Coordinating Complex Care Across Years: Specialists, Settings, and Decision Points

Many older adults live with multiple chronic conditions managed by several specialists, in and out of hospitals, across years. Coordinating this care so that decisions reflect the whole person rather than each condition in isolation is its own skill. This applied course teaches that skill. By the end of this course you will be able to coordinate care across multiple specialists, run structured family meetings around major decision points, recognize patterns that signal a need for a change in approach, and align care with your parent's stated goals as their situation evolves. What you will learn: - How to build a unified care summary that travels with the patient across providers - How to align the goals of care across specialists, primary care, and the family - How to recognize when aggressive treatment of one condition undermines overall quality of life - How to prepare for major decision points such as new diagnoses, hospitalizations, and care setting changes - How to run family conferences with the clinical team that produce actionable shared decisions - How to track patterns over months including weight, function, falls, hospitalizations, and cognition - How to revisit goals of care annually and after each major event The course is structured around six applied modules. Each produces a written artifact: a unified care summary, a goals-of-care document, a pattern-tracking template, a decision-point preparation worksheet, a family conference template, and an annual review plan. This course is written for primary caregivers and care coordinators managing complex healthcare across years. By the end you will move from appointment-by-appointment reactivity to coordinated care that reflects your parent's whole situation and stated goals.