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Care Coordination and Transitions in Care 

Care Coordination and Transitions in Care
Chapter:
Care Coordination and Transitions in Care
Author(s):

Finly Zachariah

, Brenda Thomson

, Matthew Loscalzo

, and Laura Crocitto

DOI:
10.1093/med/9780190201708.003.0030
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date: 27 January 2020

The United States is in a healthcare crisis, with an influx of patients, unsustainable growth and expenditures in healthcare, significant shortages in healthcare professionals, and patients and families who are navigating a complex and changing system. Patient-centered communication conducted in a shared decision-making model enables patient values and goals to be aligned with therapy. Transitions between care settings are pivotal moments for the patient and family; if done poorly, they can increase confusion regarding the plan of care and put patients at risk. The formation of interprofessional teams that work across settings is crucial to ensure that transitions include patient education, follow-up, and support. A model in practice at City of Hope National Medical Center is highlighted to depict an exemplary care coordination pathway. This model illustrates how time-sensitive, tailored, educational information, embedded in interprofessional team communication, can enhance transitions in care and lead to quality patient-centered outcomes.

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