Healthcare delivery is a collaborative activity involving many individuals playing myriad roles. Clinical informatics often emphasizes the role of physicians, nurses, pharmacists, and other staff acting in concert to ensure that key clinical tasks are performed. Only recently have clinical informatics systems begun to model the complex interactions of the team supporting care in the home. Most posthospitalization care and most chronic care management require coordination across teams working from delivery organizations and both the formal and informal teams delivering care in the home. This degree of coordination requires targeted communication and maintenance of both a care record and a care plan.
Capsule Commentary on Luo et al., A Comparison of Health Plan- and Provider-Delivered Chronic Care Management Models on Patient Clinical Outcomes
