Tools for Success
The following tools provide clinicians with material that can assist them in purposefully aligning their teaching process with interprofessional team-based care. Your clinical practice is busy and your team is focused on patient care. While some primary care practices have an experienced patient-centered medical home or accountable care organization, many others do not have a formal interprofessional collaborative practice. These tools will assist all practices.
This fictional case study will allow preceptors to characterize their practice and environment with learner(s). While analyzing the case you will have the opportunity to discuss how you approach team-based care, use a virtual and onsite referral network, organize chronic care management and communicate how your practice patterns and values shape patient care. Case Study
Learners might shadow a team member from each part of the practice. This could include the receptionist, business manager, medical assistant, RN, APRN, PA, social worker, patient navigator, community health worker, etc. The objective is for the student to assess how each member contributes to the process of caring for the patient. Require the student to keep notes/reflections on the staff members’ roles, responsibilities and scope of practice, and give the student an opportunity to share his or her reflections with the entire team.
Functions and Tasks
Each office/site has many tasks and functions that occur before, during and after the delivery of patient care. The preceptor, team and learner might create a list of all the functions and/or tasks that are important in delivering care. For each function/task identify which team member is responsible and follow up with the question of “are they the best to complete that function/task?” Be sure to identify outside resources for functions/tasks, as well. Some functions/tasks might be poly-pharmacy, nutritional counseling, domestic violence, social issues, homelessness, depression assessment, and child neglect. Take time to reflect on the list you create.
The Team Huddle1
- Promotes team building, communication and organization
- Avoids duplicated work and takes advantage of memb’s strengths and scope of practice
- Gives other members of the team the opportunity to create the patient’s care plan
- Promotes teamwork
How to Huddle?
- Explain how the huddle is done at your practice. When? Where? Why? How?
- Suggestions on how to incorporate “huddle” into office if not being used.
- If the practice does not currently use the huddle method, they should start slow and select one patient case to discuss each week.
- Criteria for the case could be a chronic condition or special need (older, non English speaking)
- Brief presentation; discussion on the care plan; roles of team members; are there outside referrals needed; debrief using Team Debriefing Tool Using Four Core Competencies.
Patient Case to Develop a Collaborative Care Plan
Select a patient case from your panel. Read the patient case aloud and decide who would be the ideal choice for team leader and explain your rationale for selection.
- As a team, prioritize the top 5 concerns for the patient.
- Once the top 5 concerns concerns have been identified, ask the group to identify the healthcare team member(s) to provide the intervention task. Describe why you selected the individual(s) to perform this role – i.e. how does this fit in their scope of practice and skill set?
- Ask the group if there are other resources needed for patient care that are outside of the immediate care team? What perspectives would they have brought to the care planning process? Identify how the healthcare team accesses these resources.
Team Debriefing Tool Using Four Core Competencies
- What are the roles of each member of the care team?
- Did members of the team encourage the ideas and opinions of other members?
- Did it appear team members had confidence in one another? Give specific examples.
- Did the team define its goals?
- Did individuals appear to respect the contributions of individuals from other disciplines?
- Did it appear that the team members valued each other’s opinions? Give specific examples.
- Were the patient’s interests represented during the development of the care plan?
- Did team members actively listen to one another?
- Was the discussion distributed among all team members and not dominated by one person? Give specific examples.
- How did the team communicate and coordinate care?
- What barriers were there to communication?
Roles and Responsibilities
- Did individuals appear to understand the contributions from other disciplines?
- Were there examples of role overlap between members of the team? Give specific examples.