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Interprofessional Care Planning Guide

The document discusses interprofessional care planning and assessing patient needs. It outlines the importance of teams having clearly defined goals and understanding their purpose. It also provides steps for teams to holistically consider a patient's medical, emotional, social, environmental, and economic needs when developing an interprofessional care plan.

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100 views2 pages

Interprofessional Care Planning Guide

The document discusses interprofessional care planning and assessing patient needs. It outlines the importance of teams having clearly defined goals and understanding their purpose. It also provides steps for teams to holistically consider a patient's medical, emotional, social, environmental, and economic needs when developing an interprofessional care plan.

Uploaded by

RazaCreciaLastrillaMeneses
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Interprofessional Care Planning1

Teams are generally organized to achieve specific programmatic goals. Primary health care
teams may work with patients/clients, families, communities, stakeholders and others to achieve
patient and/or population health goals. In order for an interprofessional primary health care team
to function effectively, the team’s purpose and goals should be clearly understood and agreed
upon by all members. These goals – whether short or long-term – also need to be feasible,
because the interprofessional team may function in a variety of settings and the team
membership, types and intensity of services provided, and overall goals may vary.

Once the team has identified programmatic goals, team members will need to identify what this
may mean in reality. For example, if “improve patient outcome” is a goal used by a team,
successful outcomes will need to be defined case by case. If health promotion or disease
prevention activities are a goal for the team, then the team will need to identify the health needs
of the specific population they wish to address, the interventions to address these needs, and the
strategies for evaluating the effectiveness of the intervention and impact on health needs. The
process of interprofessional team care planning is the means of achieving consensus on desired
patient and/or population health outcomes.

An interprofessional team developing care plans for patients/clients must be able to approach
care in a holistic manner, considering the needs of the patient/client in a broad manner, and
considering how different, yet pertinent information fits together.

The ability of each discipline to contribute to the care plan will depend on each team member’s
understanding of the connections between problems. The team may agree that “optimal health”
is the goal for the patient/client. However, the means for achieving or arriving at the goal may
differ between professions. These differences are in part a result of each discipline’s background
training, expertise and approaches to problem-solving and patient care. These differences are a
significant element of interprofessional collaboration as different perspectives enable team
members to view and approach problems in new ways. Different perspectives must be embraced
by the team and integrated as part of the interprofessional approach to patient/client care. Team
members need to respect the different kinds of expertise each profession brings to the group.

An interprofessional care plan, whether it is developed for an individual patient/client or a


community, will not work unless the team has a system for recording and monitoring who will
be responsible for what and by when. This record-keeping should be completed before the end
of the meeting and available to all team members to remind them of their responsibilities. In
addition, the team must have in place a system (formal and informal) for communicating on the
steps of the plan between team meetings. This type of communication is often informal with
different professions talking with each other as needed.

Steps in Assessing Patients Needs2

Handling a complex case requires team members to consider the patient/client’s medical,
emotional, social, environmental, and economic needs. Using the grid and the questions
provided below, team members can consider the holistic (biopsychosocial) needs of the patient
and their situation. In developing an interprofessional care plan, the team needs to identify the
expected activities and the responsibility of each team member (e.g. initiation, follow-up, and
reporting results).

Considering the patient/client’s medical, emotional, social, environmental and economic


needs, answer each of the following questions:

1. What is the overarching goal? At least three perspectives need to be considered and
reconciled:
o patient/client
o his/her family
o team

2. What are the patient/client’s problems? (e.g. medical, emotional, social, environmental
and economic).

3. What is the impact of each problem on the patient/client’s health?

4. What strengths and resources does the patient/client have or can be mobilized to deal
with each problem?

5. What additional information is needed to adequately define the problem or its


implications?

6. What is the plan of care? (What needs to be done; who will do it; when will it happen?)

7. What priority should be assigned to each problem? How important is its effect on the
overarching problem?

8. What outcomes should be expected for each problem? (e.g. expressed in measurable
terms, appropriate time to look for the outcome

1
Hyer, K., Flaherty, E., Fairchild, S., Bottrell, M., Mezey, M., Fulmer, T., et al. (Eds.). (2003).
Geriatric Interdisciplinary Team Training: The GITT Kit (2nd ed.). New York: John A. Hartford
Foundation, Inc.
2
Hyer et al. (2003)

Common questions

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Integrating the expertise of different professions in developing a care plan is important because it enriches the planning process with varied insights and skill sets, ensuring comprehensive care that addresses multidimensional patient needs. Such integration fosters innovative solutions and enhances the overall quality and continuity of care by leveraging the strengths of each discipline .

Reconciling perspectives between the patient, their family, and the healthcare team influences the overarching goal in interprofessional care by fostering a more inclusive approach that takes into account diverse expectations and preferences. This alignment ensures that the care plan is patient-centered and tailored to meet identified needs while respecting the insights and expertise of each stakeholder group, thus enhancing adherence and satisfaction with the care provided .

Having a system for recording and monitoring responsibilities is crucial in interprofessional team care planning as it ensures clarity and accountability among team members. This enables all members to stay informed about who is responsible for each aspect of the care plan, facilitating effective follow-up and coordination between team meetings .

Strategies to evaluate the effectiveness of interventions in addressing population health needs include setting clear, measurable objectives and outcomes, conducting regular assessments and feedback loops, using a combination of qualitative and quantitative metrics, and adapting approaches based on evidence gathered through rigorous data analysis and stakeholder input .

Effective communication enhances the execution of an interprofessional care plan by ensuring that all team members are aware of the plan's steps and their respective roles. Communication facilitates the sharing of updates and challenges, promoting collaboration and adaptive problem-solving between professions, which is crucial for timely adjustments and improvements in patient care .

Identifying population health needs plays a pivotal role in setting programmatic goals for interprofessional health care teams by highlighting specific areas for intervention. Understanding these needs allows teams to develop targeted strategies, select appropriate interventions, and establish metrics for evaluating success, all of which drive efforts to improve population health outcomes effectively .

The background training and expertise of different professions influence the approach to achieving "optimal health" by contributing varied problem-solving methods and patient care strategies, shaped by each discipline's unique perspective. This diversity allows the team to view and approach problems in novel ways. Such variability requires team members to respect and integrate these differing approaches into the overarching interprofessional care plan .

Challenges from differing problem-solving approaches in an interprofessional care team include potential conflicts and misunderstandings due to varying priorities and methodologies. These can be mitigated through open communication, mutual respect, and structured team meetings where diverse perspectives are acknowledged and reconciled, fostering a collaborative environment focused on achieving shared goals .

An interprofessional team must consider the patient's biopsychosocial needs—encompassing medical, emotional, social, environmental, and economic factors—because these elements interactively impact the patient's overall health and well-being. Holistic consideration allows for more comprehensive care planning that addresses underlying issues and leverages the strengths and resources of the patient, ultimately promoting better health outcomes .

The diversity of professional backgrounds within interprofessional health care teams contributes to problem-solving by providing a range of perspectives and expertise, enabling team members to approach issues innovatively. Such diversity promotes comprehensive analysis of complex health problems and the development of well-rounded, effective solutions that consider all aspects of patient care .

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