Principles of Care Coordination
Name
Institutional Affiliation
Health Care Coordination
Introduction
Health care teams are unique to each other by their modes of operation, purpose, composition of membership, methods of communication, size, and setting.o Despite these unique characteristics, there are core principles that encompass their collective purpose. Some of these principles include shared objectives, a clear role description, mutual trust, effective communication, and quantifiable outcomes and processes. These principles are intertwined, although they are independent of each other.
Shared Goals
The basis for a competent health care team is the team’s uptake of the laid collective objectives for achieving positive patient care outcomes. Shared goals must actively involve the patient, the caregivers, and other family members (Song et al., 2017). To that extent, teams share several practices and stages about instituting shared roles. Caregivers and the family are an integral part of the team that seeks to provide patient-centered care that creates a social impact on society. Commitment to patient involvement in teamwork is a central principle acknowledged by the patients and their families as the real owners of the care plan.
In integrating patients into the healthcare team, the role of the patient in the team is defined and embraced with a shared commitment. The teams frequently evaluate their progress on the shared goals and coordinate with the patients and their families to refine the aims and work towards achieving them. In most instances, these updates are done daily during the patient-centered hospital-physician rounds, where the daily events are reviewed, and an assessment care plan created with a focus on the progress towards patient discharge. The teams reaffirm the commitment to the shared goals and allow clarification where there are misunderstandings. The organizational features that contribute towards the attainment of shared goals include;
- Giving time, space, and support for a comprehensively exchanging of information between team members whenever they begin to work with a new patient or family.
- We are working on establishing a written care plan accessible to all members and is updatable by all team participants.
- Supporting the capacity of the team for progress monitoring for the patient/ family shared goals.
Clear Roles
The expectations for each team member regarding their responsibilities, accountabilities, and functions increase the team’s effectiveness and enable it to enhance the division of labor, which achieves more. Health care team members come from diverse backgrounds, which means that they have diverse skills and knowledge as well as behavioral characteristics based on the practices within their lines of discipline. Teams are also influenced by the cultural and social norms that exist within their workplace environments. Integrating patients in the teams requires careful planning because these are a unique set of team members in many ways, given that they do not have any formal training in matters to do with healthcare (Olmos-Ochoa et al., 2019). Language may become a barrier when patients cannot articulate themselves to the other team members. Team membership keeps changing because patients join and leave the teams many times, forcing the reconstitution of the team regularly to adapt to the new changes continuously. Patients always learn new rules and customs of the new health care team.
Collaboration within team members ensures that roles assignment harmonizes experiences for the benefit of the patients; hence clear and measurable expectations are necessary for every member of the team. The factors that facilitate the realization of clear roles include:
- Allocating time, space, and supporting interprofessional training aimed at giving opportunities for practicing skills and values that enhance teamwork.
- Facilitating and enhancing communication within the team on issues about their roles and responsibilities.
- Restructuring the care process by evaluating the team members’ capabilities to ensure the provision of safe and effective patient care.
Mutual Trust
Personal and professional support of team members enhances the provision of health care services. Mutual trust entails establishing, maintaining, and creating provisions for addressing trust issues as well as mitigating the breach of trust (Gross et al., 2016). Trust, therefore, trust is the fabric that interweaves the team members to function to their full potential by relying on the support they receive from the other team members.
Personal values of each member, which are essential in establishing and upholding trust, include; discipline, honesty, creativity, humility, and curiosity. Effective communication between health care providers and patients can enhance or foster a trusting relationship.
The values within an organization that promote mutual trust include;
- Creating the time and space to support team members to interact and know each other well.
- Embedding the values of high-performance team-oriented care in the education and hiring processes.
- Developing the skills and resources within the team for effective communication and conflict resolution.
Effective Communication
The team’s communication skills are regularly refined using consistent channels of communication that are accessible to all team members. A failure of the team members to provide accurate, quick and active information and understanding to each other will lead to ineffective communication. Successful team communication incorporates several channels, including telephone conversations, text and chats messages, email, and even though teleconferencing using technologies like zoom and Skype. Framing the communication content causes the effectiveness of the communication and is considered a critical element of a team and not an individual (Khera et al., 2017). Setting high standards for consistent and clear professional communication among the team members is a precursor to a high-achieving team. Effective communicators are keen listeners who actively listen to the other team members’ contributions, including the patients and their family members. The latter participate more in the team by listening, and their contributions are facilitated through active listening to other team members.
The organizational characteristics of effective communication include;
- Creating sufficient time and space to support the team’s meetings both physically and virtually to deliberate on a care course and other processes.
- Training of members in the expectations and methods of shared communication.
- Making use of digital literacy in electronic media capacities and resources such as email and web-based support options to facilitate seamless communication among the members of the team with special consideration to the patients and their families.
Measurable Process Outcomes
The team uses feedback to highlight successes and failures of the group as well as track and improve on its performance. Highly effective teams integrate all the team-based care principles discussed above. Shared goals aim to achieve better outcomes in patient-oriented care through the sharing of roles and responsibilities among the team members with accountability (Sharma et al., 2018). Furthermore, they emphasize the importance of trust relationships by active participation in building and maintaining respect and trust. Teams must embrace effective communication in the patient care process. Continuous measurement of the team’s effectiveness enables it to identify potential barriers, and it facilitates the design of the strategies to overcome them. Team-based health care is assessed through two metrics; team functioning and process outcomes.
The characteristics that support useful measurement of team outcomes within an organization include;
- Continuous improvement and prioritization of team outcomes by ensuring that data provided makes a positive contribution to the team efforts.
- Development of routine procedures for measuring team function to enable continuous improvement in team-based care processes.
- Provision of sufficient time, space, and support for team members to collectively evaluate the processes and outcomes.
Conclusion
The principal objective of coordinating health care provision is to ensure that the patient and their family are central to the team’s aspirations. Team-based care must match resources to the needs of the patient to maximize value. Efficiency is enhanced through consensus building and establishing clear communication channels.
References
Gross, A. H., Leib, R. K., Tonachel, A., Tonachel, R., Bowers, D. M., Burnard, R. A., … & Bunnell, C. A. (2016). Teamwork and electronic health record implementation: a case study of preserving effective communication and mutual trust in a changing environment. Journal of Oncology Practice, 12(11), 1075-1083.
Khera, N., Martin, P., Edsall, K., Bonagura, A., Burns, L. J., Juckett, M., … & Majhail, N. S. (2017). Patient-centered care coordination in hematopoietic cell transplantation. Blood advances, 1(19), 1617-1627.
Olmos-Ochoa, T. T., Bharath, P., Ganz, D. A., Noël, P. H., Chawla, N., Barnard, J. M., … & Finley, E. P. (2019). Staff Perspectives on Primary Care Teams as De Facto “Hubs” for Care Coordination in VA: a Qualitative Study. Journal of general internal medicine, 34(1), 82-89.
Sharma, N., O’Hare, K., O’Connor, K. G., Nehal, U., & Okumura, M. J. (2018). Care coordination and comprehensive electronic health records are associated with increased transition planning activities. Academic pediatrics, 18(1), 111-118.
Song, H., Ryan, M., Tendulkar, S., Fisher, J., Martin, J., Peters, A. S., … & Singer, S. J. (2017). Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: a mixed-methods study. Health care management review, 42(1), 28-41.