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Interprofessional team building and case management 

Interprofessional team building and case management
Chapter:
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.

Updated on 27 August 2020. The previous version of this content can be found here.
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date: 23 October 2021

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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