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Improving Care Coordination of Patients With Chronic Diseases

      Highlights

      • Care coordination is a critical strategy to promote patient safety and well-being.
      • Clinicians can initiate relationships with community agencies to develop referral guidelines.
      • Clinicians can create a referral network of specialists with whom the nurse practitioner is familiar.
      • Clinicians can strive toward a shared health record to transfer, communicate, and track health information.
      • Clinicians should be attuned to the care coordination process to assess the quality of care and optimize patient health outcomes.

      Abstract

      Patients with chronic conditions often encounter challenges during care transitions to specialists or other facilities. The Care Coordination Model is a method of examining care transitions that enables the multidisciplinary team to integrate collaboration between clinical care areas, resulting in improved health care quality. Challenges faced by the clinicians are identified, and strategies to address these issues are described to foster a culture of safety and quality care.

      Keywords

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      Biography

      Hsiao-Hui Ju, DNP, RN, FNP-BC, CNE, is an assistant professor at The University of Texas Health Science Center Cizik School of Nursing, Houston, and can be contacted at [email protected] .