Coordinated Value: There’s Power to be Found in Collaboration

Leading health care organizations are building and maintaining winning cultures by giving multiple professional constituencies a voice in patient care.

In today’s team-based health care environment, a pharmacist can be a physician’s trusted advocate. It’s a role that Sean Jeffery, PharmD, AGSF, embraces wholeheartedly as director of clinical pharmacy at Integrated Care Partners of Hartford Healthcare in Wethersfield, Connecticut.

By providing prescription guidance, Jeffery helps many of the health system’s 2,000 providers — and particularly its 400 primary care practitioners — bridge any potential gaps in patient care. “They’re the champion for the patient,” he says of the physicians.

Jeffery informs physicians about new medications and safety concerns. He also compares peers’ prescribing patterns and recommends generics when appropriate. “Some physicians need some extra TLC,” says Jeffery, a board-certified geriatric pharmacist who previously worked for a VA health system and also is a clinical professor at the University of Connecticut School of Pharmacy.

James Cardon, MD, FACC, a noninvasive cardiologist and Integrated Care Partners’ chief executive officer, who oversees the care management team, notes that “most providers welcome the additional support and the insight.” Clinical pharmacists, he adds, “can be the eyes and ears for our primary care providers and specialists.”

That’s how it’s supposed to go. Research has demonstrated that when health care organizations nurture a collaborative culture among physicians, nurses, pharmacists and other allied professionals, patient care is enhanced while costs decrease. As team-based models continue to take root in managed health care, the workload of care increasingly is distributed among practice staff. And while the physician remains as the leader of this team by tradition, other professionals are beginning to assert their voices and influence.

When humans interact, conflict has the potential to follow, but effective leaders can find common ground in bringing different working groups together to achieve the same goal: better patient outcomes.

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At Cleveland Clinic, implementation of a team-based model for high-use cancer patients reduced unnecessary hospitalizations, emergency department visits, unplanned readmissions and length of stay, according to a study presented at the American Society of Hematology’s annual meeting in December 2017.

In the cancer institute, about 6 percent of the Cleveland Clinic’s patients account for about 40 percent of unplanned readmissions within 30 days of discharge and emergency room visits. Many of them are oncology patients. “These patients continue to be the highest risk of future admissions, ICU stays, ED visits, overuse of chemotherapy and underuse of hospice resources,” the study’s authors noted.

To address this issue, the hospital formed an interdisciplinary care team of palliative medicine and oncology physicians, social workers, care coordinators, advanced practice providers, nurses, pharmacists and psychologists.

The interdisciplinary care team strongly suspected that a few patients were driving the metric of readmissions. About 10 percent of those who were readmitted ended up back in the hospital multiple times. “It’s a good population to focus on,” says Alberto Montero, MD, MBA, CPHQ, a medical oncologist and quality improvement officer at Cleveland Clinic.

Starting in October 2016, on a bimonthly basis, the team began discussing patients who had had two or more unanticipated hospital readmissions in the preceding 60 days. Then they developed individualized care plans in an attempt to break the cycle of repeated unplanned readmissions and ED visits, Montero says.

“Hospitalization is a major contributor to cost,” he says. “Unplanned readmissions are not only not good for patients — in many cases, it’s a sign of some sort of failure or breakdown in their care.”

The team notes a specific plan in the patient’s chart for the emergency department to follow. Barring any acute issues, the plan directs the emergency physician to discharge the patient with instructions for scheduling a follow-up appointment with his or her outpatient oncologist within five to seven days. “We have very good adherence to that,” Montero says. “It has been sustainable.”

Providing palliative medicine at home or telemedicine in a local clinic can help avoid unplanned readmissions. “We really look at different ways to ensure that the patient’s needs are addressed, so they don’t have to come to the emergency room or be admitted to the hospital,” he says.

Lack of transportation also could be a barrier to care for some patients, so it’s important to enlist a social worker’s help in resolving the problem. “We recognize that a lot of unplanned readmissions have to do with social issues, not just medical issues,” Montero says.

Including a psychologist on the interdisciplinary team also can help reduce unnecessary emergency department visits and readmissions by addressing behavioral issues or transitions, regardless of patient age, says W. Douglas Tynan, PhD, ABPP, director of integrated health care practice at the American Psychological Association.

Tynan says a well-rounded team can help determine when an issue doesn’t require pharmaceutical intervention, and when psychological intervention can help alleviate the anxiety that patients and families sometimes experience. “Staff in hospitals are really well-intended and really want to do the right thing,” says Tynan, who practiced as a pediatric psychologist in hospital inpatient and outpatient settings. But “sometimes, they have a hard time reading the signals that family members give off.”

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Maintaining a solid interdisciplinary relationship with other providers helps maximize everyone’s performance, particularly under stressful circumstances. It can prevent errors and near-misses in various situations — for instance, during patient handoffs such as a transfer from open heart surgery to the intensive care unit, says Mary Dale Peterson, MD, MSHCA, FASA, FACHE, incoming president-elect of the American Society of Anesthesiologists and vice president of Driscoll Health System in Corpus Christi, Texas.

“If we look at the airline industry, it’s a great example. We’ve seen such a tremendous improvement in airline safety in the last two decades,” Peterson says. “Yes, you have a pilot and co-pilot, navigators and flight attendants. Everybody on that team is able to speak up if there’s a safety issue.” In health care, she adds, “We have tried to emulate the airline industry in learning from them.”

Delegating tasks among interdisciplinary team members is important as well. Other health care professionals — not just the physician — can manage some of the patient’s needs, says Hal Lawrence, MD, FACOG, chief executive officer of the American College of Obstetricians and Gynecologists. In fact, “it really enables more services to be provided and better utilization of the physician’s training and skills for more complicated issues,” he says. “There are other team members who can take of more-straightforward ones.”

Within each team, original roles and responsibilities should be defined and clarified. “We all need to know what our skills and abilities are,” says Lawrence, who practiced as an OB-GYN in Asheville, North Carolina, for three decades. “None of us can do everything.”

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Opportunities for interdisciplinary collaboration are on the rise in education and hands-on training. Students of medicine, nursing, pharmacy and social work are encouraged to interact and team up on projects, says Lori Bishop, MHA, BSN, RN, CHPN, vice president of palliative and advanced care at the National Hospice and Palliative Care Organization.

“When you can start to see the value of that early on, and build in the education, then you’re going to get a better collaboration when you move out of that space,” she says.

Bishop has observed the evolution toward an interdisciplinary health care environment since she “cut her teeth” as a hospital bedside nurse in the early 1980s. “There was definitely a hierarchy in the hospital culture,” she recalls, adding that the trend has shifted away from a top-down leadership style. “A culture where there’s such a strong hierarchy does not bode well for safety.”

In contrast, a culture that values everyone’s contribution would, for example, encourage team members to double-check an order and speak up if something is amiss. “It starts at the leadership level for setting the tone and expectation for that type of collaboration,” Bishop says.

Ensuring participation from a variety of health care professionals on a committee can facilitate analysis of root causes and optimization of quality standards. “Having an interdisciplinary representation during the problem-solving makes for a richer improvement,” she says.

Hospice physicians, nurses, social workers, chaplains and pharmacists typically hold interdisciplinary meetings a minimum of every two weeks to discuss the patients whose care they’re managing. A patient’s primary care physician often can’t participate in real time, Bishop says, so the team usually sends notes and offers the opportunity to comment or make changes.

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Carol Greenlee, MD, FACP, FACE, chair of the council of subspecialty societies at the American College of Physicians, maintains that health care practices still need to make progress in becoming more interdisciplinary.

“One of the big cultural and operational issues has been that we all worked in silos,” she says, explaining that health care professionals viewed themselves as “self-sufficient solo heroes.” That type of mentality led to “disconnected care,” says Greenlee, who helped develop ACP’s High Value Care Coordination Toolkit .

“When the physicians’ lounge was the central gathering point, we connected more,” she says. “It turns out that the doctors’ lounge helped connect care and reduce burnout, and as they disappeared, more separation was created.”

The electronic medical record has taken on the appearance of fostering connections, but too often it has supplanted interpersonal communication. And in some instances, partners of the same medical group have declined to share protocols, as they displayed an “inborn competition of wanting to be better than everybody else,” says Greenlee, who practiced as an endocrinologist for 32 years, the last decade in Grand Junction, Colorado.

But she is also noticing an uplifting trend. “Now, we strive to have patient-centered team care where different team members play different positions or roles in caring for the patient,” she says. “The scheduler helps ensure the patient gets the appointment they need. The medical assistant or nurse no longer just ‘rooms the patient for the doctor’ but plays a part in the care the patient receives. Instead of looking at their job as doing tasks to help the physician, everyone is focused on meeting the patient’s needs.”

At Children’s Hospital Colorado, a recent initiative focused on including bedside nurses in family-centered patient rounds. During a visit with the child and family, the physician turns to the nurse and asks, “Is there any information from the nursing team that we need to consider for the assessment?” says Daniel Hyman, MD, MMM, chief medical and patient safety officer at Children’s Hospital Colorado, located on the Anschutz Medical Campus in Aurora, Colorado.

“There is a recognition that different perspectives people have from different disciplines are not just necessary, but they’re essential to accomplish the best outcomes that we can for our patients and our families,” he says.

On most of its floors, the recent addition of a clinical pharmacist to these rounds is another example of “expanding interdisciplinary involvement.” By referring to a mobile tablet, the pharmacist can provide expedited insight into medication management and answer questions from the patient’s family and the health care team, Hyman says.

Pharmacists increasingly are being incorporated into consulting roles and while being viewed as core members of the interdisciplinary team for their skills in medication management. “But until other providers have worked with pharmacists, they may not understand the expertise and what they can bring to the table,” says Anne Burns, RPh, vice president of professional affairs at the American Pharmacists Association.

One of the fastest-growing segments of the pharmacy profession is incorporating pharmacists into physician group practices or accountable care organizations. Pharmacists often work in collaborative agreements under a physician’s guidance to monitor patients with chronic diseases and their medications between appointments with other providers, Burns says.

“They can contribute significantly to improving outcomes and controlling costs,” she says, noting that “turf issues” among providers tend to subside in team-based care models. “As we evolve and realize that one person can’t do everything, the move to have many members working together seems to be catching on, and I think it’s good for patients.”

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By sharpening focus on a patient-centered approach, the interactive dynamic becomes less competitive and more collaborative, says Stuart M. Levine, MD, FACP, president and chief medical officer at MedStar Harbor Hospital and senior vice president of MedStar Health in Baltimore, Maryland.

“The way you align the team members is through common sense of purpose and having a clear eye on the outcomes that you want to envision,” says Levine, who is also a practicing rheumatologist.

An interdisciplinary pilot effort, launched in summer 2016, gradually expanded to every hospital in the system. It’s now deployed in all 10 of MedStar’s hospitals in Maryland and Washington, D.C.

From large group education to more intimate training with team-based exercises, stakeholders from a variety of disciplines helped create media and online-based learning materials. Videos offered a snapshot of interdisciplinary rounding and a standardized checklist to ensure safety and transitions of care by hitting “salient points for every patient,” Levine says.

Afterward, weekly touchpoint calls led by a senior program leader share best practices and troubleshoot any challenges. “We’re constantly learning,” he says. “We’re constantly refining. We’re constantly adapting the model.”

Susan Kreimer is a freelance health care journalist based in New York.