1. Moreo, Kathleen BSN, BHSA, RN-BC, CCM, CDMS
  2. Lattimer, Cheri BSN, RN
  3. Lett, James E. MD, CMD
  4. Heggen-Peay, Cherilyn L. PhD
  5. Simone, Laura PhD


Purpose/Objectives: 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).


Primary Practice Setting(s): 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.


Findings/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.


Implications for Case Management Practice: 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.