- Section 1 Ageing population and policy
- Section 2 Key concepts in care of older adults
- Chapter 14 A life course approach for understanding later life sustainability
- Chapter 15 Ageing, multimorbidity, and daily functioning
- Chapter 16 Comprehensive geriatric assessment: evidence
- Chapter 17 Comprehensive geriatric assessment
- Chapter 18 Engaging older patients in their treatment and care
- Chapter 19 Models of healthcare for older people
- Chapter 20 History taking and physical examination
- Chapter 21 Communication
- Chapter 22 Interprofessional team building and case management
- Chapter 23 Age-friendly environments and their role in supporting Healthy Ageing
- Chapter 24 Principles of medication management
- Chapter 25 Optimizing pharmacotherapy for older patients
- Chapter 26 Limitations in the evidence for safe and effective medications for older people
- Chapter 27 General principles of recovery and rehabilitation
- Chapter 28 The approach of dying and death, and the mourning process of the survivors
- Chapter 29 Legal and ethical issues in care of older adults
- Section 3 Principles and organization of care
- Section 4 Age-related biological changes, altered physiology, and vulnerability to diseases and chronic conditions
- Section 5 Geriatric syndromes in clinical practice
- Section 6 Nutrition and metabolism
- Section 7 Mobility disorders: prevention, impact, and compensation
- Section 8 Infections in older adults: epidemiology, pathophysiology, diagnosis, and management
- Section 9 Cancer: epidemiology, pathophysiology, diagnosis, and management
- Section 10 Vascular diseases: epidemiology, pathophysiology, diagnosis, and management
- Section 11 Neurological disorders: epidemiology, pathophysiology, diagnosis, and management
- Section 12 Cognitive decline and dementia in older adults: epidemiology, pathophysiology, diagnosis, and management
- Section 13 Mental health of older adults
- Section 14 Management of common medical conditions: epidemiology, pathophysiology, diagnosis, and management
- Section 15 Palliative medicine and end-of-life care
- Section 16 Healthy ageing
(p. 165) Interprofessional team building and case management
- Chapter:
- (p. 165) Interprofessional team building and case management
- Author(s):
Ellen Flaherty
, Michaela Halnon
, and Terry Fulmer
- DOI:
- 10.1093/med/9780198701590.003.0022_update_001
Update:
Information regarding the John A. Hartford Foundation Age-Friendly Health Systems and the Geriatric Interprofessional Team Transformation in Primary Care (GITT-PC) programmes has been added.
References have been updated, slight grammatical changes made, and Michaela Halnonadded as an author.
Interprofessional team care (ITC) and case management are essential to achieve the best patient-centred outcomes for complicated older adults with multiple comorbidities. Case management in geriatrics refers to a process of care coordination. Caring for complex geriatric patients with multiple chronic conditions requires the development and implementation of individualized, coordinated plans of care. Such plans of care often call for further evaluation, treatment, referrals, and patient or caregiver education, or both. Typically, this care coordination occurs in an interprofessional team of geriatric healthcare providers—which may include physicians, geriatric nurses, pharmacists, psychiatrists, therapists, and social workers. The components of good team care include effective communication, conflict resolution, understanding and respecting team member’s and responsibilities, and team governance. Formal training is necessary to achieve these skills. Providing efficient and effective team care is both challenging and critical in an environment of accountable care with a burgeoning over-85 population.
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- Section 1 Ageing population and policy
- Section 2 Key concepts in care of older adults
- Chapter 14 A life course approach for understanding later life sustainability
- Chapter 15 Ageing, multimorbidity, and daily functioning
- Chapter 16 Comprehensive geriatric assessment: evidence
- Chapter 17 Comprehensive geriatric assessment
- Chapter 18 Engaging older patients in their treatment and care
- Chapter 19 Models of healthcare for older people
- Chapter 20 History taking and physical examination
- Chapter 21 Communication
- Chapter 22 Interprofessional team building and case management
- Chapter 23 Age-friendly environments and their role in supporting Healthy Ageing
- Chapter 24 Principles of medication management
- Chapter 25 Optimizing pharmacotherapy for older patients
- Chapter 26 Limitations in the evidence for safe and effective medications for older people
- Chapter 27 General principles of recovery and rehabilitation
- Chapter 28 The approach of dying and death, and the mourning process of the survivors
- Chapter 29 Legal and ethical issues in care of older adults
- Section 3 Principles and organization of care
- Section 4 Age-related biological changes, altered physiology, and vulnerability to diseases and chronic conditions
- Section 5 Geriatric syndromes in clinical practice
- Section 6 Nutrition and metabolism
- Section 7 Mobility disorders: prevention, impact, and compensation
- Section 8 Infections in older adults: epidemiology, pathophysiology, diagnosis, and management
- Section 9 Cancer: epidemiology, pathophysiology, diagnosis, and management
- Section 10 Vascular diseases: epidemiology, pathophysiology, diagnosis, and management
- Section 11 Neurological disorders: epidemiology, pathophysiology, diagnosis, and management
- Section 12 Cognitive decline and dementia in older adults: epidemiology, pathophysiology, diagnosis, and management
- Section 13 Mental health of older adults
- Section 14 Management of common medical conditions: epidemiology, pathophysiology, diagnosis, and management
- Section 15 Palliative medicine and end-of-life care
- Section 16 Healthy ageing