The collaborative care model: What it is and how it helps
Although nursing has always tried to promote cooperation, empathy, and understanding, the history of healthcare has often revolved around competition, with specialists jealously guarding their fields. This has made it difficult for patients with complex care needs to get the treatment they require. Only this century have things really started to change for the better, with increased efforts being made to develop cooperative strategies across the sector. One of the products of this new approach is the collaborative care model, which is transforming outcomes for such patients and improving the lives of many more. This article looks at what it is and why it’s making such a difference.
What is collaborative care?
Nursing as a profession is founded on the principle of holistic care. It’s not just about treating specific diseases but also improving the overall wellbeing of the patient. Collaborative care aims to do something similar by bringing together healthcare professionals from different fields to support patients with chronic illnesses and complex care needs. This often includes members of the psychiatric profession due to the recognition that long-term illness often leads to conditions like depression and anxiety, while half of the patients with psychiatric illnesses also have physical ones. The aim is to have these different professionals work together to address every aspect of the patient’s care. When this is done in an organized manner, with records shared across departments and outcomes carefully tracked, it significantly reduces the risk of patients falling through gaps in the system and missing out on crucial interventions.
Recognizing intersecting conditions
Living with chronic illness and taking high-potency drugs to control chronic illness make an individual more likely to develop secondary conditions. What’s more, pre-existing conditions which did not significantly impact the quality of life can become much more debilitating when combined with a serious chronic illness. For instance, a person who has previously managed fairly well in resisting an addiction may find it much more difficult when also dealing with chronic pain, and a person with mild rheumatism affecting the joints may find that it has a much bigger impact on day-to-day life when combined with muscle weakness, which makes it more difficult to protect joints from strain. Nevertheless, many patients report that it’s difficult for them to persuade healthcare staff to take such intersections into account and that they often find themselves getting shuttled back and forth between departments with nobody fully prepared to take responsibility for their care. Collaborative care aims to address such difficulties and address the unique difficulties experienced by patients with complex comorbidities.
Integrating mental and physical healthcare
Although physical and mental illnesses often coincide, and some illnesses, such as multiple sclerosis, can have both physical and psychiatric symptoms, it has historically been difficult to get adequate support for both at the same time. At the most extreme end of this, people who receive psychiatric care as inpatients have often struggled to get access to specialist treatment for physical illness or have been detained in environments that actively damage their physical health. Patients spending long periods in hospital for cancer treatment, for example, often suffer from psychiatric disintegration as a consequence of isolation or loss of social connections. With collaborative care, these problems can be solved.
The model requires, at the very least, an assessment to determine whether psychiatric support is necessary during treatment for a long-term or chronic physical illness, and vice versa – it requires that the physical health needs of psychiatric patients be subject to review. The majority of cases are not as dramatic, but this approach is still very effective as a preventive measure as it ensures that overall health is properly monitored regardless of the nature of the primary condition for which the patient is being treated.
Bringing different specialists together
Collaborative care provides a framework for bringing different specialists together and enabling them to contribute to patient care efficiently and cooperatively. It begins with establishing who needs to be involved to provide appropriate care, with the primary care provider assembling a multidisciplinary team that may incorporate professionals based in different hospitals or clinics alongside local support teams. Patient records need to be available to all these practitioners, something which has become significantly easier since the shift to electronic records as these can be updated by any treatment provider and the changes instantly visible to other members of the team.
Once this has been established, regular meetings can be held so that the patient’s care needs can be discussed, and treatment pathways agreed upon. Except in cases of severe progressive disease, these will usually be frequent to begin with, then less so once the patient achieves a level of stability. When other commitments make it difficult to bring everybody together in person, virtual meetings can be an effective way to keep up regular communication and ensure that no aspect of care is being overlooked.
Integration of primary and secondary care
Collaborative care is generally led by the patient’s primary healthcare team, simplifying healthcare delivery, and making it easier for treatment to be provided locally, which is helpful when patients find it difficult to travel. In most cases, multiple secondary care providers are involved, but no single secondary care provider takes control of the case. Because patients can develop additional needs over time, the primary care provider will add additional people to the team as required. If a specialist comes to believe that their services are no longer needed, they should liaise with the primary care provider before ending their involvement.
Although secondary care providers will make a lot of the important decisions within this treatment framework, treatments will, where possible, be provided through the patient’s primary care physician. This means that specialists need to spend less time on delivery, focusing instead on sharing their knowledge, and things are easier for the patient because they do not have as many people, departments, and locations to deal with. Patients with anxiety-related conditions, dementia, or certain forms of neurodiversity find it much less stressful if they receive most of their treatment from just one or two familiar people.
Focusing on individual patient needs
When healthcare facilities are under-resourced, there is often pressure to shuttle patients through as fast as possible by designing efficient treatment models that will work for almost everyone. The trouble is that this will never be appropriate in the case of patients with complex needs. The collaborative care model begins with looking at the individual patient as a whole human being, taking account of their medical and psychiatric needs, access needs, and specialized support needs. It acknowledges that everybody is different, and that in complex situations, it’s much more efficient to make exceptions than systematize everything as this reduces the risk of patients getting worse.
When focusing on individual needs, it’s important not to assume that those needs are unchanging and recognize that they may not have been properly recorded by prior healthcare providers working with a different set of protocols. This is one of the reasons why the collaborative care model places a heavy emphasis on engaging directly with the patient — while they might not understand their conditions as well as an expert, they will have insights into their own needs, which nobody else possesses.
Planning care with the patient
It is an important part of the collaborative care process that clear plans be drawn up to establish care pathways so everybody involved knows what is going to be done and that the patient should be a part of this process. When multiple individuals and departments are involved in care, this approach helps to reduce the risk of mistakes being made due to misunderstandings. The patient’s understanding and fully informed consent are as vital, from a safety perspective, as anybody else’s due to the complications that can develop when, for instance, patients fail to keep up with the protocols established for them; for instance, by ceasing to take pills or do exercises.
When they are closely involved in directing their care, patients are much more likely to be compliant. They also feel more empowered, which helps them to sustain their confidence in managing their illness and coping with gruelling treatment. The degree of control patients want is variable and is affected by factors like pre-existing confidence levels, education, professional background, age, and energy levels, so healthcare professionals need to be flexible when determining how best to engage with them.
A proactive approach to treatment
Patients with chronic illnesses are particularly vulnerable to developing serious complications because they often find managing their conditions on a day-to-day basis exhausting, which means that, even if they appear to be coping well, they may lack the resources to address new, developing symptoms as they arise. Issues which would be minor for the average patient can thus become serious as a result of neglect. When healthcare providers take a proactive approach, it’s easier to catch new or worsening symptoms at an early stage, and easier to provide preventive care to keep the patient in better health in the first place.
Taking a proactive approach necessitates revisiting cases even after they have become stable to identify symptom issues and examine the possibility of using newly developed treatments. How often cases need to be revisited and reviewed depends not just on the conditions involved but also on the general competence of the patient. Where practicable, patients should be advised to refer themselves for review, through their primary care providers, in the event of problems arising.
Treatment that acknowledges the social environment
When somebody experiences a chronic illness, its impact is not usually limited to that individual but affects everyone around them. The collaborative care model recognizes this and acknowledges the crucial role close friends and family members often play in the provision of day-to-day care, as well as the fact that their own physical and mental health may suffer as a result of this. The American Collaborative Family Healthcare Association encourages practitioners to engage with key members of a patient’s support system and involve them in making decisions about care — although, of course, any mentally competent patient should always have the final word.
Courses focused on training as a family nurse practitioner now routinely incorporate a focus on collaborative care — click here to find out more about Carson Newman University’s courses in this area. Due to the nature of their work, family nurses also have to bring these principles to bear, frequently, when providing geriatric or pediatric care or when assisting otherwise vulnerable adults living in the community.
The importance of evidence
Unlike some other popular integrated care models, collaborative care is based strictly on the provision of treatments that have been scientifically demonstrated to be effective in the treatment of the patient’s diagnosed conditions. It requires that there be a solid evidence base for each aspect of care provided. As such, it does not involve the use of alternative medicine, except in contexts where there is proof that a particular treatment gets measurable results and does so safely (in which case the ‘alternative’ label tends to be swiftly lost). The same applies to complementary therapies, which purport to be harmless because they don’t require patients to discontinue other treatments, but which may sometimes interfere with their efficacy.
As always, however, it is important to be willing to listen to the patient’s views on such matters, if only so that the patient will be open about the use of such treatments, enabling any potential issues to be identified, quantified, and dealt with. It is in nobody’s interest for a patient to be consuming additional substances with a potential pharmaceutical effect in secret. Healthcare providers should be open to engagement with the patient without engaging with alternative practitioners as part of the care process.
Accountability
Just as there is a risk of different departments passing the buck in traditional care models, there is a risk that in collaborative care some healthcare providers will fail to pull their weight. This is addressed through the deployment of strict accountability provisions and the careful measurement of patient progress. Importantly, healthcare providers are reimbursed based on the quality of treatment provided, not the quantity — that is, not by the length of time a patient spends in hospital, or the amount of counseling provided. This also reduces the risk of patients finding themselves subjected to unnecessary treatment simply because their insurers are willing to keep paying for it.
Where different departments have traditionally taken very different approaches to measuring clinical outcomes, they must work together at the outset to agree on a standard which can be used by everyone in relation to care provision for a specific patient. There is an elevated risk of mistakes if records are, in effect, being translated each time they are passed between departments.
A learning opportunity
Although specialization is vital to developing in-depth knowledge in specific healthcare fields, the downside is that it can make it harder to keep up with developments in other areas. When patients with complex conditions are concerned, this can have detrimental effects. It also makes it harder for new knowledge in one field to filter through to others, even when it might result in improvements there too. Collaborative care changes this because it gives specialists the opportunity to spend more time with people from other departments. As well as enabling the sharing of expertise, this encourages engagement with fresh perspectives, potentially allowing long-established professionals to gain new insights into their day-to-day work by looking at it in a fresh way.
Working in collaborative care also gives practitioners more in-depth knowledge of intersectional issues, making them better at anticipating them when they have not been raised directly, and helping them to achieve an understanding of what living with chronic illness is like from the patients’ perspective.
Helping the patients who fall short of clinical goals
As a rule, collaborative care makes the most dramatic difference when it is provided to patients who have a history of falling short of clinical goals. This is because the underlying cause of that failure often does not lie with the patients or with the severity of the illness but is simply a consequence of inadequate treatment provision. In traditional healthcare environments, patients with complex needs risk being written off as ‘difficult’. A more informed and cooperative approach to care sees those apparent difficulties melt away, leading to transformational outcomes following which even patients with lasting or severe illnesses can become much easier to treat and develop a much more positive relationship with healthcare providers. For an individual nurse, there are few things as rewarding as seeing a patient who has struggled for years suddenly recover their optimism and begin to get on top of their problems, leading to a much more positive future.
