title: Integrated Transitions of Care for Patients With Rare Pulmonary Diseases.
abstract: OBJECTIVE
  Many continuing education (CE) resources are available to support case management professionals in developing competencies in transitions of care (TOC) that apply generally across disease areas. However, CE programs and tools are lacking for advanced TOC competencies in specific disease areas. This article describes 2 projects in which leading TOC, case management, and CE organizations collaborated to develop CE-accredited interdisciplinary pathways for promoting safe and effective TOC for patients with rare pulmonary diseases, including pulmonary arterial hypertension (PAH) and idiopathic pulmonary fibrosis (IPF).
  
  
  METHODS
  The interdisciplinary pathways apply to PAH and IPF case management practice and TOC across settings that include community-based primary care and specialty care, PAH or IPF centers of expertise, acute care and post-acute settings, long-term care, rehabilitation and skilled nursing facilities, and patients' homes.
  
  
  CONCLUSIONS
  Both PAH and IPF are chronic, progressive respiratory diseases that are associated with severe morbidity and mortality, along with high health care costs. Because they are relatively rare diseases with nonspecific symptoms and many comorbidities, PAH and IPF are difficult to diagnose. Early diagnosis, referral to centers of expertise, and aggressive treatment initiation are essential for slowing disease progression and maintaining quality of life and function. Both the rarity and complexity of PAH and IPF pose unique challenges to ensuring effective and safe TOC. Expert consensus and evidence-based approaches to meeting these challenges, and thereby improving PAH and IPF patient outcomes, are presented in the 2 interdisciplinary TOC pathways that are described in this article.
  
  
  CONCLUSIONS
  In coordinating care for patients with complex pulmonary diseases such as PAH and IPF, case managers across practice settings can play key roles in improving workflow processes and communication, transition planning, coordinating TOC with centers of expertise, coordinating care and TOC for patients with comorbidities, providing patient and caregiver education, promoting engagement between patients and the team, advancing the care plan, and improving ongoing adherence to treatment in order to maximize the patient's pulmonary function. Details regarding these interprofessional roles and responsibilities are provided in the full interdisciplinary TOC pathways for PAH and IPF.
authors.affiliation: Kathleen Moreo, BSN, BHSA, RN-BC, CCM, CDMS, is CEO and founder of PRIME, a 22-year-old independent medical education company and accredited provider of continuing education for federal, government, closed system, and commercial supporters. In 2016, Ms Moreo was awarded the Alliance for Continuing Education in the Health Professions (ACEhp) Leadership Award as well as the Alliance Distinguished Leadership Award. She was also awarded the ACEhp William Campbell Felch Award for Research in Continuing Education. She is a past president of the Case Management Society of America and has authored many peer-reviewed journal articles as well as online and print books on case management, care coordination, and transitions of care. Cheri Lattimer, BSN, RN, is Executive Director for the National Transitions of Care Coalition (NTOCC). Her leadership in quality improvement, case management, care coordination, and transitions of care is known on the national and international landscape. Her work has been featured in several publications, including Professional Case Management, The Healthcare Executive, Dorland's Case in Point, and Seniority. She was a contributor and reviewer for the Case Management Society of America Core Curriculum for Case Management and The Integrated Case Management Manual. James E. Lett, MD, CMD, is Medical Director of Avar Consulting, Inc., in Rockville, MD. He also serves as a member of the Board of Directors of the National Board for the National Transitions of Care Coalition (NTOCC). Dr. Lett served on a CMS workgroup to revise the survey manual for nursing homes, and he recently cochaired the national workgroups that produced the transitions of care pathways for both pulmonary arterial hypertension and idiopathic pulmonary fibrosis featured in this article. Dr. Lett is a past president of the American Medical Directors Association. Cherilyn L. Heggen-Peay, PhD, is a senior medical writer at PRIME. She was instrumental in organizing the national workgroup that resulted in the interdisciplinary transitions of care pathway for pulmonary arterial hypertension that is described in this article. Dr. Heggen-Peay was a contributing author for the pathway for pulmonary arterial hypertension. Laura Simone, PhD, is a senior medical writer at PRIME. She was instrumental in organizing the national workgroup that resulted in the interdisciplinary transitions of care pathway for idiopathic pulmonary fibrosis that is described in this article. Dr. Simone was a contributing author for the pathway for idiopathic pulmonary fibrosis.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Moreo
authors.forename: Cheri
authors.initials: C
authors.lastname: Lattimer
authors.forename: James E
authors.initials: JE
authors.lastname: Lett
authors.forename: Cherilyn L
authors.initials: CL
authors.lastname: Heggen-Peay
authors.forename: Laura
authors.initials: L
authors.lastname: Simone
mesh_terms: D019090:Case Management / Q000458:organization & administration*; D002908:Chronic Disease / Q000534:rehabilitation*; D019033:Delivery of Health Care, Integrated / Q000379:methods*; D004502:Education, Medical, Continuing; D006801:Humans; D006976:Hypertension, Pulmonary / Q000534:rehabilitation*; D010360:Patient Transfer / Q000379:methods*; D035583:Rare Diseases / Q000534:rehabilitation*