By Dawn Armstrong
Making collaborative care happen
By Dawn Armstrong
Do you wish that the Chiropractic profession in Canada could be less marginalized; that we could all be a more integral part of the mainstream of our health-care system? For our patients’ sake, I believe that would be a good thing – but what will it take to make that happen? How can we change the system? We can change it by changing what we are doing every day in our own practices.
No doubt our patients like us. We’re good listeners, we have great hands and we work very hard to educate our patients about the magnificent integrating power of the nervous system and how our particular brand of hands-on health care can help them in so many ways. For the benefit of our patients, we could do a much better job of integrating our skills and knowledge with that of other health professionals.
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Perhaps you’ve tried a collaborative approach to patient care. You have reached out to a few of the GPs in the neighbourhood, but not much came of it. You recommended that some of your new patients consult with a personal trainer or a massage therapist. You pass out business cards. You hope for co-
operation on the case but you almost never hear back from the trainer or the RMT about what their plan is for the patient, or ever receive any referrals from them in return. Your front desk person seems to be dropping the ball; they’re not always on-board with the patient’s treatment plan. Patients disappear – maybe it’s because they are so much better.
It can be very discouraging and it doesn’t seem fair. We want to be a more recognized and respected part of the patient’s health-care team – and we believe we deserve to be included.
Now would be a good time for a reality check. The patient’s family doctor has never consulted with you or referred anyone for care. They don’t seem to appreciate your particular expertise so you choose not to share it with them. They remain in the dark on the specific details of this patient’s chiropractic care.
And, what about the patient? Are they really better? Or have they become lost to other health-care providers – who are giving them a different message – because they were unclear on what’s really wrong with them and how you can help? The truth of it is they’ve wandered off and fallen between the cracks of a fragmented system, and it didn’t have to happen.
A second reality check – if we want to be “in-the-loop,” we have to be prepared to make our own loop. We are not likely to be invited to be part of the system’s team – we need to step up to the plate and become the leader of our own patient’s team.
Integrated patient care is all about relationships and the best relationships are based on clear communications, both in person and in writing. The three keys to effective integration of services are using the right paperwork, finding the right people, and establishing the right protocols.
In a nutshell, if you want to integrate your patient care with other health professionals, you must commit to keeping good clinical records. A collaborative approach requires the sharing of all sorts of information – facts that have been collected from the patient, decisions that have been made about them and details of what they have been told – are only the start. A clear record of the treatment provided and the response to care are also important points to be shared, so are the specialist reports you requested and any correspondence you’ve sent or received on behalf of the patient.
The best way to do this is to start with the right forms. Whether you use electronic health records or pen and paper, the right templates with diagrams, charts and blanks to be filled in will facilitate quick documentation of all the important facts.
The most useful form in a patient’s file is a simple Report of Findings form – a point by point summary of their problem, your findings, your diagnosis and your recommendations for care (i.e. the treatment plan). The patient gets a copy of it on their second visit – your message is clear, in black and white. You heard them, you examined them, you know what’s wrong and you know how to help them.
The most necessary form in a patient’s file – at least from the privacy commissioner’s point of view – is a statement that makes clear your policy about sharing the patient’s information. Discuss with them the fact that you will be communicating with other specific practitioners. Have them sign on the dotted line to confirm their permission.
The right people
If you want to be the leader of a winning team, you need to choose the right people to work with and consistently make an effort to give them what they need. You will also need to let them know what you need from them in order to do best by your patient.
Personality, character and expertise matter – make sure you get a good sense of the nature of the health-care professionals you decide to collaborate with. One trait that seems particularly critical is their ability and willingness to communicate.
The people you choose to be on the patient’s team could be sharing space in your clinic, or they could work out of an office 100 miles away – in either case, there are many ways to communicate. A phone call, a face-to face, a text, a fax, a handwritten note, an email – depending on the situation, all of these are useful. (Legally, if you don’t write it down it didn’t happen, so be sure to make brief, written notes in their file regarding the date/subject of any important conversations.)
If you are keeping patient records that are legible, logical and complete – as we are all expected to – you will have enough material to provide others on the team with what they need.
One of the very best ways to facilitate teamwork in patient care is to do “rounds.” Different practitioners get together to look at specific cases and discuss their ideas on the causes and the treatments of particular conditions. The process can be highly edifying for practitioners and very useful for finding answers to cases that are unusual or complex.
The idea of participating regularly in a chiropractic rounds is very appealing to most of us – the chances of it happening are slim.
If the different practitioners are located in the same physical space, one would expect it to be relatively easy to arrange rounds. But you would be wrong. Apparently, it is almost impossible to get a diverse group of professionals who are paid by the treatment to show up for something on a volunteer basis. If the practitioners are physically spread far and wide, it can be even trickier to get together.
Tips on conducting rounds:
- Schedule them in regularly – say the first Monday of every month, for one to two hours
- One person should be in charge of each session – take turns
- Everyone on the team should expect to participate and contribute
- Have clear goals and a defined agenda – keep the discussion focused on the case
- Provide food and beverages – it helps with attendance for some reason
Rounds can help you get to know exactly what others on your team can do for patients. This will help you refer with more confidence and let you tailor the information you provide to assist them in helping your patient.
If everyone is on the same page, you can all benefit from learning from a common patient, and working toward common purpose: the welfare and health of your patients.
Once you’ve found the right people and you’ve set up your clinical record keeping in a way that is consistently complete, legible and useful to everyone, you need to establish the rules of engagement, i.e. certain protocols to ensure patients don’t get lost between the cracks. No doubt we all have our own particular sense of how we should run our practices, but there are some guidelines that seem especially effective.
Produce a written report of findings for all new patients so your front desk staff and any other pertinent team members know exactly what is going on
Employ common messaging – practice explaining what you do, use simple language and make sure that everyone involved in the patient’s care is saying the same thing
Develop strict habits for regularly producing and disseminating reports/notes/letters about your patient and their care. Remember to sign/date incoming correspondence as “read.”
Arrange ways to make it easy for the front desk to schedule appointments with the other people on your team
We’re good at many things, but not everything that a patient might need to get well. We should all get to know and join forces with others who can help. Talk to them, tell them what you’re doing, find out what they’re doing, be prepared to provide good notes and expect to hear back – guide and support a real team effort.
If you want to be an integral part of our health-care system, you must establish clear channels of communication between you, your support staff, the patient and every other practitioner who has a stake in their care. Everyone’s busy, but make the time to make connections. Cross-referrals, consultations, collaboration and co-operation are the key to cultivating the effective relationships that will allow the patient to get what they most need – a caring team of professionals who talk to each other and provide customized treatment approaches that work.
Just as the nervous system integrates all of our bodily functions, we chiropractors have the opportunity to become the builders of ‘loops,’ which will effectively integrate our services into the fabric of our communities. It is up to us to make that happen.
Dr. Dawn Armstrong is a graduate of CMCC and has been in practice for nearly 30 years. She is currently focused on promoting life-long learning and professional development and has created a continuing education course – Clinical Record Keeping: A Hands-On Approach. Learn more at