Module G: Transdisciplinary Team Care

CE Credits: 2.0


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.

Learning objectives: After completing this module the case manager will be able to:
» Discuss the evolving landscape of chronic care delivery
» Advocate for a transdisciplinary approach to effective discharge planning
» Review the scope of transdisciplinary interactions in HF management
» Describe the impact of socioeconomic factors
» Discuss national standards for culturally and linguistically appropriate services
» Review CM credentials, licensure, certification and practice standards

Advance your professional practice:: Case managers are positioned to guide HF patients through a variety of points of care, from the ER to home health care. By understanding the full breadth of the transdisciplinary team, and how the CM can interact with each team member, case managers can serve patients effectively.


Improve organizational performance: Since HF patients are at a high risk of rehospitalization, it is vital that every member of the transdisciplinary team learns to work together to support each other. That way, we can offer our HF patients tailored and consistent interventions at each step in treatment.