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3 ways to achieve patient-centered care with interdisciplinary collaboration

September 17, 2018 | 5 min read

By Robert Nieves, JD, MBA, MPA, BSN, RN

Medical collaboration

With the right processes and technology, healthcare teams can work more efficiently and improve outcomes

Caption: ©

Digital technology has the potential to improve healthcare efficiency and outcomes in countries worldwide. Just recently, I was in Sydney speaking at the Nursing Informatics Australia (NIA)opens in new tab/window Conference, where I had the opportunity to engage with nurses and various other healthcare professionals about this very topic.

The Australian healthcare system appears remarkably successful in delivering good health outcomes with reasonable cost control. However, as in many countries, the system continues to be fragmented. This results in a duplication of services and leaves gaps in care provided to the patient.

The care fragmentation experienced by patients today is rooted in a lack of integration and coordination of care due to the absence of a shared “patient story” and a longitudinal plan of care that is shared among interprofessional team members when patients transition from one care setting to another.

How to put patients at the center of care

To achieve a truly successful care planning process, the patient must be at the center of care. I would like to share three important things that patient care teams can do to promote patient-centered care:

1. Follow an effective evaluation process.

The written reflection of the patient’s progress, where the clinician “steps back” and evaluates whether the care being provided is working and documents the patient’s overall progress in relation to the expected outcomes and goals – is most often absent or, at best, very difficult to find in most Electronic Health Record (EHR) systems. For the evaluation process to be effective requires the following key elements:

  • First, ongoing and consistent surveillance, which studies show is an often missed or omitted aspect of care. This omission often leads to injuries arising from the patient’s underlying disease that could have been prevented through early detection and appropriate and timely intervention.

  • Second, the plan of care and the interventions are continuously revised, updated and individualized based on assessed patient needs and their response to the care provided.

  • Finally, evaluation is documented following a standardized framework that facilitates communication and knowledge sharing of the patient’s overall status. The information obtained from the evaluation becomes an integral part of the professional exchange process (change of shift report).

2. Use a clinical decision support tool for care plans.

One big mistake most organizations make when creating care plans is to develop them as a series of tasks/activities that are timed and scheduled to populate the work lists. With this approach, care planning is often reduced to clearing tasks from the worklist. Clinical Tteams need to view care plans as an opportunity to provide their colleagues with a powerful clinical decision support (CDS) tool that is fully integrated into their everyday workflow at the point of care. For a care plan to be a CDS tool, it should be based on evidence, designed to standardize the care provided, and provide concise and relevant information to the clinician. That information fosters knowledge, and knowledge combined with action leads to better patient outcomes.

3. Focus on patient education.

One of the most frequently omitted aspects of care is patient education. The most common practice is for education to be done when discharging a patient. Engaging patients by providing them relevant and timely education is critical to ensuring adequate transitions of care. A successful patient education program starts on admission, and the goal to educate the patient should be a vital component of care planning.

Ensuring that the patient and the primary caregiver is knowledgeable about what to do post-hospitalization reflects the accountability of the entire interprofessional team. Evaluating the patient’s understanding and providing educational handouts and interactive videos specific to their assessed needs throughout the hospital stay help the care teams build meaningful connections with their patients, prompting better questions, conversation and learning. An educated patient and or primary caregiver with an appropriate discharge plan does impact readmission rates, minimizes anxiety and improves the overall patient experience. Patient education and engagement is ultimately about the patient and provider working together to improve the health and well-being of the patient.

The benefits of interdisciplinary collaboration and EHR integration

We have examples of client hospitals that achieved interdisciplinary collaboration and improved patient outcomes with care planning integrated into their EHR. The majority of these hospitals struggled with manual, paper-based care planning and documentation systems that hindered the delivery of collaborative, individualized and standardized care. Since implementing Elsevier’s Care Planning, our client hospitals have achieved standardized evidence-based practice, enhanced patient-centered care, reduced redundancies, and improved productivity and regulatory compliance. They also achieved 90+ percent compliance with using appropriate care plans based on symptoms and admitting diagnosis.

Connecting the dots in healthcare

The saying that “team work makes the dream work” has never been truer than in healthcare.

Those at the frontline of care – nurses and allied health clinicians – must all recognize that longitudinal care planning is a critical tool in assuring patient-centered care. As a result, longitudinal care coordination must move from an aspiration by healthcare organizations to an imperative. This can be done by embracing the culture of teamwork and “knowledge that empowers,” which is essentially transforming the data and knowledge we have into actionable steps we can take to improve the quality of care.

Effective longitudinal care coordination requires a comprehensive approach, including the adoption of evidence-based CDS solutions to guide the total culture transformation required to create new care delivery methodologies that decrease fragmentation and improve patient outcomes.


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Robert Nieves, JD, MBA, MPA, BSN, RN

Vice President of Health Informatics

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