5.4.3.1 Patient CMO theory 6: Explaining how assessment and care
planning by an interprofessional team results in better care
coordination
Box 22: Patient CMO theory 6
Resource + Context à Reasoning = Outcome
Shared IP team assessment and care planning - Co-location of services and providers - In-person hand-offs and transfers - Simultaneous first-hand information sharing reduces the number of hand-offs and transfers.
- Face-to-face interaction result in better quality, more effective hand-offs and transfers
Better care coordination
The faculty clinicians and students who designed, developed and experienced the clinic believe when an interprofessional team is responsible for patient assessment and care delivery (mechanism - resource), patients experience better quality handoffs (or hand-overs) and transfers, and there is a reduced need for multiple hand-offs between care providers and transfers between facilities resulting in better care coordination (outcome). A clinic manager stated the following with regards to hand-offs:
"I think that if you could work towards that, where you're like, more closely connected and you know, you're doing the assessment together. Like maybe you have the same exact chart, it's not going to a different facility. And so I guess working better together to make sure like the patient's getting the best care possible. Rather than having more handoffs, or more, like transfers from one place to another. Like people who always, like, consistently know what's happening. It's not like, ‘oh I have to call Dr so- and-so, and then we had to call you know, X, Y, Z, and then it's a bunch of phone tag"
(Student Clinic Manager).
Two contextual factors were identified that were thought to influence the attainment of this outcome. These were the co-location of services and providers within the clinic, and the use of in-person hand-offs and transfers.
Context – Co-location of services and providers
The co-location of specialty services and providers within the same IP clinic (context) was thought to reduce the number and increase the timeliness of hand-offs and transfers.
"We can go straight to one of the specialty clinics and hand-off the patient right there and then. It's just so great to be in the same building. We can talk to each other about a possible referral and make it happen. Yeah, like I said, right there and then" (Clinic Manager).
Context – In-person hand-offs and transfers
Hand-offs and transfers in the clinic occur in- person through face-to-face communication, followed by documentation and referrals within the electronic record. This was thought to be an important feature in achieving the outcome of better care coordination.
Mechanism reasoning – Simultaneous information sharing and more effective humanistic communication
The simultaneous, first-hand information sharing that occurs during an IP patient
assessment was suggested to reduce the need for multiple patient hand-offs and transfers. During an interprofessional team assessment, multiple professions are simultaneously hearing the same information. Information is communicated to the different professional care providers at the same time within the same patient encounter. Interviewees reasoned this reduces the need for multiple hand-offs and transfers. A student leader explained it as follows:
" So we all hear the same story revealed at the same time. We don't have to pass it from one person to another. We hear it in real time, right from the patient. It doesn't get, well… I guess you could say, it doesn't get messed up or lost in translation. We don't need to hand-off to each other, we all get the same information at the same time" (Student Leader).
Interviewees also reasoned that the in-person nature of the handoffs and transfers increased their quality by providing a more effective form of communication between care providers and introducing a more humanistic approach (mechanism - reasoning). In-person patient transfers provide an opportunity to introduce the patient to their new care providers. The introduction of the patient by one provider to another, rather than them being
transferred as information on a page of notes, was thought to improve the quality of hand- offs and transfers by introducing a more human touch to the process (mechanism reasoning). Such care delivery by an IP team was thought to result in better care
coordination, by reducing the number and increasing the quality of hand-offs and transfers between care providers. A student volunteer, who had worked in patient care before joining their current health professional education programme, described the importance of hand- offs and referrals occurring in person:
"It's important because I've worked in places where you got a referral from a physician and you treat the patient but all you send back is the written update, the written progress note and there is no conversation at all. There's no phone call, there's no face-to-face interaction really talking about this patient. So that's when, kind of, information's lost. So you're kind of just stats on a piece of paper and that's what determines improvement or not. So it's important to have that communication, and in-person" (Student Volunteer).
A student leader described how patient referrals and hand-offs occur in the clinic as follows:
“We get the in-house referral from the doctor or the physician assistant, and yeah, they, and then we treat them and you know we say okay you’re going to go back to the doctor, see what they say…. they talk with each other. You know this patient is progressing this way, I am concerned about this, can you take a look, give us your ideas, that kind of thing. So being in the same building, having that ability to talk with each other is really helpful” (Student Leader).
And from another student:
"Yeah, because you know in a regular outpatient facility they'd refer to PT and what they might get back is a discharge note or something like that. So like, that
conversation piece is the additional thing that happens in the clinic. It's better. Better for the patients too, we get to take them to meet the other people who will care for them. They actually meet them. We get to hand them over in person, introduce them as a real person” (Student Clinic Manager).