Improving Outcomes in Heart Failure. Mod G. Transdisciplinary Team
This module finishes the HF course by looking at the ways that case managers—who interact with heart failure patents at many steps along the disease path—can best coordinate their efforts with the transdisciplinary team of healthcare providers. It begins by looking at one overall goal of the process—to avoid preventable readmissions to the hospital—and how a careful discharge process plays a role in that (such as, making sure the patient has a well-timed follow-up appointment with the appropriate team member). Next, using a case study, the module then examines how the case manager can support the patient’s medication adherence, perhaps by walking a patient through coverage issues, to make the medication regimen simpler and more affordable. The model then finishes by exploring the importance of culturally and linguistically appropriate services (CLAS), professional credentials and licensure, all of which can help case managers maximize their effectiveness within the transdisciplinary team.