Integrated Transitions of Care for Patients With Rare Pulmonary Diseases

Kathleen Moreo¹, Cheri Lattimer, James E Lett+2

• ¹Kathleen 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.