Can you describe your role in facilitating interdisciplinary care coordination for patients with chronic diseases

Can you describe your role in facilitating interdisciplinary care coordination for patients with chronic diseases, such as heart failure, chronic obstructive pulmonary disease (COPD), or diabetes mellitus, to ensure seamless transitions between healthcare settings and promote continuity of care across the care continuum? Furthermore, how do you engage patients and their families as active participants in care planning and decision-making processes, fostering shared decision-making and patient empowerment to improve treatment adherence and health outcomes?