Interdisciplinary Plans of Care involve teamwork as well as patients’ input

Rarely has there been a better example of teamwork than the 'Miracle on the Hudson' Airbus floating in an icy river in midtown Manhattan in January 2009.  Captain Sullenberg was praised for his skill and leadership during the landing and evacuation, but he is the first to say that the outcome might have been very different without the teamwork of the crew, air traffic controllers, passengers and first responders.

In healthcare, most collaboration isn't quite that dramatic, but teamwork is still vital to improving health and saving lives.  At Riverside Shore Memorial Hospital, a new model of highly-individualized care planning called Interdisciplinary Plans of Care (IPOC) brings the entire team of caregivers – including the physician, nurse, pharmacist, physical therapist, respiratory therapist, wound care nurse, palliative care, discharge planner, pastoral care and dietitian – together at the same time each day to discuss each patient's individual treatment goals and progress.

The 'my patient' model of care - where each practitioner is responsible for his or her own separate sphere - is undergoing a change due to more complex illnesses and an aging population.  No longer is a nurse, physician or other caregiver making 'silo' decisions on a parallel track with other practitioners, instead they collaborate for a more holistic approach.

During the IPOC meeting each morning, the team discusses changes in the patient's situation, the tests or rehabilitation that are expected that day and the needs the patient will have once released from the hospital.  The care plan begins on the day of admission and continues through discharge.  Each 24-hour period has its own care requirements and patient goals.

"We're getting an idea earlier on what the patient is going to need.  Having everybody there in the room, we're able to discuss test results and problems with an eye toward the patient's goals.  Respiratory, palliative care and physical therapy experts attend, and they're able to let us know early on what continued therapy the patient will need," Misuna said.  "It's significantly lowering the chance that a patient can't go home solely because some home need like oxygen hasn't been set up yet."

Riverside Health System as a whole has committed to changing its model to this innovative approach.  Riverside Shore Memorial was the first acute care hospital in the system to implement IPOC late last year.  "We are leading the way for the entire system," said Beverly Misuna, director of nursing and patient care services at the hospital.

"It's a significant innovation because the entire patient care team commits to being in the same room at the same time every day instead of communicating in smaller groups.  Since it has proven over time to be the best approach to improve health outcomes for the patient, we are excited to bring it to our community," said Susan McAndrews, Vice President and Administrator at the hospital.

IPOC is made easier by

Riverside 's commitment to electronic health records.  When the electronic information is combined with information discussed with the patient at the bedside, technology and the human element are working together in the best interest of the patient.

 "They really like that we ask them what their goal for the day is," Misuna said.  "The patient's daily goal may be to have less pain or to be able to walk around.  Their ultimate goal may be to be able to cook for themselves, or to live by themselves, or to get out of here by Saturday for a family member's birthday.  Sometimes their goals are different than ours, so together we agree on what is appropriate.  Achieving the patient's goals is a critical piece of what we call the Riverside Care Difference which is our daily reminder to keep safety, quality and respect for the patient at the forefront of all we do."

Patients appreciate being a part of the process.  Patient satisfaction scores have increased since the Shore started the program.  "In our close-knit community, very few of the patients we care for are strangers," said Misuna.  "Every patient is a V.I.P. to us, and this model of care is what we want for our own family members."

"Patients are driving their care," said McAndrews.  "Patient care improvement is the number one outcome.  Having nurses collaborate with all the people involved, not just nurses doing nursing and therapists doing therapy, is knocking down the barriers to deliver better care.  Everybody has something to contribute," McAndrews continued.

Published: March 6, 2013