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Disease Presentation

Interdisciplinary collaboration is crucial for the care of complex chronic patients. Name the specialists or consultant fields that you most frequently contact for care of chronic patients you’ve seen in the past. What are the barriers your chronic patients face in regard to following through with referrals to these specialists as well as follow-up with their primary care manager? Explain the methods and personnel involved in your specific clinic for assisting with and monitoring follow-up appointments and referral completion.

Describe some strategies to increase successful follow-up and referral completion by your clinic’s patients, keeping in mind healthcare equity and access for all patients. Include the names and links of at least two specific programs or resources in your area, and patient eligibilty for the program or resource.

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