Interprofessional Collaboration and Care Coordination (Hoffman Sullivan – Davis Advantage for Medical-Surgical Nursing, Third Edition)

Vocabulary flashcards covering key terms and concepts from Chapter 2: Interprofessional Collaboration and Care Coordination, including care transitions, team roles, and patient education strategies.

Interprofessional Collaboration

Partnership between the healthcare team and the patient, including shared decision making, effective communication, mutual respect, and shared responsibility.

open ended questions

questions that encourage detailed responses and dialogue, fostering deeper understanding and communication in clinical settings.

Care Coordination

Deliberate organization of patient care activities and information across settings to achieve safe, timely, efficient, and patient-centered outcomes.

Transitional Care Model

A patient-centered approach that manages transitions from acute to post-acute settings, aiming to avoid poor outcomes, ensure continuity of care, and facilitate safe transitions for chronically ill adults with comorbidities; managed by a transitional care nurse.

Care Transitions Program

Program using transitions coaches to assess a patient’s unique situation, provide education, coaching, and encouragement, and reduce rehospitalization.

Project RED (Re-Engineered Discharge)

A discharge optimization initiative designed to improve discharge planning and reduce readmissions.

Project BOOST (Better Outcomes for Older Adults Through Safe Transitions)

A discharge-transition program aimed at improving outcomes for older adults through safe transitions.

8P Scale

A screening tool used in discharge planning to identify patient needs and risks before transition.

Comprehensive discharge instruction tool

A standardized tool used to provide complete, understandable discharge instructions to patients.

Patient-Centered Medical Home (PCMH)

A model of care for patients with multiple comorbidities emphasizing patient-centered, interprofessional coordination, and accessible care.

Guided Care Program

A program aiming to improve patient outcomes and quality while reducing costs through long-term nursing interventions.

Transforming Care at the Bedside (TCAB)

Initiative focused on safe and reliable care, nurse retention, vitality and teamwork, patient-centered care, interprofessional team effectiveness, value-added processes, and transformational leadership.

Teach-back

A patient education method where information is explained in plain language and the patient is asked to repeat back what was learned, ensuring understanding in a non-shaming way.

Nurse as Patient Care Coordinator

Nurse role described by the American Academy of Ambulatory Care Nursing; coordinates care and transitions using a care coordination and transition management model.

Interprofessional Care Team (ICT)

A collaborative team comprising registered nurses, unlicensed assistive personnel, providers, rehabilitation therapists, respiratory therapists, dietitians, case managers, pharmacists, and ad-hoc members who collaborate for patient care.

Home Care Coordinator (HCC)

A member of the ICT who develops and coordinates the home-care plan and arrangements after discharge.

Transition Guide

A member of the ICT who guides the patient through transitions between care settings.

Case Manager

Professional who oversees the patient’s care plan, coordinates services, and facilitates transitions across settings.

Pharmacist

Medication specialist who reviews medications, provides counseling, and supports safe transitions and adherence.

Dietitian/Nutritionist

Nutrition professional who plans and supports dietary needs during transitions and recovery.

Ad-Hoc Members

Supplementary ICT members such as interpreters, chaplains, legal counsel, palliative care coordinators, substance abuse counselors, and post-discharge call nurses.

Interpreter

A person who translates information for non-English-speaking patients to ensure understanding.

Palliative Care Coordinator

ICT member who coordinates palliative and end-of-life care planning as needed.

Social Worker

Advocate and coordinator who assists with psychosocial needs, discharge planning, and community resources.

5 Rights of Delegation

Five criteria for delegating tasks: Right task, Right circumstance, Right person, Right direction/communication, and Right supervision/evaluation.