Interprofessional Healthcare Team Meeting (IPE)
Summary
TLDRThe video features Ral Kar, medical director of a clinic, discussing the interprofessional collaborative approach for treating patients with multiple chronic diseases. The clinic's transdisciplinary team, including medical professionals, social workers, and health promoters, focuses on holistic care, addressing medical, educational, and socioeconomic barriers. The team discusses a patient's care plan, highlighting their collaborative efforts to navigate complex healthcare needs and connect patients to community resources.
Takeaways
- 🏥 The clinic specializes in caring for unfunded patients with multiple chronic diseases who frequently use hospital or emergency services.
- 👥 Care is provided through a transdisciplinary team model that includes a provider, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist.
- 🤝 The team operates with a flattened hierarchy, emphasizing collaboration and equal input from all members, regardless of their professional role.
- 📋 The team's approach is patient-centered, focusing on education, health literacy, and addressing socioeconomic barriers to care.
- 🏠 The team conducts home visits, which are crucial for understanding patients' lifestyles and providing personalized care.
- 📝 The clinical pharmacist plays a vital role in consulting on medication management across all teams.
- 👩⚕️ The advanced practice registered nurse provides comprehensive care, including physical exams, diagnostics interpretation, and patient education.
- 👩💼 The medical social worker addresses biosocial concerns and barriers, such as family dynamics, finances, and mental health, that impact patients' health.
- 🌟 The health promoter or community health worker establishes trust with patients and serves as a liaison between health services and the community.
- 🍽️ The dietitian, with a focus on diabetes education, works with patients to understand their dietary needs and lifestyle, often conducting home visits for better rapport.
- 📆 The team coordinates care by reconciling medication lists, managing appointments, and ensuring patients have access to necessary resources like Meals on Wheels.
Q & A
What is the primary focus of the clinic described in the script?
-The clinic focuses on the care of unfunded patients with multiple chronic diseases who are high utilizers of hospital or Emergency Department Services.
How does the health care delivery model differ in this clinic from traditional settings?
-In this clinic, care is delivered through a transdisciplinary team model that removes hierarchy, emphasizing collaboration and equal importance of all team members' voices.
What roles do the team members play in the patient's care plan?
-Team members include a provider, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist, each contributing unique skills to address medical, educational, socioeconomic, and community resource needs of the patients.
What is the significance of the patient-centered approach mentioned in the script?
-The patient-centered approach involves the patient as part of the care team, considering their unique needs and circumstances to formulate realistic care plans and improve outcomes.
How does the advanced practice registered nurse contribute to the team?
-The advanced practice registered nurse provides comprehensive care, including physical examination, diagnostics interpretation, prescribing, patient education, care coordination, and communication with other providers.
What specific challenges does Mr. John Smith face as described in the case conference?
-Mr. John Smith faces challenges such as an upcoming change in housing, safety concerns due to leaving the stove on, psychiatric symptoms possibly indicating medication issues, and visual hallucinations leading to an emergency department visit.
What is the role of the medical social worker in addressing Mr. Smith's situation?
-The medical social worker assists Mr. Smith in addressing biosocial concerns and barriers, such as family relationships, finances, housing, transportation, and mental health, which may hinder his health.
How does the health promoter or community health worker contribute to Mr. Smith's care?
-The health promoter establishes trusting relationships with patients, serves as a liaison between health and social services, facilitates access to services, and improves the quality and cultural competence of service delivery.
What is the significance of the dietitian's role in the team, particularly for Mr. Smith?
-The dietitian provides specialized care for patients with conditions like diabetes, hypertension, and other dietary needs, offering home visits for a better understanding of the patient's lifestyle and to tailor care accordingly.
What steps are being taken to address Mr. Smith's immediate needs and future sustainability?
-The team is planning to increase their involvement with Mr. Smith by providing wraparound care, connecting him with resources like Meals on Wheels, assisting with medication management, and exploring housing opportunities to ensure his immediate needs are met and a more sustainable long-term plan is in place.
Outlines
🏥 Introduction to the Interprofessional Healthcare Team
Ral Kar, the medical director, introduces the clinic's focus on caring for unfunded patients with multiple chronic diseases who frequently use hospital services. The clinic operates through a transdisciplinary team model, which includes a provider, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist. The team aims to provide comprehensive care, emphasizing education, health literacy, and addressing socioeconomic barriers. They also strive to connect patients with community resources and specialty care. The video will showcase the team's collaborative process in creating a patient's care plan, highlighting the unique, flattened hierarchy that values every team member's input equally.
📝 Roles and Experiences in the Healthcare Team
The team members discuss their roles and experiences. The physician explains the collaborative nature of the team, where no single voice dominates, allowing for a more rewarding practice. The advanced practice registered nurse uses a holistic approach to manage patient conditions, considering psychological, financial, and social factors. The clinical nurse navigator serves as the team lead, facilitating meetings and developing care plans. The medical social worker addresses biosocial concerns and barriers to health, such as family dynamics and housing. The health promoter, or community health worker, establishes trust with patients to improve service delivery and cultural competence. The dietitian, who works with multiple teams, focuses on lifestyle and provides home visits for a better understanding of patients' needs.
🏠 Case Discussion: Mr. John Smith's Changing Circumstances
The team discusses the case of Mr. John Smith, who is facing housing instability and health concerns. He is moving in with family due to the closure of his current residence, but he has a history of anxiety and past verbal abuse from a family member. The team is increasing its support to ensure his care continues, with plans to address his housing situation, medication management, and coordination with specialists. They also discuss his recent emergency room visit due to visual hallucinations and concerns about his medication regimen, which may be causing side effects. The team is working to reconcile his medication list and communicate effectively with all his healthcare providers.
💊 Medication Management and Memory Concerns for Mr. Smith
The discussion continues with Mr. Smith's memory issues and the complexity of his medication management. The team is concerned about potential side effects from his medications and the need for accurate, up-to-date medication lists. They plan to reinforce medication management during home visits and consider options for outpatient programs to support his mental health. The team also addresses his recent cognitive test results, which showed no significant cognitive decline, and the implications for his insurance coverage and potential need for neurologic testing.
🏡 Addressing Mr. Smith's Immediate Needs and Long-Term Care
The team concludes the discussion by focusing on Mr. Smith's immediate needs, such as ensuring he has access to food and managing his gastroparesis through Meals on Wheels. They also plan to reinforce his calendar with upcoming appointments and create a shared document to keep track of his healthcare journey. The team aims to provide comprehensive support, including evaluating his recent ER and psychiatry visits, to consolidate his care and address any issues that may be contributing to his symptoms.
Mindmap
Keywords
💡Interprofessional Collaborative Competencies
💡Transdisciplinary Team
💡Healthcare Navigation
💡Health Literacy
💡Socioeconomic Barriers
💡Chronic Diseases
💡Care Coordination
💡Community Health Worker
💡Clinical Pharmacist
💡Patient-Centered Care
💡Holistic Approach
Highlights
Clinic focuses on care for unfunded patients with multiple chronic diseases and high utilization of hospital services.
Healthcare delivery is through a transdisciplinary team model that includes a variety of healthcare professionals.
Team members include physician, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist.
Emphasis on medical care, education, health literacy, and addressing socioeconomic barriers.
Team seeks to connect patients to community resources and sub-specialty care.
Physician role in the team setting is collaborative, with no hierarchy.
Advanced practice nurse provides holistic care, including home and phone visits.
Clinical nurse navigator facilitates team meetings and develops interdisciplinary care plans.
Medical social worker assists with biosocial concerns and barriers to health.
Health promoter acts as a liaison between health services and the community, addressing social and cultural contexts.
Registered dietitian provides nutritional care and education, with a focus on diabetes management.
Team discusses Mr. John Smith's care plan, addressing recent changes and challenges.
Mr. Smith is moving to a new living situation, which presents both risks and support opportunities.
Team plans to increase involvement to provide wraparound care for Mr. Smith.
Concerns about Mr. Smith's medication management and potential side effects are discussed.
The team considers Mr. Smith's mental health, including recent hallucinations and memory issues.
Coordination of care and communication among specialists is emphasized to ensure Mr. Smith's needs are met.
The importance of patient education, particularly regarding diabetes management, is highlighted.
Team members collaborate on housing solutions and ensuring Mr. Smith's safety and well-being.
The team discusses the potential for Mr. Smith to participate in a diabetes education class for potential benefits.
Coordination of Mr. Smith's medication list and calendar is part of the ongoing care plan.
The team considers Mr. Smith's dietary needs and the possibility of connecting him with Meals on Wheels.
The importance of reinforcing Mr. Smith's understanding of his condition and treatment is discussed.
The team plans to evaluate Mr. Smith's recent ER visit and psychiatric care to consolidate his treatment plan.
Transcripts
I'm Ral Kar medical director for a
clinic that oversees the care of
patients with multiple chronic diseases
the purpose of this video is to
demonstrate the interprofessional
collaborative
competencies by visualizing an actual
transdisciplinary
team in the process of creating a
patient's care plan our Clinic focuses
on the care of unfunded patients with
multiple chronic diseases who are high
utilizers of the hospital or Emergency
Department Services these
patients often have difficulty
navigating through the Health Care
system which can be quite complex and
also face multiple barriers seeking and
obtaining care care is delivered through
a transdisciplinary team model our team
consists of a provider either a
physician a nurse practitioner or a
physician assistant a nurse Navigator a
social worker and a health promoter or
also known as a community health worker
we also have a dietician who
participates on the team there is a
clinical pharmacist available in the
clinic who consults on all the teams as
well together the team provides not only
medical care but also provides a heavy
emphasis on education health literacy
and addressing socioeconomic barriers to
obtaining care we also seek to connect
patients to various resources in the
community and sub specialty care you're
going to meet the members of a care team
hear about their roles experiences
working on a team and observe a typical
case conference where they are
discussing a patients care
plan I'm a general internist by training
at what is unique to The Physician role
in this team setting versus a more
traditional uh hospital setting or
clinic setting is that the hierarchy is
removed and so my voice in an
interprofessional team is no more
important than any other person's voice
at the table um which is very rewarding
and a gratifying way to practice because
you gain a lot from your other team
members and you're really able to lean
on them for things that we can't
completely handle as Physicians
ourselves as the advanced practice
registered nurse on our team for uh I
care for our patients in the clinic and
in the home setting and also by phone
when necessary during these visits I use
a holistic approach to evaluate and
manage new and ongoing patient
conditions I provide comprehens a
comprehensive perspective to our
patients Healthcare needs um this means
that in addition to considering the
patient's medical conditions I also eval
evaluate psychological Financial social
family circum and family circumstances
in order to formulate a realistic care
plan physical examination interpretation
of Diagnostics prescribing patient
education care coordination and
communication with other providers are
some of the specific tasks I perform
daily I also act as a team resource to
troubleshoot complex
issues in regards to working with a team
we utilize a patient- centered approach
to care and consider our patient to be
part of our team as a team we all
contribute un unique skills knowledge
and qualities that allow us to identify
strategies that can lead to improved
outcomes for our patients we communicate
with each other frequently both in
formal meetings and informally by email
and phone calls at our formal case
conferences we review our patient cases
and discuss the care plan and patient
needs as a clinical nurse Navigator I
serve as the team lead including
facilitating the weekly team meetings
additionally I help to develop revise
and communicate interdisciplinary care
plans with the team my role in patient
care involves a combination of home
visits office visits and telephone
conversations with the patient for the
purpose of education assessment and care
coordination my nursing background
includes just over 3 years of intensive
care experience and a Bachelor's of
Science and nursing as a medical social
worker on a transdisciplinary team my
role is to assist patients in addressing
biosocial concerns and barriers that may
hinder them from being as healthy as
they can or hinder them from focusing on
their healthare needs these barriers
often include family relationships
finances housing transportation and
mental health concerns my interactions
with patients include bios
biopsychosocial assessment
individualized treatment planning care
coordination discussion of referral to
federal state county and City
programs and
education within the hospital system for
which I work um I've worked for almost 5
years all medical social workers must
have earned a master of Social Work
degree prior to hire and hold a licensed
master a social work licensure or
licensed clinical social work licensure
as a health promoter Community Health
worker I'm a Frontline Public Health
worker whom establishes trusting
relationships with patients to better
serve as a liaison link intermediary
between Health and Social Services and
the community to facilitate access to
services and improve the quality and
cultural competence of Service delivery
I'm also certified as a clinical nurse
assistant having worked in an orthot
trauma unit for 7 years for certifying
as a health promoter and Community
Health worker uh in this
interprofessional team um I help
patients understand and incorporate
their care plan into their lives
considering social and cultural context
um I also help identify barriers to the
team that they were unaware of um in my
list of Duties I reinforce education
taught to patients with chronic
illnesses uh assist patient with
preparation for important appointments
visit patient in hospital Andor Patients
Preferred locations such as home visits
or clinical uh appointments help locate
patients whom have become inactive or
are homeless uh accompany patients to uh
Primary Care specialty and other Health
Community Resource appointments uh coach
patients in order to promote self-care
Independence patient advocacy resource
allocation liaison for patient between
medical community and Community
Resources help identify safety hazards
in patients dwelling and help manage
patient source of transportation and or
communication I am a registered
dietitian I have a bachelor's degree in
nutrition and I have been a certified
diabetic educator for 11 years and have
worked in the outpatient setting for the
past 16 years my role as dietitian
within the team is slightly different
than the other team members and that the
dietician is not specifically designated
to one team but instead is designated to
three or four different teams I try to
schedule as many of my appointments as
home visits because I find that I have a
better chance to obtain an ACC accurate
picture of the patient's
lifestyle and also that I tend to have
much better rapport with the patient
when I have home visits um the majority
of the patients I see are for
diabetes but in addition to that I also
have referrals for hypertension
congestive heart failure high
cholesterol celiac disease as well as uh
periodic interal tube feeding I rely on
communication from my team members for
accurate information as to why I've
received the referral as well as what
the patient is wanting out of the
referral I look to my designated
advanced practice nurse when I am
confronted with a medical condition
outside of my scope of care and for
example a patient with a very high blood
sugar during the visit I also
periodically make referrals to my other
team members when a patient need arises
that is also outside of my scope of care
um for example if a patient needs to be
accompanied to a specialty
appointment okay so in our meeting today
I think we're going to talk about uh Mr
John Smith who has had some recent
changes so Megan do you want to speak a
little bit more about the changes sure
um so as El mentioned we we visited
yesterday to his residence at front
steps um we learned actually when we got
there that he is going to be leaving as
of tomorrow and this was brand new
information to him yesterday as well so
um we this has been sort of I think a
little bit cing um he's living with a
few other residents and most of them are
pretty independent and it seems as
though Mr Smith has been being watched
out for by these roommates which is very
sweet but it's not their responsibility
it's not part of what they're supposed
to be there they're supposed to be there
for their own
Services um but it seems as though
separately that they're closing the
house so the last of the roommates
actually moves out tomorrow as well so
that we know one
there and in addition to that it he's
been leaving the stove on so it's been
he's he's unsafe by himself and he has
also it seems as though his psychiatric
symptoms have been presenting themselves
um maybe his medications aren't working
at this point maybe he's um so that
that's something that has recently been
visited but he most recently uh seemed
to be having some visual hallucinations
and saw something on the wall that was
very upsetting to him so it actually
resulted in him going to the emergency
department um and so besting this has
all been coming coming to a head so Leah
the I think most of you know her she
runs The recuperative CARE program
through front
steps um so she had a conversation with
me yesterday we happened to be there and
the plan is for him to move in with his
mom and stepdad I think we've spoken
before he has some anxiety around his
stepdad uh he used to live with them
there's uh dad uses alcohol stepdad us
alcohol and there's been some verbal
abuse in the past so he he's got some he
was pretty anxious about it but
recognizes that it's the only other
option right now so where I see us
coming in is to really step up our
involvement with him provide some
wraparound care and try to to fill in
where he's been so dependent on Leah and
front steps for so long that we really
need to step up our involvement and make
sure that he gets the care he needs
until he gets well continuing on past
the time that he gets more housing
different housing
situation and I can help to um find some
programs to help get him out of the
house I know that's going to be a focus
for him going forward um at least in the
interim with hopefully this is just a
temporary situation and we can find him
something more sustainable long term um
I can help with that and and one thing
that I did hear recently that I think
would be a perfect fit for him is
there's a diabetes education class um it
sounds like it's um it's on Tuesdays I
think once a week for a couple hours and
if he goes to seven out of the eight
classes he gets a a grocery store gift
card for about $200 so I think that
would be right up his alley in several
ways so um I think Kristen I think
you're connected with the dietitian that
runs that program right I know the
dietician that facilitates that so I can
get him in touch with her okay yeah that
would be great okay I think that would
be a good place to to start so and
relating to his housing I will be seeing
him tomorrow because his um funding is
about to expire his map card so as I'm
there while we're waiting for his
appointment to start we can start
calling around and seeing if there's any
housing opportunities for him since we
know his current situation has to be
temporary since he's not comfortable
being at home
so um well Megan you had mentioned um
the hallucinations and some um memory
and mental health issues and I know I
know he's on many meds for many chronic
conditions and I'm kind of concerned
that you know these meds may be causing
some issues for him and and it sounds
like we may not even know exactly if
he's on all of those medications and
he's got several Specialists so they may
not even have the most upto-date
medication list so um I'll work to uh
reconcile his medication list and then
chenia maybe we can uh coordinate so
that um we can communicate the most
accurate medication list to all of his
specialists and his primary care doctor
that sounds great idea yeah I mean
usually since I accompany him to these
appointments to make sure that if there
are any changes I also assist him uh
communicating that to all of his
providers is he being stable with his
primary care provider
um yes but um you know just
Transportation has been an issue you
know getting him to his appointments um
he always complains about foot paint um
he doesn't have the best diabetic shoe
so I'm going to try to help him
coordinate that but um if he loses front
steps they are the ones that also
assisted him with getting into his
appointments so that's that's going to
be another issue that we're going to
have to kind of figure out but he he he
does try to make it to his appointments
they never have the um updated med list
so that's been an issue so really
communicating to the providers is going
to be the key here that's something an
and I can work on together reaching out
to them that actually couple those
points um we he did earlier last week I
accompanied him to an appointment with
his psychiatrist atcc
and so hopefully we're we can address
those um the psychiatric concerns that
seem to be presenting themselves right
now they did what sort of brought it on
was of course the emergency room visit
but also of course um his ixa yeah has
it increases blood sugar as one of a
side effects so they've decided to put
him back on HD he's not it for a few
days now um but he does have a history
of tarto discinesia um as result of that
he's had some hand tremors so he's a
little bit concerned about that but um
the psychiatrist and and Mr Smith
decided that they were they would try
that at this point um
also he had regarding the memory that
you had addressed he the psychiatrist
did do a cognitive test on him the mini
mental status exam and he actually did
pretty well on it on a scale of 30 he
got a 25 which is wonderful because it's
demonstrating that he's not you know
having some cognition issues of course
but I think demonstrating it in to day
living yeah we had discussed that
there's that memory the gaps in there
that short-term memory is really
troubling from our perspective
so um we were hoping that if he scored
low enough on this exam that that would
suggest that he would be eligible for
disability and then he could with that
Associated funding source of Medicare or
Medicaid depending on his work history
that you would be able to go ahead and
get some neuros testing um but you can't
get the neuros testing unless you have
um a funding source such as Medicaid or
M Medicare and map won't pay for it so
so it's kind of um hoay for having a a
high level high score on your cognition
test but also what's going on with his
memory and and getting him some good um
long-term insurance coverage so so just
want to update you guys on that and
regarding the memory issues as well as
you guys know I had been doing uh weekly
home visits with him to um help fill his
pill box and make sure his medications
are refilled and that kind of thing um
so we can try to move those um to the
hospital I guess uh if he's open to that
I think he will be to get out of the
house um so when I do those it's it's
obviously really helpful for me that you
have those medication lists and then if
you guys could help to reconcile the
medication list so that I'll know um
what needs to go in his pill box um and
I'll help him with that we'll also try
to make as many of the calls as we can
during those visits um but sometimes I
know there's still some followup that he
needs to do afterwards to get some
medications so for the most part you
know I because he does like his
independence as much as he can have it
so I I will occasionally send him a
reminder to just call the pharmacy and
do the the refill so it helps him it
helps him to
be he and also he completed his um SE
and behavior health IOP program with
Julie and Julie had recommended that he
now that he's completed that that he
continue um with an outpatient program
where he can actually work and get a
meal um he can be there a couple days a
week um and he's also expressed some
interest in doing some alanon classes to
deal with the stress of being at home
with his dad and the potential alcohol
abuse that could continue to happen
there so there'll be other ways for him
to get out of the house it sounds like
he's expressed interest so he has he
actually mentioned an Austin Clubhouse
which I was going to try to get
information for so when I do see him
tomorrow it is a um map renewal
appointment I was going to kind of help
him do some research and provide
whatever I can find so and if you have
any ideas let me know M we'll do so
having him see you and I think we should
continue to help him brainstorm some
options help him get out of the house
sounds good I'll definitely do that on
my weekly visits and and additionally
obviously the pill boxes and um you know
assessing him for the various concerns
that we have um we know he has the the
memory issues and other clinical things
going on so I can help keep an eye on
those and and check vitals and things
like that as well as well um and
speaking of those weekly visits I wanted
to mention to you Kristen the last um
home visit that we had with him he
mentioned that he was having a low blood
sugar uh whenever he was getting off the
bus one day and so he um went to the
convenience store to buy a Diet Coke and
drink that um in hopes of reming his low
blood sugar so um between you and I
maybe we can both give him some
education on um on diabetes and um
hypoglycemia have sugar in it so you
have your pill box fill on which on
Tuesdays I try to do them usually on
Tuesdays okay so how about if I go see
them on every Thursday sure so we
reinforce that the appropriate treatment
for with the memory concerns I think
that's probably going to be our our plan
is to just continue to reinforce things
with them oh and uh he mentioned to me
that he's concerned with his living with
his mother that his stepfather is not
really giving him access to the food in
the house and also I've heard that the
food in general there is very high high
in fat which is really bad for his
gastroparesis and limited stomach
motility so I was thinking I'm going to
connect him with uh Meals on Wheels they
actually have a low fiber um PID option
for people with gastro press oh that's
great I didn't know that yeah so he'll
get a hot meal every day of the week he
does have snap as well so hopefully
supplement that as well okay that'll
help those two working together will
hopefully address those concerns and
another thing you and I could work
together on um usually when he comes in
for his weekly or when I see him at home
or now it's probably going to be in the
hospital um his weekly visit um we
reconcile his calendar I know he has a
lot of Specialists and appointments and
things like that um so that's one thing
maybe you and I can both work on is
reinforcing that calendar and just
making sure that it's updated with every
appointment you go to that the follow-up
appointment is listed on his calendar
and I'll help to reinforce that and and
get that reconciled every time I see him
weekly maybe we can create a Word
document that we can all see so whoever
sees him can take a recent copy of
allice appointment absolutely right and
I know he keeps his own calendar as well
so just making sure that that document
is updated with his calendar sounds good
the one last thing I would like to bring
him up to the office and just evaluate
um his recent ER visit his recent
Psychiatry visit and sort of consolidate
everything make sure that there's
nothing that we're doing that's making
him worse or causing the hallucinations
he's got definitely got poly Pharmacy as
an issue um and in addition to that he's
medically complex has mult comorbidities
which could be causing um there could be
metabolic things causing his
hallucination so we definitely want to
rule those things out okay yeah and I'll
make sure that my next visit with him
for pill box and assessment and
everything actually happens at the
hospital I think he'll be fine with that
and then that way we can send him to the
lab while he's here great thanks a lot
but then with then if he comes in a week
and a half or something we should be
able to he should be able to tell you
how he's feeling about his symptoms if
if it is in fact psychiatric as opposed
to something else great great okay
thanks all right thanks
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