慢性閉塞性肺疾患患者の効果的なケア移行を促進するための専門職連携

Transitions of care are the movement of a patient from one care setting or provider to another. Interprofessional collaboration is critical in ensuring patient safety and satisfactory health outcomes. Each time an interprofessional team transfers a patient, the team performs three important roles: representing the patient, providing patient information for other team members, and coordinating the transition. Poor transitions of care may contribute to negative health outcomes, especially for patients with chronic health conditions, complex medication regimens, and high-risk treatments. We present a case study of a patient with complicated chronic obstructive pulmonary disease that depicts the importance of successful interprofessional collaboration during the transition of care from hospital to home illustrating the unique contributions of the various disciplines involved in the patient's care.