Collaborative Care Model

Collaborative Care provides exceptional healthcare in which patients, families, and health professionals are consistently able to co-create care that is meaningful, safe, reliable, resilient, efficient, and exquisitely responsive to the hopes, needs, goals and purposes of everyone involved.

Applying the Collaborative Care Model

The Collaborative Care model was implemented by a single inpatient team at University Hospital in January of 2015. The team included nurses, physicians, (attending, residents), medical students, pharmacists, a social worker and a physical therapist. Each discipline’s workflow was adjusted to allow frequent interactions with bedside-rounding that was patient-centered, focusing on patients’ stories and values surrounding care. A standardized safety checklist was utilized during every patient discussion. Additionally, the team met daily for a 30-minute reflective session to discuss and document afterwards.

Key Components of the Model

Workflow/observation

Traditional
Collaborative
Patients and Families
Often not present for assessment & planning
Actively engaged in care assessment & planning
Goals of care
Set by practitioners; Explained to the patient
Jointly developed; Transparent, co-created
Workflow
Parallel workflows
Integrated workflow
Communication
Ad hoc, individual
Essential to collaboration
Reflection
Individual – a foundation for professional growth
Collective – a foundation for team learning/improvement
Inter-professional
Added on
Embedded
Fundamental approach
Centered in processes
Centered in relationships


When looking at Traditional Care vs. Collaborative Care we can highlight some of the changes that we see as explained by the animation.

These changes enhance the capacity for:

  • Mindfulness that allows for role-modeling behaviors/practices in care which leads to the respect for others.
  • Heedfulness which lets the healthcare team make informed decisions with the patient and family goal of providing positive outcomes.
  • Learning, occurring at every level, as roles of the team are learned by others and concepts and information about different aspects of each role are discussed.

Geographical Localization

The process of grouping patients together on the unit by medical team to allow for continuity in care across the entire Inter-disciplinary team.

By geographically localizing patients during daily workflow at the unit Hospital level, it allows for improved communication with bed control and a faster discharge time for patients.

  • Improved communication with bed control allows for the proper placement of patients with different medical teams so that they are placed in the proper areas.
  • Faster Patient Discharge. The charge RN role becomes more important as they work with bed control and coordinate with the bedside nurses so that the appropriate discharges coincide with appropriate admissions of patients onto the unit or teams.

We recognize that implementing this process can be a large hurdle or small one based on the flow and process of the medical units; however, having the right tools in place is a key component for minimizing workflow. This can be accomplished through geographic localization, time management on rounds, patient placement and continuity of care with healthcare team members.

Daily goals of care

Implemented by discussing team goals and writing them down on a centralized communication. Interpreting the goals achieved creates an open dialogue, builds trust and a rapport between the patient, family and team of providers.

Reflections and Communication

Data gathered during collaborative care shows a shift in the overall conversation as noted by the data below:

 Collaborative Care Rounds Chart2Collaborative Care Rounds Chart

Collaborative Care Rounds Table 

When comparing the actual length of time that occurs between Traditional Rounds and Collaborative Care Rounds, we found very little change overall in terms of time. However, our research showed that the percentage of engagement with the patient showed a significant increase.

Collaborative Care Rounds 

Patient and Family Engagement

Data collected shows how Collaborative Care has changed the culture of healthcare in a positive manner from patient engagement, increased communication, and even HCAHPS scores. In approaching care in a social and qualitative manner, patient stories and experiences have an overall positive outlook.

Daily Workflow Schedule

We have found that keeping a Monday-Friday schedule helps create symmetry for a teaching team that uses a rotational schedule for interns, residents and students. This helps the team stay on task and provides a sturdy foundation for the patients and their families.

Daily Workflow Schedule Example

8:15 - 9:00     Attending Rounds with Students and SICK Shorts
9:00 - 9:15     Run list with Medicine Team, Case Manager, Physical Therapy and Pharmacy
9:15 - 10:30   Round with Full Team
10:30 - 11:30 Continue Rounds w/Partial Team (includes: medicine team and all other providers that are still available to meet)
1:15 - 1:45     Reflection
2:30 - 3:00     Dedicated Teaching Time

This schedule allows for changes that may occur over the day while setting specific non-negotiable times for everyone to be on the same page and allows other medical teams and services to be aware of the team’s availability.