Duke 'colors outside the lines' with care teams
Duplication, overlap targets of collaborative effort
Multidisciplinary teams that collaborate on a patient's care, seeking the most effective use of each employee's skills, are the centerpiece of an innovative program at Duke University Medical Center in Durham, NC.
These care management teams, which dispel organizational "silos" in favor of interactive efforts, are examples of "coloring outside the lines," says Rosalind Connor, MSM, director of patient access services.
The teams are linked to the hospital's service centers for various patient groups, Connor says. There's a heart center team, a surgical team, a mother/baby team, and a medical team. The teams began in December 1996 and still are being formed. "We're now starting transplant and oncology teams," she says.
The care management teams consist of patient access services representatives, clinical dietitians, social workers/discharge planners, case managers, clinical nurse specialists, and/or advanced practice nurses, she explains. Before the reorganization, those employees worked side by side in the service centers, but for the most part, they kept to their own pieces of the puzzle.
With the institution of the care management teams, many of those employees met for the first time to discuss their roles and services, she says. The idea is to "look at duplications and overlap and how to more efficiently provide service for a broader range of patients."
In weekly meetings, individual team members list their competencies and areas of expertise. The results can be enlightening, Connor points out. While patient access services employees understandably consider themselves experts in financial information, case managers also claim finance as an area of expertise.
"Team members had not met like this before and didn't have an appreciation or understanding of what others did," she says. "Maybe they didn't understand the difference between a discharge planner and a social worker, or between a social worker and a case manager."
The brainstorming led the team to pose this kind of question: What if, when patient access representatives verify the patient's insurance, they also verify the durable medical equipment provider and home health agency the patient will use? That would replace the old practice of having the patient access rep find out the patient's insurance coverage, enter the information in the computer, and then pass the ball to the case manager, who makes additional calls based on the individual needs of the patient, Connor says.
Having the patient access rep take on financial duties allows case managers to concentrate on truly managing the patient, she points out. "Why spend time [checking insurance requirements] when you could be negotiating to get the patient a longer stay or a better rehab program?"
Patient access services, meanwhile, is becoming more proactive. A newly redesigned insurance verification form incorporates the collection of information all the disciplines need upfront, including managed care questions aimed at correctly identifying preferred provider organizations.
This new spirit of collaboration could, for example, help avoid patient/family confusion. "If you have a social worker, discharge planner and advance practice nurse coming to the patient's room, they could all be asking the same question," she says. The idea is to decide who's the best person to ask it. "You could have - in the scope of practice - a social worker [asking the question], but you could have an advance practice nurse who's more of an expert."
Understandably, there have been turf battles associated with the new examination of roles, as well as concerns about job security, she says. "When people start looking at questions like, `Why are three or four people doing the same thing?' their first reaction is fear, that maybe their jobs are in danger.
"The truth is, we probably need this many people, that [before] we were missing patients." Those patients could be better served, Connor suggests, if the organization is more definitive about who's an expert in a particular aspect of care.
Although the turf battles have not been resolved completely, employees are gaining a better understanding of the value involved in "spreading the wealth" of expertise and getting other disciplines involved, she says. "It's been a great culture change."
Basically, the teams look at how the organization can provide more service with less cost, keeping in mind patient and staff satisfaction, quality indicators, outcomes, and financial outcomes. Two front-line employees lead each team, as befits the organization's philosophy of staff empowerment and shared governance, she says. "They put the agenda together, take care of the minutes, and run the meeting."
Connor and her peers at the director level in other disciplines serve as administrative liaisons for each team. She serves as liaison for the hospital's heart center team, meeting with her colleagues on an oversight committee that discusses team dynamics and recommends the formation of new teams.
As long as they stay within the guidelines outlining the teams' overall purpose, each care management team can pick its own projects, Connor explains. The heart center team, for example, recently addressed readmissions, examining charts and collecting data on patients who were readmitted within 30 days. "We look at the services each of us at the table are providing, what needs improvement, and who can improve [what they are doing]." While keeping a close eye on readmissions, the team is looking at roles directly affecting delays in discharge, she says.
Other team projects include the following:
o care of post-op patients and their families (surgical team);
o delays in admission times and barriers to timely discharge (oncology team);
o effects on cost and length of stay (medicine team);
o improvements in coordination of services for new mothers with substance abuse problems.
The teams farthest along in development have made great progress for patients and their families, Connor adds. "There's a lot of good work for patients going on. It's really paid off from that point of view, and that's why we're all here."
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