As our society ages, so does the incidence of chronic diseases requiring continuous monitoring and self-management practices. Despite our nation's wealth and its sophisticated systems and technology, many vulnerable adults still experience inadequate medical care resulting in undesirable consequences. In this themed issue, we address chronic disease management emphasizing effective models, strategies, and instruments used to promote interprofessional collaboration and care coordination.

Hirschman et al introduce the use of two current models of care: the Patient Centered Medical Home (PCMH) and the Transitional Care Model (TCM). Used in combination, the PCMH and TCM have demonstrated their ability to address the needs of vulnerable older patients with chronic diseases through collaboration and communication among practitioners from different disciplines. Emphasizing coordinated care across transitions from the acute setting to the clinic to the home, the study team shared lessons learned as well as barriers and facilitators to implementing the combined PCMH and TCM.

Clarkson et al report on the efficacy of initiating the Heart Failure University (HFU), an interprofessional posthospital discharge educational program. Comparing the HFU group (intervention) to the hospitalized patient standard instruction group (control), the authors were able to document effectiveness in reducing 30-day hospital readmissions for those participating in the HFU. The findings emphasize the importance of educational-based disease management programs to promote self-management practices in a heart failure population.

Bordelon et al report on findings from a literature synthesis exploring interprofessional rounding (IPR) as an effective communication method to improve patient care quality and safety in complex hospitalized patients. The authors expand on the benefits of IPR and suggest evidence-based strategies to address current gaps in the integration of IPR using activation, standardization, and participation.

Beaird et al enlighten us further about IPR reporting on the use of the Patients' Insights and Views of Teamwork (PIVOT) survey for patients to evaluate teamwork during rounding. The authors demonstrate improvements in patient ratings of hospital rounds when these used structured IPR as compared to unstructured rounding. Using the PIVOT survey, the authors concluded that perceptions of teamwork are valuable and using IPR that is structured better conveys collaborative practices to patients.

Gangadharan et al discuss findings from an observational study of human factors associated with IPR in a pediatric intensive care unit. Using a work sampling approach, the team was able to identify value-added versus nonessential activities that could serve as a basis for initiatives to improve the efficiency and value of IPR.

Hodgson et al introduce a conceptual framework used to develop a preliminary outcome-based measure for rating care coordination quality. The authors propose the use of an interdisciplinarity score using the Agency for Healthcare Quality and Research's Patient Safety Indicators (PSIs) as a coordination-sensitive health outcome.

We close the pages of our themed issue with our online supplement showcasing the work of Schuller et al who report on the use of a centralized discharge phone call (DPC) program to enhance care transitions and prevent costly hospital readmissions. Following implementation of the DPC in an academic medical center, the authors were able to demonstrate the effectiveness of the centralized DPC as compared to a previous program of phone calls conducted by nurses staffing individual units. The centralized DPC supports the value of dedicated resources to enhance the success of initiatives aimed at improving care transitions and reducing hospital readmissions.