Care Coordination: Physicians Working as Teams

When a patient goes to the clinic, they often see a nurse and a doctor. However, when they go to the hospital, they might be treated by many nurses and doctors and even specialists.

As clinical cases do not require as many healthcare professional interventions as critical cases that enter hospitals, the lack of a coordinated care cycle is not as easily seen. However, in hospitals, it is evident that the network of doctors treating a patient is a linear line, not a circle of care.

When a general practitioner needs expertise from a specialist, the patient is often handed off. The same goes for when a patient is admitted to the ER and needs surgery. Patients go from one pair of capable hands to another. Patients don’t rotate back to the first doctor that saw them and the doctors that treated that patient rarely interact with one another.

So how can the healthcare system move towards a care cycle rather than an assembly line?

The Downfalls of Linear Medicine

Medicine has always been about doctors working alongside nurses and other healthcare professionals. Doctors are solo practitioners working among colleagues that all have a common goal: to treat their patients and ensure their health. Why is it though, that they work among them and rarely with them on a single patient?

Eric Dishman presented the concept of “Care Networking” in his TED talk video on how Healthcare should be a team sport:

In his talk, he explains how he was once diagnosed with a “heart problem” and was prescribed various medications for five weeks until a nurse noticed a problem with his list of medications. Three different doctors had prescribed three different versions of the same drug to him. He didn’t have a heart problem, but rather an overdose problem that led him to having heart palpitations and the reason he kept being treated.

“We have got to go beyond this paradigm of isolated specialists doing parts care to multidisciplinary teams doing person care. Uncoordinated care today is expensive at best and it is deadly at worst. Eighty percent of medical errors are actually caused by communication and coordination problems amongst medical team members.”

In fact, incorporating more medical personnel in the care cycle has proven to be more efficient and lead to better quality care and positive patient outcomes. A Denver clinic has applied the team-based approach by having a medical assistant interact with patients much more than the doctor, collecting information such as medical history and symptoms as well as listening in on doctor visits. They are then better suited to go over a patient’s course of treatment with them after the visit and ensure they understand everything.

Not only does this ensure a more accurate care coordination centered around the patient, but it also frees up some valuable time for the doctor, allowing him or her to see more patients.

Working Towards Team-Based Care Coordination

Having doctors and nurses interact with one another surrounding a patient rather than a medical file can solve many errors. This should not be a concept, but rather, a reality. Care coordination should start well before a patient needs to be admitted to the emergency room.

Not only do medical assistants help in hospitals, but clinics can play a big part in care coordination and diminishing patient trips to the ER. With nurses going over patient files, speaking to patients, collaborating on certain treatment paths and working as a team, healthcare can move towards preventive plans rather than interventions.

Utilizing services such as chronic care management also allow for closer ties with patients through monthly calls. They allow care professionals to assess a patient’s chronic illnesses and ensure they are not only well cared for, but feel empowered.

Through detailed care plan reviews each month, patients are given the resources and tools to manage their chronic conditions and their doctors and care team are always aware of the slight changes in conditions the moment they happen. Having easy access to all notes also lets many team members review and ensure the health and safety of their patients.

This will become increasingly important with healthcare moving from volume-based to value-based care payment methods under MACRA.

The whitepaper New Options in Chronic Care Management discusses the CCM program and it’s contribution to care coordination through personalized care from nurses that work with both the patient and doctor.

Download the Whitepaper

About the Author

Jennifer Morency is the Content Marketing Strategist for Wellbox, the all-inclusive solution for tracking and billing for Chronic Care Management and Annual Wellness Visits, as well as offering in-demand Telemedicine and Remote Patient Monitoring services.


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