Penelope A. Moyers, Christina A. Metzler; Interprofessional Collaborative Practice in Care Coordination. Am J Occup Ther 2014;68(5):500-505. doi: 10.5014/ajot.2014.685002.
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(i) Promoting broad payment and practice reform in primary care, including patient-centered medical home models for high-need applicable individuals; …(iii) Utilizing geriatric assessments and comprehensive care plans to coordinate the care (including through interdisciplinary teams) of applicable individuals with multiple chronic conditions; …(v) Supporting care coordination for chronically-ill applicable individuals at high risk of hospitalization through a health information technology-enabled provider network that includes care coordinators, a chronic disease registry, and home tele-health technology; …(vii) Utilizing medication therapy management services; …(viii) Establishing community-based health teams to support small-practice medical homes by assisting the primary care practitioner in chronic care management, including patient self-management activities. (ACA § 3021)
The deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care. (McDonald et al., 2007, p. 41)
Models are patient and family caregiver–centered in concept and design that support shared decision-making.
Interprofessional teams match services to patient and family needs to gain the highest value.
Team leadership shifts according to patient and family needs, preferences, and expertise of team members.
Existing and new payment mechanisms recognize evidence-based models led by any discipline that are associated with improved quality outcomes and cost reduction.
Explicit and seamless links connect patients, providers, and caregivers to community resources.
Teams have high reliance on the expertise, skills, and services of registered nurses.
Care coordination and transitional care provide seamless transition experiences for patients and family caregivers.
Ongoing quality measurement and comparative effectiveness research are needed to test these assumptions and define best practices. (p. 331)
Engage patients, families, and communities in the design, implementation, improvement, and evaluation of efforts to link interprofessional education and collaborative practice.
Accelerate the design, implementation, and evaluation of innovative models linking interprofessional education and collaborative practice.
Reform the education and lifelong career development of health professionals to incorporate interprofessional learning and team-based care.
Revise professional regulatory standards and practices to permit and promote innovation in interprofessional education and collaborative practice.
Realign existing resources to establish and sustain the linkage between interprofessional education and collaborative practice. (p. 2)
Patient-centered care—Relationship-based care focuses on the whole person and understanding and respecting each patient’s needs, culture, values and preferences
Comprehensive care—A team of providers (may include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, mental health workers, social workers, and others) work to meet each patient’s physical and mental health care needs, including prevention and wellness, acute care and chronic care.
Coordinated care—Care is coordinated across the broader health care system, including specialty care, hospitals, home care, and community services and support. This is particularly critical during transitions between sites of care, such as when patients are discharged from the hospital.
Superb access to care—Patients have access to services with shorter waiting times for urgent needs, enhanced in-person hours, around the clock telephone or electronic access to members of the care team, and alternative methods of communication such as e-mail and telephone.
Systems-based approach to quality and safety—The PCMH uses evidence-based medicine and clinical decision support tools, engages in performance measurement and improvement, measures and responds to patient experiences and satisfaction, practices population health management, and publicly shares robust quality and safety data and improvement activities. (p. 1)
The Patient Centered Medical Home (PCMH) 2011 program is for practices that provide first contact, continuous, comprehensive, whole person care for patients across the practice. PCMH has at its foundation the Joint Principles developed by the primary care medical societies (American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics, American Osteopathic Association):
Personal clinician provides first contact, continuous, comprehensive care;
Care is coordinated or integrated across the health care system;
Whole-person care includes provision of comprehensive care and self management support and emphasizes the spectrum of care needs, such as routine and urgent care; mental health; advice, assistance and support for making changes in health habits and making health care decisions. Preventive care is also a key component of the expectation for clinician focus. For purposes of this paper, certain standards of NCQA were reviewed for their relationship to occupational therapy education.
Team leadership, the ability to coordinate team members’ activities, ensure appropriate task distribution, evaluate effectiveness, and inspire high-level performance;
Mutual performance monitoring, the ability to develop a shared understanding among team members regarding intentions, roles, and responsibilities so as to accurately monitor one another’s performance for collective success;
Backup behavior, the ability to anticipate the needs of other team members and shift responsibilities during times of variable workload;
Adaptability, the capability of team members to adjust their strategy for completing tasks on the basis of feedback from the work environment; and
Team orientation, the tendency to prioritize team goals over individual goals, encourage alternative perspectives, and show respect and regard for each team member. (p. 587)
National Coalition on Care Coordination (N3C; http://www.nyam.org/social-work-leadership-institute-v2/care-coordination/n3c/about-n3c.html), with a particular focus on older adults, was formed in 2008 as a partnership between Social Work Leadership Institute, the American Society on Aging, and Rush University Medical Center. The N3C represents 37 organizations to advocate for enactment of public policies that support care coordination.
National Transitions of Care Coalition (NTOCC; http://www.ntocc.org) was formed in 2006 to improve the quality of care coordination and communication when patients are transferred from one level of care to another. NTOCC works with more than 30 professional associations, medical specialty societies, standards bodies, regulators, and government organizations to develop, review, test, critique, and implement NTOCC-produced tools and materials supporting improved transitions in care.
Patient-Centered Primary Care Collaborative (http://www.pcpcc.org/) is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians, and others to develop and advance the PCMH. The purpose of the organization is to disseminate results and outcomes from medical home initiatives, advocate for public policy that advances and builds support for primary care and the medical home, and convene stakeholders to promote learning, awareness, and innovation of the medical home model.
Partnership to Fight Chronic Disease (http://www.fightchronicdisease.org) is a national and state-based coalition of patients; providers; community, business, and labor groups; and health policy experts committed to raising awareness of chronic disease as the number one cause of death, disability, and rising health care costs.
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