Interprofessional Collaboration in Transitional Care: System Outcomes, Governance Strategies, and Measurement Frameworks in IPC-Driven Case Management Models

Authors

  • Djembor Sugeng Walujo Institut Ilmu Kesehatan Bhakti Wiyata
  • Erwanto STIKes Kendedes Malang

DOI:

https://doi.org/10.61978/curatio.v2i2.1410

Keywords:

Interprofessional Collaboration, Case Management, Transitional Care, Nurse-Led Interventions, Readmission Reduction

Abstract

Interprofessional collaboration (IPC) has become an essential strategy in improving healthcare outcomes, particularly in transitional and chronic care settings. This integrative literature review explores how IPC-driven case management models influence system-level outcomes, support accountability and role clarity within teams, and are governed through policy and training mechanisms. Evidence demonstrates that IPC-integrated models especially nurse-led transitional interventions can significantly reduce 30-day hospital readmissions, enhance continuity of care, and improve patient satisfaction. However, implementation challenges persist, particularly in the areas of cross-sector governance, communication infrastructure, and measurement standardization. Limitations include inconsistent effectiveness across patient subgroups and contextual settings, as well as variability in evaluation frameworks. To strengthen IPC implementation, future research should focus on refining patient targeting, enhancing cross-setting coordination mechanisms, and harmonizing IPC measurement tools across cultural contexts. This review offers a comprehensive synthesis of conceptual frameworks, operational strategies, and validated instruments that underpin effective IPC in integrated care systems.

References

Ardyansyah, B. D., Cordier, R., Brewer, M., & Parsons, D. (2024). A Psychometric Evaluation of the Indonesian Version of the Collaborative Practice Assessment Tool (CPAT) for Assessing Interprofessional Education and Collaborative Practice Among Health Practitioners and Students. Narra J, 4(3), e1106. https://doi.org/10.52225/narra.v4i3.1106

Camicia, M., Lutz, B. J., Summers, D., Klassman, L., & Vaughn, S. (2021). Nursing’s Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community. Stroke, 52(12). https://doi.org/10.1161/strokeaha.121.033938

Cardon, T., Griffith, A. K., Koutsoftas, A. D., Rieken, C. J., & Eaton, A. (2024). What Is Working for Practitioners: A Mixed Method Analysis Using the Collaborative Practice Assessment Tool. Seminars in Speech and Language, 45(03), 213–227. https://doi.org/10.1055/s-0044-1787098

Chen, W. T., He, H., & Chow, Y. L. (2022). The Evolving Roles of Nurses Providing Care at Home: A Qualitative Case Study Research of a Transitional Care Team. International Journal of Integrated Care, 22(1). https://doi.org/10.5334/ijic.5838

Donnelly, C., Ashcroft, R., Mofina, A., Bobbette, N., & Mulder, C. (2019). Measuring the Performance of Interprofessional Primary Health Care Teams: Understanding the Teams Perspective. Primary Health Care Research & Development, 20. https://doi.org/10.1017/s1463423619000409

Gaboury, I., Breton, M., Perreault, K., Bordeleau, F., Descôteaux, S., Maillet, L., Hudon, C., Couturier, Y., Duhoux, A., Vachon, B., Cossette, B., Rodrigues, I., Poitras, M.-È., Loignon, C., & Vasiliadis, H. (2021). Interprofessional Advanced Access – A Quality Improvement Protocol for Expanding Access to Primary Care Services. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06839-w

Gautun, H., Hellesø, R., & Veenstra, M. (2021). The Association Between Hospital Nurses’ Perspectives on Their Information Practices and Quality of Care Transitions in Older Patients: A Nation-Wide Cross-Sectional Study. Tidsskrift for Omsorgsforskning, 7(2), 85–96. https://doi.org/10.18261/issn.2387-5984-2021-02-07

Hanskamp‐Sebregts, M., Gurp, P. J. v., & Braspenning, J. (2023). Design and Validation of a Questionnaire to Measure Interprofessional Collaborative Practice for Auditing Integrated Hospital Care: Empirical Research. Journal of Continuing Education in the Health Professions, 44(3), 171–179. https://doi.org/10.1097/ceh.0000000000000544

Hantouli, M. N., Monsell, S. E., Davidson, G. H., Chaing, J., Comstock, B. A., Dervish, A. A., Gionet, N. J., Howard, S., Jimenez, N., Kim, C., Liberman, M. M., Lindo, E. G., Marcum, Z. A., Ong, T. D., Serrano, E., Simons, K., Sun, L. S., Zaslavsky, O., & Austin, E. J. (2024). Pharmacy Integrated Transitions (PIT) Trial: A Protocol for a Pragmatic Cluster-Randomised Crossover Trial. BMJ Open, 14(12), e088786. https://doi.org/10.1136/bmjopen-2024-088786

Hossen, Md. B. (2017). On the Selection of Appropriate Proximity Measurement for Gene Expression Data. International Journal of Biomedical Materials Research, 5(5), 59. https://doi.org/10.11648/j.ijbmr.20170505.11

Hudon, C., Aubrey‐Bassler, K., Chouinard, M., Doucet, S., Dubois, M., Karam, M., Luke, A., Moullec, G., Pluye, P., Tzenov, A., Ouadfel, S., Lambert, M., Angrignon-Girouard, É., Schwarz, C., Howse, D., MacLeod, K. K., Gaudreau, A., & Sabourin, V. (2022). Better Understanding Care Transitions of Adults With Complex Health and Social Care Needs: A Study Protocol. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07588-0

Jepma, P., Latour, C., Barge, I. H. J. ten, Verweij, L., Peters, R. J., Reimer, W. J. M. S. op, & Buurman, B. M. (2021). Experiences of Frail Older Cardiac Patients With a Nurse-Coordinated Transitional Care Intervention - A Qualitative Study. BMC Health Services Research, 21(1). https://doi.org/10.1186/s12913-021-06719-3

Jones, K. A., Clark, A. G., Greiner, M. A., Sandoe, E., Giri, A., Hammill, B. G., Houtven, C. H. V, Higgins, A., & Kaufman, B. G. (2023). Linking Medicare-Medicaid Claims for Patient-Centered Outcomes Research Among Dual-Eligible Beneficiaries. Medical Care, 61(12), S131–S138. https://doi.org/10.1097/mlr.0000000000001895

Knight, S., Trinkle, J. K., & Tschannen, D. (2019). Hospital-to-Homecare Videoconference Handoff. Home Healthcare Now, 37(4), 198–207. https://doi.org/10.1097/nhh.0000000000000755

Laursen, M. G., Rahbæk, M. Ø., Jensen, S. D., & Prætorius, T. (2023). Experiences of Young People Living With Type 1 Diabetes in Transition to Adulthood: The Importance of Care Provider Familiarity and Support. Scandinavian Journal of Caring Sciences, 38(1), 126–135. https://doi.org/10.1111/scs.13214

Levert, M. J. (2017). Web-Based Knowledge Transfer (KT) Strategies and Technology Issues: The Case of a Cooperative Oncology Project. Journal of Healthcare Communications, 02(04). https://doi.org/10.4172/2472-1654.100088

Lima, M. A. D. da S., Magalhães, A. M. M. de, Oelke, N. D., Marques, G. Q., Lorenzini, E., Weber, L. A. F., & Fan, I. (2018). Care Transition Strategies in Latin American Countries: An Integrative Review. Revista Gaúcha De Enfermagem, 39(0). https://doi.org/10.1590/1983-1447.2018.20180119

Lindquist, L. A., Miller, R., Saltsman, W. S., Carnahan, J. L., Rowe, T. A., Arbaje, A. I., Werner, N. E., Boockvar, K. S., Steinberg, K., & Baharlou, S. (2016). SGIM-AMDA-AGS Consensus Best Practice Recommendations for Transitioning Patients’ Healthcare From Skilled Nursing Facilities to the Community. Journal of General Internal Medicine, 32(2), 199–203. https://doi.org/10.1007/s11606-016-3850-8

McNeil, D., Strasser, R., Lightfoot, N., & Pong, R. (2016). A “Simple” Evidence-Based Intervention to Improve Care Transitions for Frail Patients With Complex Health Conditions: Why Didn’t It Work as Expected? Healthcare Quarterly, 19(2), 67–72. https://doi.org/10.12927/hcq.2016.24702

Morgan, S., Pullon, S., McKinlay, E., Garrett, S., Kennedy, J., & Watson, B. A. (2020). Collaborative Care in Primary Care: The Influence of Practice Interior Architecture on Informal Face-to-Face Communication—An Observational Study. Herd Health Environments Research & Design Journal, 14(1), 190–209. https://doi.org/10.1177/1937586720939665

Naylor, M. D., & Berlinger, N. (2016). Transitional Care: A Priority for Health Care Organizational Ethics. The Hastings Center Report, 46(S1). https://doi.org/10.1002/hast.631

Nurchis, M. C., Sessa, G., Pascucci, D., Sassano, M., Lombi, L., & Damiani, G. (2022). Interprofessional Collaboration and Diabetes Management in Primary Care: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes. Journal of Personalized Medicine, 12(4), 643. https://doi.org/10.3390/jpm12040643

Pedrosa, R., Ferreira, Ó., & Baixinho, C. L. (2022). Rehabilitation Nurse’s Perspective on Transitional Care: An Online Focus Group. Journal of Personalized Medicine, 12(4), 582. https://doi.org/10.3390/jpm12040582

Rammohan, R., Joy, M., Magam, S. G., Natt, D., Patel, A., Akande, O., Yost, R. M., Bunting, S., Anand, P., & Mustacchia, P. (2023). The Path to Sustainable Healthcare: Implementing Care Transition Teams to Mitigate Hospital Readmissions and Improve Patient Outcomes. Cureus. https://doi.org/10.7759/cureus.39022

Reese, R. L., Clement, S. A., Syeda, S. N., Hawley, C. E., Gosian, J., Cai, S., Jensen, L., Kind, A., & Driver, J. A. (2019). Coordinated‐Transitional Care for Veterans With Heart Failure and Chronic Lung Disease. Journal of the American Geriatrics Society, 67(7), 1502–1507. https://doi.org/10.1111/jgs.15978

Rudolph, C., Petersen, G. S., Pritzkuleit, R., Storm, H. H., & Katalinic, A. (2019). The Acceptance and Applicability of a Patient-Reported Experience Measurement Tool in Oncological Care: A Descriptive Feasibility Study in Northern Germany. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-4646-4

Sulistyaningsih, S., Aprillia, R., Annisa, L., & Febrianti, C. P. (2023). The Effectiveness of Interprofessional Collaboration Practice to Reduce the Risk of Stunting: An Integrative Review. Jurnal Aisyah Jurnal Ilmu Kesehatan, 8(2). https://doi.org/10.30604/jika.v8i2.1680

Theodorou, J., Rotz, M. E., MacPhail, L. A., Idahosa, C., Fornatora, M., Tweddale, E., & Virtue, S. M. (2018). Designing and Evaluating an Interprofessional Practice Experience Involving Dental and Pharmacy Students. American Journal of Pharmaceutical Education, 82(6), 6298. https://doi.org/10.5688/ajpe6298

Trefethen, E. (2021). A Literature Review on the Benefits for an Interprofessional Educational Program to Increase Novice Nurse Awareness of Case Management in Heart Failure. Professional Case Management, 26(2), 70–81. https://doi.org/10.1097/ncm.0000000000000438

Valverde, P., Ayele, R., Leonard, C., Cumbler, E., Allyn, R., & Burke, R. E. (2021). Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: A Comparison of Hospital and SNF Clinicians’ Perspectives. Journal of General Internal Medicine, 36(8), 2251–2258. https://doi.org/10.1007/s11606-020-06511-9

Wieser, H., Mischo-Kelling, M., Cavada, L., Lochner, L., Fink, V., Naletto, C., & Vittadello, F. (2022). Evaluating Measurement Properties of the Adapted Interprofessional Collaboration Scale Through Rasch Analysis. Healthcare, 10(10), 2007. https://doi.org/10.3390/healthcare10102007

Yamamoto, Y., & Haruta, J. (2019). Translation and Cross-Cultural Adaptation of the Japanese Version of the Assessment of Interprofessional Team Collaboration Scale-Ii (J-Aitcs-Ii). Mededpublish, 8, 195. https://doi.org/10.15694/mep.2019.000195.1

Zensho, M. (2019). Structure of Nursing Practice Implemented by Discharge Planning Nurses In Support During Transition to Homecare; Focus on Multidisciplinary Professional Case Conference Settings. Journal of Comprehensive Nursing Research and Care, 4(2). https://doi.org/10.33790/jcnrc1100154

Zhang, P., Xing, F., Li, C., Wang, F., & Zhang, X. (2018). Effects of a Nurse‐led Transitional Care Programme on Readmission, Self‐efficacy to Implement Health‐promoting Behaviours, Functional Status and Life Quality Among Chinese Patients With Coronary Artery Disease: A Randomised Controlled Trial. Journal of Clinical Nursing, 27(5–6), 969–979. https://doi.org/10.1111/jocn.14064

Downloads

Published

2025-04-30

How to Cite

Walujo, D. S., & Erwanto. (2025). Interprofessional Collaboration in Transitional Care: System Outcomes, Governance Strategies, and Measurement Frameworks in IPC-Driven Case Management Models. Curatio : Journal of Advanced and Specialized Nursing, and Care Planning, 2(2), 103–116. https://doi.org/10.61978/curatio.v2i2.1410

Issue

Section

Articles