literacy or cognitive deficits. This allows providers to find effective ways to overcome these barriers and improve communication with these clients.
Follow-Up Telephone Calls and Home Visits
Programs like Medication REACH and BOOST have introduced follow-up telephone calls to improve transitions of care. These calls focus on important aspects like the client’s medication list, any side effects experienced, their overall health, and any challenges they face in filling their prescriptions. The timing of these calls varies, ranging from 24 to 72 hours after discharge. The aim is to promptly address client needs, resolve any issues during the transition between care settings, and assess their ability to self-manage their health. However, a systematic review found that follow-up telephone calls alone didn’t have a significant impact on readmission rates (Crocker et al., 2012). Van Spall et al. (2019) found that making the follow-up part of a patient-centered intervention that included follow-up calls, nurse-led home visits, and interprofessional clinics were associated with a reduction in readmissions and death in heart failure clients.
Many programs, including the Veterans Affairs (VA) and Accountable Care Organizations (ACO), have also adopted post-discharge home visits by different health care providers (Pedersen et al., 2017). These visits allow providers to monitor vital signs, check laboratory test results, manage medication usage, provide additional health education, and identify new problems. Additionally, telehealth services (or telemedicine) can remotely monitor a client’s health status at home and transmit this information to health care providers. This enables adjustments to drug regimens as necessary, potentially preventing rehospitalizations. Srivastava et al. (2019) found that personalized and client-centered home telehealth monitoring in heart failure clients was successful in reducing admissions without an increase in outpatient visits or hospital readmission in VA clients (Figure 30.6). During the COVID-19 pandemic, studies highlighted a novel and sustained shift to telehealth that they found reduced barriers to accessing high-value services for older adults during transition periods like discharge to home (Anderson et al., 2021).
Strategies to Improve Safety and Continuity of Care for Vulnerable Clients
Care coordination is a critical aspect of health care for vulnerable clients, particularly those with behavioral health needs and those in need of end-of-life/palliative care. Effective care coordination strategies are essential to ensure that these clients receive timely and appropriate services that meet their unique needs. Strategies such as collaborative care models, care teams, and the use of EHRs can help facilitate effective care coordination, ultimately resulting in improved outcomes for vulnerable clients.
Clients transitioning for end-of-life or palliative care services require specialized care that addresses their physical, emotional, and spiritual needs. Effective care coordination for these clients involves ensuring access to appropriate services, including hospice care, counseling services, and pain management. It also involves identifying and addressing cultural and spiritual needs to ensure that care is provided in a compassionate and respectful manner (Reeves et al., 2020).
Transitional care for behavioral health discharges poses a challenge due to the vulnerable period that clients experience during the transition from acute mental health inpatient to community care. Clients discharged from behavioral health hospitals may experience additional risks and anxiety during this period as they adjust to new environments and face potential challenges in accessing follow-up care. Additionally, clients with mental health conditions may have complex care needs that require specialized support and resources, which may not be readily available in the community.
Evidence-based discharge planning for behavioral health clients involves using strategies that have been shown to improve client outcomes and reduce readmissions. This includes conducting a comprehensive needs assessment, collaborating with clients and their families to develop a client-centered care plan, coordinating care and services with community providers, and ensuring timely follow-up appointments and communication between inpatient and outpatient providers (National Institute of Mental Health, 2019).
Effective discharge planning also involves providing clients with education and resources to manage their condition, including medication management and crisis support, and involving family members or other caregivers in the transition process (National Alliance for Suicide Prevention, 2019). Research has shown that evidence-based discharge planning can improve client outcomes and reduce readmissions for clients with mental health conditions (Pincus et al., 2016). By providing clients with the support and resources they need to manage their condition, evidence-based discharge planning can help clients successfully transition from inpatient to outpatient care and improve their overall quality of life.
Quality Through Care Coordination and Transition Management
The main goal of transitional care models is to create a care plan that meets the specific needs of each client and provides continuous care across different settings. This involves organizing practical arrangements, educating clients and their families, and coordinating services during transitions.
Nurses are often at the forefront of quality improvement initiatives. They can actively participate in interprofessional teams, contribute to the development of care protocols and standards, and provide valuable feedback based on their firsthand experiences. Nurses are directly responsible for monitoring and assessing clients and performing immediate interventions to reduce risk or prevent medical complications. Nurses also oversee other care providers, such as certified nursing assistants (CNAs), licensed practical nurses (LPNs), patient care technicians, caregivers, and more. A nurse educates clients and family members regarding post-hospital care before discharge. Nurses’ keen observations and drive for client safety at each of these intersections can contribute to quality improvement.
Quality improvement initiatives around transitions of care must be interprofessional and can be led by nurses. The areas for improvement can be around the care planning and include the following steps that could be optimized:
- Assessment: The transitional care nurse, who specializes in caring for clients with chronic conditions like heart disease, stroke, COPD, cancer, and diabetes, begins by evaluating the client’s health status and behaviors, the level of care and support needed, and their health goals.
- Accumulating Data: The nurse collects all the necessary information and enters it into the health care provider’s electronic medication administration record (eMAR) system. This data is used to develop a personalized care plan for the client.
- Access: Authorized health care professionals like doctors, nurses, and social workers can access the care plan to provide evidence-based daily care to ensure the client’s optimal health upon discharge.
- Appointments: The transitional care nurse continues to provide care even after the client leaves the hospital. This includes home visits or remote appointments for about 12 sessions, ensuring a smooth transition from the hospital to the home environment.
- Adjustments: The nurse remains available via telephone for clients and their families to seek additional medical advice when needed. This is crucial for identifying changes in the client’s health condition and making necessary adjustments to their care.
The box below provides an example of a quality improvement project.
Quality Improvement Project Example
A standardized discharge process for clients transitioning from the hospital to their homes or other care settings is one example of a quality improvement project that focuses on transitional care. This project aims to improve communication, reduce readmission rates, and ensure seamless transitions for clients.
- Project Goal: The goal is to develop and implement a standardized discharge process that promotes effective communication, client education, and coordination of care during the transition from hospital to home or other settings.
- Interprofessional Team: A team of health care professionals, including nurses, physicians, case managers, pharmacists, and quality improvement experts, is formed to lead the project.
- Gap Analysis: The team conducts a thorough assessment of the current discharge process to identify areas for improvement. This may involve reviewing existing protocols, interviewing staff, and analyzing client feedback.
- Development of Standardized Protocols: Based on the findings, the team develops standardized protocols and guidelines for the discharge process. This includes clear instructions for medication reconciliation, client education materials, follow-up appointment scheduling, and communication with primary care providers.
- Staff Education and Training: The team provides comprehensive education and training sessions for health care staff involved in the discharge process. This ensures that all team members understand their roles, responsibilities, and the new protocols.
- Implementation and Monitoring: The standardized discharge process is implemented and closely monitored for effectiveness. Key metrics to monitor may include readmission rates, client satisfaction scores, and adherence to the protocols.
- Continuous Improvement: Regular meetings and feedback sessions are conducted to evaluate the project’s progress and identify areas for further improvement. The team gathers input from clients, families, and staff to refine the process and address any issues that arise.
- Data Analysis and Reporting: The team analyzes the data collected throughout the project to assess its impact on readmission rates, client outcomes, and health care utilization. The findings are reported to concerned parties, including hospital leadership and relevant departments.
- Sustainability and Spread: Once the project has demonstrated positive results, efforts are made to sustain the standardized discharge process and spread it to other departments or health care facilities within the organization. This may involve creating implementation toolkits, sharing best practices, and providing ongoing support and education.
By focusing on improving the transitional care process through standardized discharge protocols, this quality improvement project aims to enhance client safety, reduce readmissions, and promote better coordination and continuity of care during care transitions.
HIT in Care Coordination
Evidence-based approaches using health information technology (HIT) to aid in care coordination have been developed (Marcotte et al., 2015). HIT may provide a more timely and seamless transfer of information between providers and health care settings compared with traditional paper forms. Electronic health records (EHRs) are helpful tools that can enhance providers’ access to health information, reduce redundant tests and repetitive medical histories, and improve communication between health care professionals.
Health information technology, including EHRs, mobile health (mHealth), and telehealth systems, plays a vital role in enhancing the coordination and transition of care.
- EHRs: EHRs are digital versions of clients’ medical records that provide a centralized repository of health information. They enable health care providers across different settings to access and share client data, ensuring seamless coordination and transitions. EHRs allow for quick retrieval of vital information, such as medical history, medication lists, lab results, and allergies, facilitating more efficient and informed decision-making.
- Care Coordination Platforms: HIT platforms designed for care coordination allow health care providers to collaborate and exchange information about a client’s care plan, progress, and treatment goals. These platforms enable real-time communication among the care team, supporting effective care coordination and reducing the risk of miscommunication or duplicated efforts.
- mHealth Applications: Mobile health applications, accessible on smartphones or tablets, offer clients and health care providers various tools to manage and monitor health. These applications can facilitate self-care and client engagement by providing educational resources, medication reminders, symptom tracking, and appointment scheduling. Clients can share data collected through mHealth apps with their health care providers, ensuring continuity and coordination of care (Debon et al., 2019).
- Telehealth Systems: Telehealth involves the use of technology to provide remote health care services, including virtual consultations, remote monitoring, and telemedicine. Telehealth systems enhance care coordination and transitions by enabling health care providers to remotely assess and monitor clients, consult with specialists, and offer follow-up care. This reduces the need for unnecessary hospital visits and facilitates ongoing care from the comfort of clients’ homes.
- Interoperability and Data Exchange: Interoperability refers to the ability of different health care systems and technologies to exchange and interpret data seamlessly. HIT systems that support interoperability allow for the secure sharing of client information between different health care providers and settings. This facilitates care coordination and transitions, as relevant data can be accessed by authorized personnel at the right time, leading to more informed decision-making and continuity of care.
- Decision Support Systems: HIT systems often incorporate decision support tools that provide evidence-based guidelines, alerts, and reminders to health care providers. These tools help ensure adherence to best practices and enhance care coordination by supporting consistent and standardized care across different settings. Decision support systems can prompt health care providers with relevant information during care transitions, reducing the likelihood of errors or omissions.
Theory in Action
Transitions of Care
As clients transition from one health care provider to another, their information needs to follow them. Health information exchanges (HIE) enable the fast, private, and secure movement of client information between health care organizations. The video “Transitions of Care” highlights how the Massachusetts statewide HIE (Mass HIway) enables this process.
Watch the video, and then respond to the following questions.
- How does the implementation of a health information exchange (HIE) impact the continuity of care for clients as they transition between health care providers? Consider the benefits and challenges associated with this system in ensuring that client information follows them seamlessly.
- In what ways does an HIE contribute to client safety and reduce medical errors during transitions of care? Reflect on the potential risks and benefits of sharing client information electronically across health care organizations.
- How can the use of an HIE improve the overall efficiency and effectiveness of health care delivery? Explore the potential impact of HIEs on reducing duplicate testing, enhancing care coordination, and facilitating better-informed clinical decision-making.
Collaborative Approaches in Coordinating Care
A collaborative approach in coordinating care with other health care professionals and concerned parties is essential to improve client outcomes and quality of care. Collaboration involves the integration of knowledge, skills, and expertise from multiple health care providers, including physicians, nurses, pharmacists, and other allied health professionals. According to Reeves et al. (2017), collaboration in health care requires a shared understanding of client needs, effective communication, mutual trust, and respect among health care providers.
One example of a collaborative approach in health care coordination is the use of interprofessional teams. Interprofessional teams involve health care providers from different disciplines working together to provide comprehensive care to clients. According to Bachynsky (2019), interprofessional teams can improve client outcomes, reduce health care costs, and enhance the quality of care. Interprofessional teams can include physicians, nurses, pharmacists, social workers, and other health care professionals who work collaboratively to develop and implement care plans for clients (Figure 30.7).
Another example of a collaborative approach in health care coordination is the use of care coordination platforms (see the box below). Care coordination platforms provide a centralized location for health care providers to communicate and collaborate on client care (Duan-Porter et al., 2020). These platforms can improve care coordination and reduce the risk of miscommunication or duplication of services. Clients can also use care coordination platforms to communicate with their health care providers, access educational resources, and manage their health information.
Collaborative Care Coordination Example
John Smith is a 65-year-old client who recently had a heart attack and is being discharged from the hospital. His care requires collaboration among different health care workers for effective care coordination.
- Hospital Physician: The hospital physician who treated John during his hospital stay communicates John’s medical condition, treatment plan, and medication prescriptions to the care team for a smooth transition.
- Cardiologist: John’s cardiologist, who specializes in heart conditions, reviews John’s medical history, test results, and treatment plan. They collaborate with the care team to ensure appropriate follow-up care, including medication adjustments, lifestyle modifications, and further cardiac evaluations if necessary.
- Primary Care Physician (PCP): John’s PCP plays a vital role in his care coordination. The PCP is notified about John’s hospitalization and collaborates with the hospital physician and specialists to receive updates on John’s condition, treatment, and recommendations for ongoing care.
- Pharmacist: The pharmacist ensures that John understands his prescribed medications, including dosage, frequency, and potential side effects. They collaborate with the care team to resolve any medication-related concerns, such as drug interactions or allergies, and coordinate medication refills.
- Home Health Nurse: A home health nurse visits John after his discharge to assess his recovery, provide education on post–heart attack care, monitor vital signs, and ensure proper wound care if necessary. The nurse collaborates with the hospital physician and PCP to report any changes in John’s condition and adjust the care plan as needed.
- Physical Therapist: A physical therapist works with John to develop an exercise and rehabilitation program tailored to his condition. They collaborate with the care team to monitor John’s progress, make appropriate adjustments to the therapy plan, and ensure continuity of care.
- Case Manager/Social Worker: The case manager or social worker acts as a coordinator, ensuring effective communication among all health care team members. They assess John’s social and support needs, provide resources for community services, and coordinate follow-up appointments and tests.