Interdisciplinary Plan Of Care

I found this particular portfolio more challenging than previous ones. The main reason for this was the fact that I was the required to actively take part in the assessment, planning, implementation and evaluation of a patients care within the service. Doing this came with responsibility that I had not had in previous placements.

It's important for nurses to be actively involved with an interdisciplinary team because of the increasing complexity and scope of patient problems. As these complexities and problems increase, patient care necessitates the combination of efforts of physicians from different disciplines. Actually, comprehensive patient care in today's healthcare settings incorporates attempts to solve problems that are beyond the scope of expertise and training of a single professional. Therefore, the active involvement of nurses in interdisciplinary teams is vital for the provision of comprehensive and effective patient care that help in dealing with the evolving patient problems

Interdisciplinary team work is extremely important to ensure patients receive quality care that meets their individual needs (Nancarrow, et al, 2013). To achieve this a group of health care professionals work together by bringing their different professions, assessments and evaluations together in order to design a care plan for treatment of the patient (Korner, 2010). For example if a patient is dealing with a mental health disorder such as depression or schizophrenia, the interdisciplinary team would consist of the doctor, nurse, psychologist, psychiatrist, pharmacist and neurologist. The roles and responsibilities of each team member must be based on their scope of practice including the assessment of the patient, the treatment to be given,

Multidisciplinary rounds approach calls for various members of the medical profession to synchronize individual skills, knowledge, and expertise in order to provide quality care for patients (IHI, 2015). The team members consist of nurses, physicians, “ancillary clinicians, and staff” (IHI, 2015, p.4). Each member contributes to the care of the patient individually, but in a cohesive manner (IHI, 2015). The multidisciplinary rounds care model strongly encourages and utilizes parental involvement during rounds (IHI, 2015). Multidisciplinary rounds also solicit parents and family members to communicate with the care team care as well as care team communications concerning the patient to the family (IHI, p.4). For each patient, the rounds are conducted daily (IHI, 2015). For each patient, goals are set daily (IHI, 2015). This ensures daily communication among care team and with patient and the families of the patient (IHI, 2015). The idea is to establish good coordination of care; thus, making safe and efficient care more consistent (IHI, 2015). As the protocols or the guidelines are clearly communicated among care teams, risks are identified, and staff are educated, the quality of health care improves (IHI, 2015).

Focus: Taliana, Mrs. Clark (MHS) and Ms. Smalls (MHP) review and sign Individual Plan of Care (IPOC).

Discuss the differences between inter and intradisciplinary teams, and the patient’s role in the team.

Many individuals come together to organized a care plan for a patient. The patient plays a role in the process, sharing his or her preferences and needs as they related to information sharing and health services. Family members and caregivers need to have a say in the care of the patient, as coordination failures frequently occur when care is transitioning from one party to another. Healthcare providers must be a part of the care coordination team, and this shouldn't be limited to only doctors.

First, building great teamwork is one of the most important factors to achieve successful interdisciplinary care.

Recently, my primary care clinic implemented a strategic initiative to increase patient accessibility to health care provider appointments. The managers within my clinic restructured our clinicians and nurses into health care teams called Patient-Centered Medical Homes (PCMH). PCMH involves realigning staff into teams around the primary care managers (PCMs) who have a support team helping them provide comprehensive, coordinated healthcare for patients (Army PCMH implementation manual, 2013). The PCMs are the physicians, nurse practitioners (NPs), and physician assistants (PAs) within our clinic. Each team has one PCM and three support staff (RN, LPN, CNA or medic) helping them provide care to their empanelment of patients (Army

Interdisciplinary teams involve many different specialist (physician, nurses, dietitian, social worker, physical and occupational therapist) working together for the common goal of the client successful outcome. When health care providers work together with the client, the client’s family or other pertinent caregiver we are optimizing the client’s care and treating the client holistic. Interdisciplinary team rounds allow a group of health care professionals to come together to discuss the plan of care with the patient. It is important that we continue to keep the client informed and involved in their care. Collaboration among the health care professionals is highly recognized in the hospital setting, as an important link to quality care in reaching a positive outcome. Structured interdisciplinary bedside rounds (SIBR) provide the validated structure that operationalizes interdisciplinary

IPP involves collaboration of multiple AHP working together sharing a common goal regarding the patient. These professionals are of different educational backgrounds and have a variety of training in different areas (Palanisamy, 2015). They include physicians, nurses, dietitians, nutritionists, pharmacists, social workers, mental health workers, health coaches, community health workers, exercise physiologists, and other specialists (Nester, 2016). IPP includes communication and decision making influenced by coordination, cooperation, conviction and admiration (Bridges, Davidson, Odegard, Maki & Tomkowiak, 2011). Use of these skills can ensure that AHP work together efficiently to achieve the best patient outcome. (Bridges et al.,

The macro- level coordination mechanisms being used in Unit B that were not used in Unit A included mostly included organization and communication and they work as a team, forming units in various departments. Organization design is the arrangement of responsibilities, authority, and flow of information within an organization, resulting in its organization structure (Burns, Braley, Weiner & Shortell, 2012). Macro level coordination is where the focus of analysis is on the overall coordination needs and structural approaches to address those need (Burns, Braley, Weiner & Shortell, 2012). In unit A communication among the nurses, therapists, social workers, residents, and attending physicians regarding patient care is poor, and relationships among them are strained (Burns, Braley, Weiner & Shortell, 2012). In unit B nursing staff on the unit are organized into teams, with each team responsible for assigned patients from admission to discharge, the house staff in medicine in the hospital also are organized into teams, and except when beds are not available (Burns, Braley, Weiner & Shortell, 2012). Task interdependence among staff A included patient care units Nurses, physicians, and other health professionals in unit A consisted of discipline compared to unit B where conduct interdisciplinary rounds were not something team A took seriously. Differences between the effectively functioning Unit B and the chaotic Unit A are seen by many administrators and health care

With the adoption of coordination of care rounds, Peninsula Regional Medical Center will be able to reduce the length of stay of hospitalized patients. Improving communication is key; there are multiple caregivers that contribute to a patient’s plan of care and discharge plan. Currently, physicians, nurses, and discharge planners work in silos and deliver disjointed care due to the lack of communication and collaboration. This practice results in an extended length of stay for hospitalized patients because caregivers are all working on “their” plan of care rather than formulating a solid plan of care that is developed mutually. Coordination of care rounds will consist of a multidisciplinary approach and will serve as an outlet for collaboration and will result in the delivery of patient-centered care. Geary, Cale, Quinn, & Winchell (2009) found that rounds “are a successful method of helping decrease LOS by improving communication, improving coordination of care, and improving the skill and knowledge level of the staff” (p. 298).

After watching the video of the patient care team at Christiana Care's Wilmington Hospital intensive care unit demonstrates the patient and family centered care practice of interdisciplinary rounds at the bedside, I (recreated), used ,the assessment tool for group dynamics to evaluate the group functioning (Christiana Care, 2012, Video). Overall the rating of the group function was rated acceptable however there three areas that received low scale rating (2.0) according to the key provided, (in some areas), those areas were Communications, Leadership and Situation (Team Dynamics Assessment Tool, 2012 and Christiana Care, 2012, Video).

Team work and Interprofessional coordination are illustrated at all levels of patient management. The staff accessibility to online health records indeed contributed to associate with other professionals. In addition, active participation of all the members supported team work.