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Wednesday, August 5, 2015

The Patient as the Center of the Healthcare Team


Today, there is a movement to ensure the patient is the center of the healthcare team. As a seasoned healthcare professional, I took this for granted and it was not until I was a patient that I really understood why this is so important.  It was then that I realized that the concept has not been widely adopted in our complex system. Today, reimbursement by payers such as Medicare and commercial insurers are pushing this concept and providing incentives for providers and organizations to ensure that this culture change is put into practice. Providers and organizations that do not focus on patients and their needs often pay penalties.

As the industry shifts to adopt this patient-centered mantra, professionals are taught the concepts throughout hospitals, rehabilitation centers, home healthcare agencies, skilled care facilities, and  physician practices. Topics such as patient engagement, patient- and family-centered care, and patient-directed care are being presented at national conferences, in healthcare journals, social media sites, and other venues to help raise awareness for every member of the healthcare team. 

Unfortunately, the patient and the family are not getting the same educational opportunities. Today there is an expectation that the patient and their family be active participants in their care, but there is limited education as to what this means and how the patient should play out this role.  As I have mentioned in previous posts, I created this blog to provide information to patients, their caregivers, and healthcare professionals can use to fill in some of the gaps, empower patients to be active in their care and provide the tools and resources needed to be successful. The ultimate goal is to make your healthcare experience as safe and positive as possible.

This week, I am going to explain the various professionals and people who make up the overall healthcare system; I’m going to explain the role they play and the importance your input and collaboration makes throughout your journey.

Something to think about:

As you read along think about your own team and how they were or have been influential in your care. Ask yourself some questions:
  • Did you feel comfortable talking with the members of your team and learning about your condition/plan of care?
  • Did you feel that you received answers that helped you participate in your own plan of care as a member of the team? 
  • Were you satisfied with your team or do you wish they were more responsive to your needs and goals?
  • Do you feel the team took the time to get to know the challenges you and your family and/or advocates were facing?
  • Did you have a ‘go to person’ that was responsive to you and your family?  Who was it and did you feel they were helpful? 
So that others can learn, please leave a comment regarding these questions in the comment box below so that we can get a feel for how you and your team worked together.   

One example that stands out for me that drove home the concept of patient-centered care came when a nurse came into my room one morning and asked me what my goals were for the day. I was surprised by her question as I had not been asked that in the past. I was able to come up with a few things I was worried about and questions that I had about my care. As we discussed these things and what my goals were, she noted them on the whiteboard in my room. This allowed me to keep them in mind and when the team came into examine me, I was able to point to those goals/questions and get answers and clarification. This exercise allowed me to for the first time to be an active member of the team as I realized from this exercise that my opinion mattered. As a result, I decided to keep a journal of my questions so that I had them handy for my team.  

The following are the members of the healthcare team. Each has a specific role that is meant to complement the other members of the team to ensure that safe, quality care is being provided for the good of the patient. 

Each member of the team should know the role and function of his or her team members, including you (the Patient and the family).

Captain of the Healthcare Team:

Physicians: The Physician’s role is to diagnosis and treat. He or she holds ultimate responsibility for the patient and directs the healthcare team.

Physicians can play various roles:

The Primary Care Physician is your family doctor, the doctor that oversees your general care and investigates problems. Most Primary Care Physicians will refer you to a specialist if a complex problem requires targeted treatment. It is important to keep in touch with your primary as you progress through your care so they are aware and can intervene as needed. If your primary does not come to the hospital where you are being treated, ask your treating physician to send all reports to them so they can be aware of what was done in the hospital and what the plan of care is so when you return to them so they will be up to date.  You should also ask for copies of the discharge summary and physician notes that detail your care for your binder. Sharing the binder will help your primary be aware of the care you received and where he/she will take over.

Specialists: These are physicians who have studied and focused their careers in a specific area, such as a pulmonary disease, orthopedics or cancer. Once referred to a specialist, look at his or her credentials and where he or she went to school and did research. This will help you know about their background and expertise in treating your condition. In addition, you should also check with your insurance company to make sure the specialist is part of your insurance network. Most insurance companies are part of a managed care network today. Ensuring that specialists or the hospital you are referred to is part of the network is critical. If they are not in the network, depending on your insurance company, you may be responsible for full or partial payment.  Most physician offices and hospitals will check this for you before you receive treatment, but in the end you are responsible for payment so don’t be afraid to ask.  Most of the insurance companies have websites that allow you to see what providers are in your network. So when you are given the name of a specialist, visit the website to ensure they are part of the network. If you have not been on your insurer’s website take, time to visit it as there is a wealth of information that will help you be an informed patient. In order to ensure care coordination, your specialist should send a report to your primary care doctor so he or she is aware of the plan of care and how it intersects with other health issues you might have. Again, ask for a copy of this report for your records and place in the binder for future reference. 

Emergency Department Physicians: Most hospitals have an emergency department. The doctors who work in this department are trained in emergency medicine and evaluate you to determine if you need to stay in the hospital or if you can go home. If you have to stay, the physician will call your primary doctor to communicate his or her updates and concerns. If you are admitted, the doctor caring for you should come in to visit you and discuss the plan of care within a certain amount of time. Once you leave the emergency department, you will not see this physician again, but will be cared for by your primary doctor, the hospitalists or your specialist until your discharge.

Hospitalist: A hospitalist is a physician who works for the hospital and cares for patients while they are in the hospital. This ensures that patients are seen in a timely manner and provided treatment for their conditions.  This has taken the burden off the primary care physician. Many times their practices are very busy and they don’t have time to go to the hospital. The hospitalist can write orders and manage patients. These physicians are on duty 24 hours per day, seven days per week, so if a problem arises, they can see the patient right away. The downside of having the hospitalist involved is that the primary care doctor is not directing care during the hospital stay, which can cause discord or confusion in treatment. Again, this is where your binder of notes will be helpful-- be sure to obtain the physician progress notes and discharge summary once you are ready to leave the hospital.

Residents: Large medical centers with associated medical schools typically help to teach and train residents, interns and medical students. Residents are medical school graduates who have completed an internship and are working in a hospital, clinic, or other setting to gain expertise and experience in a specific area of focus.  They traditionally work under the direction of the attending physician. Most residents choose programs in a specialty area and use the time to gain experience in their chosen field. They also will have a medical license, so they are able to practice independently if they choose.

Interns: A physician is technically an intern after he or she completes medical school. An intern usually works under the direction of the resident and/or attending physician, depending on the program. Interns are not licensed, so they cannot practice independently.

Medical Students: Men and women who are actively in school and training to be physicians are medical students.  They follow a specific course that includes theory as well as practical time. They observe or take care of patients but under the direct supervision of a licensed physician.

The Core Healthcare Team

Pharmacists: Pharmacists are regarded as medication experts. They protect the public by ensuring drug safety. The goal of pharmacy care is to maximize positive health care outcomes and improve patients' quality of life with minimum risk. Today, pharmacists must have a Doctor of Pharmacy (Pharm.D.) degree from an accredited pharmacy program in order to practice. They also must be licensed within the state where they live. The Pharmacist works with your physician to decide on the type of medication needed to treat your condition. A pharmacist also will work with the patient to reconcile their medications once they leave the hospital and move to the next level of care. This can help prevent duplication of medications which can cause serious harm. Pharmacists are trained to recognize medications that might not go together and cause an interaction that can make you sick. Pharmacists can work in the hospital, other inpatient settings or in a retail store, like Walgreens, CVS or other stores where you can pick up your prescriptions.  Talking to your pharmacist if you have a question about your medication is a good thing as they can review all of your medical care and speak with the physician ordering the medication if they see a problem.  When I was a patient in the hospital, the pharmacist was a key member of my healthcare team and kept my husband and I up to date on my plan of care. He was able to answer questions we had about procedures and also about the various medications I was getting. He took the time to explain things and to help us better understand my care.

Nurses: Nurses are the heart and soul of the healthcare team and are charged with caring for patients and their family. Nurses have various duties in the hospital and can range from the Directors of their unit, charge nurses on certain shifts, medication nurses and staff nurses who are assigned patients for daily care. The nurse’s duties vary according to their expertise and the unit they work on. Today, most hospitals hire registered nurses to provide care for patients, but there are also licensed practical nurses who work in settings such as the hospital, rehabilitation settings, and long term care facilities.  

Advanced Registered Nurse Practitioner (ARNP). An ARNP is a registered nurse who has additional training and a certification to specialize in areas such as family practice, geriatric care, pediatrics or women’s health. Depending on the State, the ARNP can work independently or under the direction of a physician. If they are independent, they can write prescriptions on their own and direct care. Many have private practices and see patients independent of a physician. As many physicians retire, the ARNP is filling gaps in primary care. 

Nurse’s Aides are an important member of the healthcare team and provide hands on care including taking vital signs, bathing, making beds, feeding patients and other non-clinical duties. Nurse’s aides are not licensed so they have to have a registered nurse oversee the care they provide. Patients and the family many times see the nurse’s aide more than the nurse and many times confide in them. The nurse’s aide can be a liaison to the nursing team and help the patient and their family better understand how the floor works and who you can reach out to if you have questions or concerns.

The Trouble Shooters of the Healthcare Team

Case Manager/Care Managers/Nurse Navigators/Patient Advocates: These are professionals who are in place to assist patients as they transition through the healthcare system. These professionals can work in the hospital, at your managed care organization, through your employer, in your physician’s office, or can be hired directly by the patient and or their family. They are in place to see that your plan of care meets your needs and that the resources you need to manage your care are in place. They work with you and are your connection to the healthcare team. You can call on them any time and ask them any question. They understand the workings of the organization, the managed care system and how to access resources that can be an important for you and your family. Many times, I hear patients and their family’s say they don’t want to ask questions or make a complaint as they are afraid that this will be held against them. No patient or their family members should be afraid to raise a question or make a complaint. Your input is an important point in preventing errors and ensuring that your care is meeting your goals. These trouble shooters should be sought out to help you with problems, discharge needs or understanding what is happening regarding your care.

Social Workers: are professionals who have expertise in helping you find the resource and support systems to meet your needs. Social workers work closely with the case manager and other members of the team to ensure you are able to move from one level of care to the next in an organized and safe manner. They can also help you find financing for your healthcare if needed through the various social systems that are in place. 

Discharge Planner: Many organizations have a discharge planner who will work with your family to ensure you have the resources in place to go home. You should let them know what your needs are and they can help put into place services, durable medical equipment, medications, and other things that will help you to be safe. Discharge planners work with the Case Manager and Social Workers. In some smaller hospitals the discharge planner may be the case manager or social worker. In larger hospitals they may be independent of each other. If you cannot go home due to your condition, they will help your family know about the type of facility that would best meet your needs. You and your family will be given choices so that you can visit them to see which facility you might want to go. They can also help coordinate home care such as nurses’ aides if you need help at home. Many services might be covered by your insurance, by your long term care policy or privately. Take time to review all of your options. I will cover insurance in a future post.

Therapists: Therapists are specialty trained professionals who can work with you to help you improve your function so you are as independent as you can be after an injury, a stroke, or complications from a chronic condition that impacts your activities of daily living. The types of therapists you may see include:  physical therapists, occupational therapists, speech/cognitive therapists, and respiratory therapists. Each has a role and will work with your healthcare team to assist you in your recovery. You may see them in the hospital, in an outpatient setting, in a rehabilitation hospital, a nursing home or your home.  Feel free to ask your therapists questions that you might have about your plan of care. If they can’t answer it, they will refer you to who would be best to address your question.

Behavioral Health Professionals: today it is recognized that patients need to be treated holistically with regard to their medical and behavioral health issues. Psychologists and Psychiatrists are seeing patients to assist them as needed and provide a therapeutic environment where they can ask questions and discuss challenges they face as they recover and adjust to medical and/or behavioral health issues.

Administration: each hospital has an administration department that is charged with operating the hospital or organization. This is where the leadership of the organization can be found.
There are various departments that make up administration each of which is responsible for the running of a specific part of the organization.  Administrators ensure that the organization is adhering to the federal state, and accreditation standards to ensure that the care provided is safe and focused on the needs of the patient. If you have a complaint or an issue with the organization, this is where you would go to voice your complaint. They will usually have a risk manager or a patient advocate on staff to listen to you, investigate the problem, and work on a solution with input from their internal team and staff. Do not be afraid to go to the administration if you have a problem. It is better to raise issues and have them resolved than to let them go.  

Support Services: Housekeeping, Maintenance, and dietary: Support services are an integral part of running a hospital or other setting where patients reside. These people are charged with preparing meals, cleaning rooms, and ensuring that equipment works as it should.  If you have a problem you can talk to these people as you will see them throughout your stay. They can be a great help to patients and their families. They may tell you to check with the nurse if you have a problem or contact the nurse for you if they cannot help you. When I was a patient, the housekeeping staff, dietary personnel and maintenance people were friendly and helpful.

Medical Records:
Keep in mind it is your right to obtain your medical records as they are your records. Some hospitals charge for them, but more and more hospitals are not charging the patient but rather providing records freely. It may take a few days for documents to be finalized following a hospital stay, so asked to be called once they are ready so you can receive your copies. These would go into the binder you are keeping of records that relate to your stay and plan of care

In Closing:

Last but not least, make sure you stay involved in your care. Many people have thought ahead and have designated family or a friend to be their advocate if they are too sick or cannot talk for themselves. In my case, my husband was my advocate as I did have a period where I was confused and could not make decisions so having him there saved my life. 

A good resource that you might want to consider is Five Wishes. This is a document that helps people express their feelings and document in one place so that their family and friends understand what they want to happen to them if their life changes and they need a voice to advocate for them. The Five Wishes ensure that each persons care is handled with dignity. Here is the link to evaluate this important resource https://www.agingwithdignity.org

You and your advocate should take the time to listen to your team, and understand the rationale for their suggestions. If you have questions or their plan is not consistent with your goals, don’t be afraid to let them know.  The Joint Commission, the organization who accredits hospitals has a program called Speak UP to encourage patients and families to share their concerns and questions. Here is the link to the program to learn more; www.jointcommission.org/speakup.aspx

Together with your team you should develop your plan of care so that it meets your medical needs as well as your life goals. You are the center of your healthcare team and your opinion is invaluable. 

As you can see, there are a lot of people involved in your care. Please take time to ask questions and raise issues that are important to you. I wish you the best of luck on your journey. 

Next week we will look at some of the challenges that can impact your journey as a patient and how you and your family can handle them.