Category Archives: Transdisciplinary
The Robert Wood Johnson Foundation’s (RWJF) LEAP National Program is working to create a culture of health by discovering, documenting and sharing innovations in the primary care workforce. To advance this goal, the program is holding a series of six webinars that highlight best practices. (Read a post summarizing the first of the six webinars.) The second of the webinars in the series focused on team-based care for complex cases. Presenters included leaders from four primary care sites around the country that the LEAP program has deemed exemplars.
Managing Care for the Most Complex Patients
Kathy Bragdon, RN, director of care management at Penobscot Community Health Center in Bangor, Maine, discussed the rapid growth of the health center, and went on to describe its system of care management for the most complex patients.
The center relies on a transitions care manager, who shares information back and forth with the hospital and with patients’ medical homes. In addition, the manager meets with patients when they are in the hospital, looking to identify potential barriers to recovery and to provide any needed referrals.
“One of the big roles—we didn’t realize how big—was that a tremendous number of patients had no primary care at the time of admission,” she said. “We worked really closely with the hospitals trying to provide those services and make that linkage to those patients who needed primary care providers.”
Richard C. Lindrooth, PhD, is an associate professor at the University of Colorado Anschutz Medical Campus. Olga Yakusheva, PhD, is an associate professor of economics at Marquette University. Both are grantees of the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative.
The Institute of Medicine (IOM) released the findings of its Committee on the Learning Health Care System in America in a report entitled “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America”[i] in September, 2012. The report recognized that the complexity of clinical decision-making is rapidly increasing and that clinicians need to continuously update their skills in order to keep up with (1) rapidly expanding diagnostic and treatment options and (2) the increasingly complex and chronic clinical condition of patients. Given the growing external demands placed on nurses, the IOM reports that a critical determinant of the success of an organization in dealing with these demands is how “a learning health care organization harnesses its internal wisdom—staff expertise, patient feedback, financial data, and other knowledge—to improve its operations.”
Nurses in particular are in an excellent position to play a central role in creating a virtuous feedback loop such that it is feasible to continuously adjust and incrementally improve systems in response to rapidly changing external demands. The report, supported by the results of a growing and increasingly robust body of academic research, stresses the important role of leadership and management in fostering and maintaining an environment within which continuous learning could take hold.