Care Coordination Team Research Articles

Nursing Rounds—A collaborative approach to improvements in emergency care

Monash Medical Centre boasts a busy Emergency Department located on the outskirts of Melbourne. The integration of Nursing Rounds (NR) is a direct response to results of an audit identifying a high proportion of nursing charts lacked adequate levels of documentation. The NR have has provided an opportunity for communication, clinical teaching and provides incite into current issues facing staff on the floor. The NR team are able to address staff concerns, documentation, patient care concerns, provide positive and constructive feed back, clinical teaching and encourage self directed learning. The reviews are held Monday through to Friday mornings. The department is split into seven work areas and the NR team visit every work station. A number of nursing charts, at each station, are selected and talked through with the staff, identifying the plan of care for the patient. Self-directed learning objectives and individual learning needs and expectations are identified. Opportunities exist to assess our model of nursing care, identify future strategies and a commitment to encourage a collaborative approach with moving forward with future developments in practice. A comparative audit of documentation and a survey to assess staff satisfaction with the NR has been conducted 6 months post-implementation identifying significant improvements. The audit provided staff the opportunity to provide suggestions for possible modifications/improvements to the rounds that will continue to provide a satisfying experience and improve care delivery. Consideration will be given to extend the information for other disciplines to join the group, i.e. care coordination team.

Comprehending Coordinated Comprehensive Care: The Devil is in the Dollars

Comprehending Coordinated Comprehensive Care: The Devil is in the Dollars

A 2020 vision of patient-centered primary care.

Patient-centered care has received new prominence with its inclusion by the Institute of Medicine as 1 of the 6 aims of quality. Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patient-centered care surveys, and publicly available information. The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care finds that one fourth of primary care physicians currently incorporate these various patient-centered attributes in their practices. To bring about marked improvement will require a new system of primary care payment that blends monthly patient panel fees with traditional fee-for-service payment, and new incentives for patient-centered care performance. A major effort to test this concept, develop a business case, provide technical assistance and training, and diffuse best practices is needed to transform American health care.

Preadmission stem cell transplantation teaching: A team aproach

The Hematology Care Coordination team addresses the educational and psychosocial needs of transplantation patients in a multidisciplinary fashion. Central to this formal education plan is the unique partnership of the Oncology-Certified RN Hematology Care Coordinator and Social Worker who assess these needs throughout the continuum of care. The process centers around a patient/caregiver educational meeting, at which time a comprehensive participative needs assessment is completed, goals are developed, and interventions are initiated.

A paradigm shift in the nature of care provision in emergency departments

Objectives: Access block to acute hospital inpatient beds has pressured emergency departments (EDs) to develop strategies to facilitate the management of patients in the community (new services) and to streamline...

A multidisciplinary Care Coordination Team improves emergency department discharge planning practice.

In response to difficulties meeting the demand for hospital services ("access block") at Royal Melbourne Hospital, a major metropolitan tertiary referral hospital, an audit of patient needs revealed a shortage of aged-care beds and a need for post-acute care. A multidisciplinary Care Coordination Team (CCT) was formed at the end of July 2000 to ensure that emergency department patients were provided with services that would facilitate their return to, or maintenance in, the community. The target population included the frail elderly, those living alone, the homeless, frequent emergency department attenders, and those with complex medical or drug and alcohol problems. As part of routine emergency department care, a risk screen was implemented to determine referral to the CCT. In the first 12 months, the CCT saw 2532 patients (5.8% of all emergency department attendances). Nearly half of these patients were discharged home with referrals to community service providers. The rate of hospital admission from the emergency department fell significantly compared with the 12-month period before implementation of the CCT (13 420 patients, 30.9% [95% CI, 30.5-31.3] v 14 217 patients, 32.6% [95% CI, 32.2-33.0]; P < 0.001). Surveys of staff, patients and carers, as well as community service providers, showed a high level of satisfaction with the CCT.

The pharmacist’s role in community palliative care

Community pharmacists have frequent contact with patients with cancer and have a wider role to play than simply drug supply, said Hilary Edmonson, pharmacist, East Riding Pharmacy Development Group. Patients with terminal illnesses want to stay at home and, in order to do so, need a well co-ordinated care team. “Pharmacist input is often missing […]

The Transprofessional Model: Blending Intents in Terminal Care of AIDS

SUMMARY Current terminal care services present dying patients and their families with a dichotomy in service delivery and the intent care between curative treatments and palliative treatments. This arbitrary dichotomy reduces patients' quality of life in many cases and robs patients and families of benefiting from the psychosocial aspects of treatment until the last few weeks of life. This article presents a blended model of care, the Transprofessional Model, in which patients receive both curative and palliative service throughout their care process. The blended intent model differs from traditional home care in that services are provided by a care coordination team composed of nurses and social workers; the traditional model of care is often case managed by a single, registered nurse. The combination of the multi-disciplinary approach to care coordination and training in both curative and palliative services in the Transprofessional Model demonstrates that this blended model of care produces a bio-psychosocial focus to terminal care as compared to a primary focus on curative services present in the traditional model of home care.

Reducing Costs and Length of Stay and Improving Efficiency and Quality of Care in Cardiac Surgery

Background. The present era of health care places major emphasis on significantly reducing cost and resource utilization while maintaining quality of care and patient satisfaction. Clinicians are being challenged to achieve this within the framework of a patient subset that is increasing in severity of disease and risk-adjusted mortality. The Brigham and Women’s Cardiac Surgical Services Management Group was formed in 1987 to help accomplish these goals. Methods. The principles we have followed involve protocols and people. The multidisciplinary group includes the chiefs of cardiac surgery and anesthesia, chief residents, physician assistants, perfusionists, intensive care unit nursing personnel, and case managers. Weekly meetings address every aspect of problems arising in the cardiac surgical service; separate weekly morbidity and mortality conferences are held. The Care Coordination Team establishes and monitors clinical pathways and recommends ways of improving all aspects of the service through a process of daily review on an individual patient basis. Results. The volume of cardiac surgery at Brigham and Women’s Hospital has increased steadily. The length of stay overall has decreased about 15%, and similarly, cost and total charges have also decreased. In addition, patient satisfaction has increased to a level of about 95%. Conclusions. The goals of cost-containment with improved patient care and outcome are possible through the collaborative efforts of representatives of all the personnel involved in cardiac care, as well as leadership by the surgical faculty.

Managed obstetrical care.

The current maternal/newborn care model is outdated and needs to be revised. The health care reform movement has created a window of opportunity to redefine the episode of pregnancy care and develop a more meaningful and more cost-effective model of care. The ultimate satisfaction for physicians will occur when they exert their natural control regarding the manner in which health care dollars are spent by managing the financial risk and the patient care. The optimal management of the health care dollar can only be achieved through initiation of an integrated model in which a coordinated care team supported by the appropriate risk assessment, education, prevention and wellness program, and medically necessary intensive care of the high-risk pregnancy are brought together effectively. An integrated model will give patients what they want: compassionate, convenient, comprehensive care. It will give the payers what they are looking for--appropriate care at an appropriate predicable cost and improved outcomes. Finally, it will give the providers what they want: control over the delivery medical care.

Stroke care coordination team: Emerging roles to improve patient outcomes: Deborah Summers, Iris Standridge, Martha Maccracken

Stroke care coordination team: Emerging roles to improve patient outcomes: Deborah Summers, Iris Standridge, Martha Maccracken

Coordinated-care teams: Improving health and social care for older Israelis

Despite the difficulties, professionals involved in the demonstration program at all levels were convinced that this was indeed the most appropriate way to coordinate care within the Israeli system. A decisive majority of field workers participating in the demonstration program were satisfied with the work of the coordinated-care team and felt that teamwork vastly improved the quality of care for the elderly.

The Patient Care Coordination Team: An Adjunct to Health Services

The Patient Care Coordination Team: An Adjunct to Health Services