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Clinical Nursing Skills

2.4 Collaborative Care

Clinical Nursing Skills2.4 Collaborative Care

Learning Objectives

By the end of this section, you will be able to:

  • Describe the collaborative care approach to health care
  • Define the fundamentals of collaborative care
  • Recognize the benefits of collaborative care

Imagine a group of healthcare professionals coming together like well-coordinated musicians, each with their own instrument to play, creating beautiful music together. That is the idea behind collaborative patient care. Each member of the team—the patients, nurses, physicians, pharmacists, therapists, and other healthcare workers—brings their unique expertise and skills to the table, with the strengths of all team members combining to make a unit that is stronger as a whole.

In the collaborative model, healthcare professionals work hand in hand, sharing information, bouncing ideas off each other, and making decisions as a collective force. It is like a brainstorming session where everyone’s voice is heard, valued, and respected. Together, the providers create care plans that consider not just the physical aspects of health but also the emotional, social, and mental well-being of each specific patient. The collaborative model is about putting the patient front and center and tailoring the care to their individual needs, preferences, and goals. If you embrace the collaborative approach to patient care, you will learn to work with a diverse team of healthcare professionals, building a solid foundation of teamwork and making a difference in the lives of those you serve.

Collaborative Approach to Patient Care

The collaborative model of patient care in nursing emphasizes the importance of interdisciplinary teamwork and effective communication among healthcare professionals to provide holistic, patient-centered care. This approach recognizes that multiple healthcare disciplines contribute unique perspectives and expertise to address the complex needs of patients. It is especially beneficial for patients with complex and/or chronic conditions. In the collaborative approach, nurses collaborate with other healthcare professionals, such as physicians, pharmacists, therapists, social workers, and case managers, as well as patients and their families to form interdisciplinary teams (Morley & Cashell, 2017). These teams work together to develop comprehensive care plans, make shared decisions, and coordinate care across different settings and disciplines. By pooling their knowledge and skills, healthcare professionals can provide a more comprehensive and coordinated approach to patient care.

Effective communication is essential for collaborative patient care. Nurses play a critical role in facilitating the collaborative care process by ensuring that patients and their families are well-informed about their conditions, treatment options, and potential outcomes. They help patients understand the risks and benefits of different interventions and support them in making decisions that align with their values, preferences, and goals. Nurses must also communicate clearly, actively listen, and exchange relevant information with other healthcare professionals. This includes sharing patient assessments, treatment plans, and progress updates. Additionally, nurses facilitate communication between different team members, ensuring that everyone has access to the necessary information to provide optimal care.

Team Member Roles in Collaborative Care

In a collaborative approach, each healthcare professional’s role and expertise are valued and respected. Nurses work collaboratively with other team members, recognizing the unique contributions of each discipline. This includes acknowledging and appreciating the expertise, perspectives, and responsibilities of other healthcare professionals involved in the patient’s care. Table 2.9 describes the roles of common team members.

Team Members Who They Are What They Do
Physicians and advanced practice registered nurses (APRNs), or providers People with medical expertise and diagnostic skills, including primary care physicians, APRNSs, and physician assistants Providers collaborate with other team members to develop treatment plans, interpret test results, and make clinical decisions. They diagnose and treat medical conditions, prescribe medications, order tests and procedures, and provide medical guidance and consultations.
Pharmacists People with expertise in medication management Pharmacists collaborate with the team to assess the appropriateness and effectiveness of medication regimens and provide recommendations for adjustments or alternatives. They review medication orders, ensure appropriate dosages and drug interactions, provide medication counseling, and offer guidance on optimizing drug therapy.
Therapists People with expertise in various forms of therapy, including physical therapists, occupational therapists, and speech-language pathologists Therapists assess and treat patients with physical, cognitive, or communication impairments. They provide therapeutic interventions, develop rehabilitation plans, and work closely with other team members to coordinate care and promote optimal functional outcomes.
Social workers People with expertise in locating resources necessary to support patients’ social and emotional needs Social workers collaborate with other team members to address social determinants of health and ensure the patient’s overall well-being. They assess psychosocial factors, provide counseling and emotional support, assist with care transitions, and connect patients with community resources and support services.
Case managers People with expertise in overseeing the coordination and continuity of care for patients Case managers help ensure smooth transitions across different care settings and support patients in navigating them. They assess patient needs, develop care plans, coordinate services, facilitate communication among team members, and monitor patient progress.
Allied health professionals Other allied health professionals, such as dietitians, respiratory therapists, psychologists, and counselors, who contribute their specialized knowledge and skills as needed Allied health professionals collaborate with the team to develop and implement targeted interventions and support patient well-being. They assess and address specific patient needs related to nutrition, respiratory health, mental health, and other areas.
Table 2.9 Members of a Collaborative Care Team (Source: ANA, 2017.)

Nursing Role in Collaborative Care

Nurses play a central role in collaborative care. They provide direct patient care, coordinate and manage care plans, and act as liaison between the patient, their family, and other healthcare professionals. Nurses assess patient needs, implement interventions, monitor outcomes, and provide education and support. They also facilitate communication and collaboration among team members, ensuring the delivery of coordinated and holistic care.

Nurses often take a lead role in coordinating the various aspects of patient care. They serve as a central point of contact, ensuring that communication flows smoothly among team members, facilitating consultations or referrals, and organizing multidisciplinary meetings. Nurses work closely with patients, their families, and other healthcare professionals to create care plans that address the physical, emotional, social, and spiritual needs of the patient.

Fundamentals of Collaborative Care

Collaborative care in modern health care is built on several fundamental principles, which include organized communication, effective data sharing, simplified referrals, and integrated scheduling of care. This patient-centric approach relies on various healthcare professionals working together, across disciplines, to ensure comprehensive and coordinated patient care. The objective is to optimize patient outcomes, enhance the quality of care, and improve the overall healthcare experience by harnessing the collective expertise of a multidisciplinary team. By emphasizing organized communication, streamlined data sharing, simplified referrals, and integrated scheduling of care, collaborative care strives to address the complexities of modern health care and provide holistic and efficient care to individuals and communities. In this discussion, we explore these key fundamentals and their vital role within the healthcare landscape.

Organized Communication

Effective communication is essential for collaborative care. Healthcare professionals must communicate clearly, openly, and respectfully with each other, sharing relevant information, observations, and recommendations. Key skills include actively listening, effectively sharing information, and maintaining open lines of communication to foster collaboration and ensure the best possible care for the patient.

Effective Data Sharing

Successful collaborative care relies on effective data sharing to ensure that relevant patient information—such as medical history, diagnoses, medications, and treatment plans—is shared accurately and in a timely manner. This allows healthcare professionals to have a comprehensive understanding of a patient’s health status, facilitating coordinated and informed decision-making. To ensure effective data sharing in collaborative care, healthcare systems need robust infrastructure for interoperable EHRs, secure data exchange protocols, and other key technologies, and providers must strictly adhere to privacy and security regulations. Policies and standards for data sharing, consent, and patient privacy must be in place to protect patient information while facilitating seamless collaboration among healthcare professionals.

Simplified Referrals

Care coordination encompasses activities such as scheduling appointments, sending referrals, and sharing information. A simplified referral in health care is a straightforward process where a healthcare provider recommends or directs a patient to see another healthcare specialist or receive specific medical services and typically involves minimal administrative steps to ensure timely and efficient care coordination. Simplified referrals help expedite patients’ access to specialty care. By streamlining the referral process, unnecessary waiting times can be reduced, ensuring that patients receive timely appointments and necessary interventions. This is particularly important for patients with complex or specialized healthcare needs, as delays in accessing specialty care can have a significant impact on their health outcomes. Simplified referrals also lead to better continuity of care, improved communication, more efficient resource utilization, and enhanced patient satisfaction.

Patient Conversations

Using Simplified Referrals to Help Patients Access Care

Scenario: Nurse walks into the patient’s room to discuss the referral process for a specialist.

Nurse: Good morning! I will be your nurse today. How are you feeling?

Patient: Hello, I’m not doing so well. My knee has been bothering me a lot, and I can hardly walk without pain.

Nurse: I’m sorry to hear that. Let’s see what we can do to help you. The nurse practitioner wants to refer you to an orthopedic specialist for a closer look at your knee.

Patient: Oh, okay. That sounds a little overwhelming. I don’t think I know any specialists in this city, and I don’t know who is covered by my insurance. Is this going to be a long process for the referral?

Nurse: Not at all. We’ve made this process simpler for our patients. We have an orthopedic specialist right here in the same building. I will send the referral over electronically and can arrange an appointment for you later this week. Would that work for you?

Patient: That’s great! I was worried it would take a long time. Thank you for making it easy.

Nurse: You’re welcome. We want to ensure you get the care you need as quickly as possible. I’ll get everything set up, and you’ll be seeing the orthopedic specialist soon.

Integrated Scheduling of Care

Implementing integrated scheduling of care focuses on optimizing the coordination and timing of healthcare services to improve patient outcomes and enhance the efficiency of care delivery. This involves coordinating appointments for patients with different healthcare providers in order to ensure smooth transitions, minimize wait times, and avoid unnecessary delays or conflicts. Coordinated appointments help streamline the patient’s journey through the healthcare system, reducing the burden of scheduling and transportation on the patient and their caregivers, preventing gaps in care, and supporting the ongoing management of chronic conditions.

Integrated scheduling also helps providers use healthcare resources more effectively. By coordinating the schedules of healthcare professionals and aligning them with the availability of facilities, equipment, and support staff, integrated scheduling helps maximize the efficiency and productivity of healthcare services. It reduces idle time, minimizes conflicts or overlaps in schedules, and ensures that resources are utilized effectively to meet the needs of patients.

Benefits of Collaborative Care

Collaborative care in health care, involving coordinated efforts among various healthcare providers, offers numerous benefits. It enhances the quality of care by allowing multiple disciplines to contribute their expertise, leading to more accurate diagnoses and tailored treatment plans. Additionally, it often results in reduced costs of care as unnecessary tests or treatments can be minimized through shared decision-making and resource optimization. Collaborative care also increases the convenience of care for patients as they can receive multiple services in one location or through coordinated telehealth consultations, reducing travel and waiting times. Ultimately, this collaborative approach fosters a patient-centered healthcare ecosystem that prioritizes both the effectiveness and efficiency of care delivery.

Improved Quality of Care

Collaborative care places the patient at the center of decision-making and care planning. Healthcare professionals from different disciplines collaborate to address the physical, emotional, social, and psychological needs of patients. This patient-centered approach ensures that care is tailored to the individual’s preferences, values, and goals. By involving patients in the decision-making process and considering their unique circumstances, collaborative care promotes greater patient satisfaction and engagement.

Collaborative care has also been shown to improve patient outcomes. When healthcare professionals work together, they can provide a more holistic and coordinated approach to patient care. By leveraging their collective expertise, they can better assess patient needs, develop comprehensive care plans, and implement appropriate interventions. Collaborative care has been associated with improved patient satisfaction, reduced hospital readmissions, better management of chronic conditions, and enhanced overall health outcomes in both preventive and acute care.

Reduced Cost of Care

Collaborative care optimizes the use of healthcare resources and promotes efficiency in care delivery. By leveraging the expertise of different healthcare professionals, tasks can be delegated to the most appropriate team members, allowing each professional to practice within the full scope of their profession. This leads to a more efficient use of resources and streamlines workflows. Collaboration also helps avoid unnecessary tests, procedures, and consultations, reducing healthcare costs and optimizing resource allocation.

Collaborative care has the potential to improve the overall efficiency and effectiveness of the healthcare system. By providing comprehensive and coordinated care, collaborative teams can reduce healthcare utilization, prevent unnecessary hospital admissions or readmissions, and optimize resource allocation. The streamlined workflows, enhanced communication, and shared decision-making in collaborative care contribute to a more efficient and cost-effective healthcare system.

Increased Convenience of Care

Collaborative care can improve access to a wide range of healthcare services. By working together, healthcare professionals can efficiently coordinate appointments, referrals, and consultations. This reduces wait times and ensures that patients receive timely and appropriate care. Improved access to services is particularly beneficial for patients with complex or multiple healthcare needs, as collaborative care streamlines the process and minimizes unnecessary delays or duplication of services.


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