Improving the Role of a Multidisciplinary Team in Transitions of Care

By Jennifer Thibodeau, M.D., M.S.C.S.

Associate Professor of Internal Medicine
Interim Section Chief, Advanced Heart Failure, LVAD/Cardiac Transplantation
Medical Director, Heart Failure

In patients with heart failure (HF), the period of transition of care – i.e., when a patient is being discharged from the inpatient setting to the outpatient setting – is a very vulnerable time. Optimizing the care during this period is essential in order to decrease rates of potentially avoidable hospitalizations, decrease risk of adverse clinical events from medication or other discrepancies, promote patients’ satisfaction in care and their quality of life, and engage caregiver support. I had the privilege of discussing the role of the multidisciplinary team during transition of care at #AHA20 in a session titled “Acute Decompensated Heart Failure: Critical Issues for the Clinician.”

Essential in the successful transition of care is a multidisciplinary team that works cohesively to manage all aspects of a patient’s care. This team can be composed of a pharmacist, a social worker, a care coordinator, a dietitian, therapists, palliative care, a transition nurse, and, importantly, the patient and any caregivers. The outpatient team, including primary care, as well as the outpatient cardiologist are also critical members.

In my lecture, I proposed that virtual visits may be an opportunity to improve transition of care for patients with HF. In 2020, virtual visits for the care of HF patients were rapidly adopted as mainstream care due to the SARS-CoV-2 pandemic. A recent small study of virtual visits following hospital admission for HF demonstrated that virtual visits were comparable to in-person visits in terms of subsequent clinical outcomes, with a trend toward decreased no-show rates. There are numerous putative advantages of virtual visits, including that they may allow more members of the multidisciplinary team to be involved in the care of the patient because the patient can get rapidly to multiple appointments from the comfort of their home. Further, the virtual format facilitates the incorporation of caregivers and family members to the visit, encouraging their engagement and involvement. Additionally, the convenience of virtual visits might allow patients to have more frequent visits with their providers, which could facilitate the optimization of guideline-directed medical therapy (GDMT) and potentially even lead to improved clinical outcomes.

Overall, the multidisciplinary team is essential to the care of HF patients during the transition from hospital to home, and virtual visits might allow for the expansion of multidisciplinary involvement, better engage patients and caregivers, and facilitate optimization of GDMT and thereby improve outcomes of patients with HF.

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