Case Study: Interprofessional Collaboration for  Chronic Disease Management in a Community Health Center  Chronic diseases such as diabetes and hypertension are prevalent in the United State

 Assessment 01 

Collaboration and Leadership Reflection Video

 For this assessment you will use Kaltura to create a 5–10 minute video reflection that addresses either an interprofessional collaboration you experienced or the case study on interprofessional collaboration presented below.

 If you choose to reflect on the interprofessional case study presented below, imagine that you are a nurse on the team and you have been assigned to interview members of the team prior to making the video reflection that you will share with the team and leadership where you will make recommendations to improve interprofessional collaboration.

 After you have thoroughly reviewed the case study below, return to the detailed instructions in the courseroom to complete your assessment. Feel free to refer back to this case study as you complete your assessment.

 Case Study: Interprofessional Collaboration for  Chronic Disease Management in a Community Health Center

 Chronic diseases such as diabetes and hypertension are prevalent in the United States and require ongoing management to prevent complications and improve health outcomes. Interprofessional collaboration is essential to ensure that patients receive comprehensive and coordinated care. This case study explores the interprofessional collaboration experience for chronic disease management in a community health center. 

 

The community health center in this case study serves a diverse population of patients with chronic diseases. The interprofessional team includes physicians, nurses, pharmacists, social workers, and community health workers who work together to develop and implement a patientcentered care plan. The team provides ongoing care to patients with chronic diseases, including regular check-ups, medication management, and lifestyle counseling.

 

The following are the responses when you asked each provider where the team could improve its interprofessional collaboration.

 

DR. JOHN LEE, a physician who specializes in internal medicine and leads the interprofessional team for chronic disease management. He is responsible for diagnosing and treating patients with chronic diseases, prescribing medications, and coordinating care with other team members.

 

“We are all trying our best to provide quality care to our patients with chronic diseases, but we also face some challenges that we need to overcome as a team. Communication is really important for interprofessional collaboration, but we fall short sometimes. 

 

“The pharmacy once changed the medication regimen of a patient without informing me or the nursing staff. The pharmacist thought the patient was taking too many pills and decided to switch some of them to a combination drug, but he didn’t consider the potential interactions or side effects of the new drug, and the patient developed a rash and nausea.

 

“Another time, a team member didn’t show up for a team meeting because she didn’t receive the email invitation that Ms. Smith sent. She said she checked her spam folder and did not find it there either. She missed an important discussion about a patient’s psychosocial needs and resources, and we had to reschedule the meeting for another day, but I don’t think it ever got rescheduled.

 

“A patient once received incorrect information about a community program that he thought would help the patient with his diet and exercise. Our community health worker didn’t verify the information with the program coordinator or update the patient’s records, and the patient went to the wrong location and time for the program. He wasted his time and money, and it hurts a patient’s trust in the whole team when miscommunications like this happen.”

 

CONNIE JONES, a nurse who works in the community health center and provides direct care to patients with chronic diseases. She is responsible for performing physical assessments, administering medications, monitoring vital signs, and educating patients about self-care and lifestyle changes.

 

“Thanks for doing these interviews! Interprofessional collaboration is so important for our team to work well together, especially for our patients with chronic diseases. 

 

“I’d say one of our biggest problems is with goal alignment. We don’t always have a shared vision and mission for patient care. We have different or conflicting goals for each patient, and sometimes we don’t even know what they are. We don’t communicate and negotiate our goals with each other all the time or with the patient and family. We just do what we think is best, because we have a lot on our plates, but we need to consider the impact on the whole team and on the patient’s satisfaction and outcomes.

 

“The other day, I had a patient who had diabetes and hypertension. He was overweight and had poor diet and exercise habits. His physician wanted him to lose weight and lower his blood pressure by following a strict diet and exercise plan. The pharmacist wanted him to take more medications to control his blood sugar and blood pressure levels. His social worker wanted him to join a support group for people with chronic diseases. The community health worker wanted him to enroll in a community program that offered healthy meals and physical activities.

 

“But none of them asked me what I wanted for the patient, or what the patient wanted for himself. They just gave me their orders and expected me to follow them. They didn’t care if the patient was willing or able to do what they asked him to do. They didn’t care if the patient had any preferences or concerns about his care plan. They didn’t care if the patient had any other needs or goals that were not related to his chronic diseases.

 

“I felt like I was caught in the middle of a tug-of-war, and I didn’t know who to listen to or what to do. I tried to balance their demands and accommodate their requests, but it was impossible. I ended up doing too much or too little, or doing something wrong or different from what they wanted me to do. The patient was confused and unhappy, and so was I.”

 

DR. VIRAJ PATEL, a pharmacist who works in the community health center and provides medication management services to patients with chronic diseases. He is responsible for reviewing medication histories, dispensing medications, counseling patients about medication use and adherence, and identifying and resolving medication-related problems.

 

“I’m glad someone’s going to help track what’s going on with our interprofessional collaboration. There’s so much need, we can all get stretched really thin, and we need to find some new strategies to better support our patients when we’re working together to provide care. 

 

“One of the major problems is our knowledge deficits. I need to know more about everyone else’s knowledge, skills, and scope of practice. I think sometimes I assume what other people on the team are doing or what they know, and I probably get it wrong sometimes. These knowledge gaps limit our ability to collaborate effectively and provide the best patient outcomes.

 

“The other day, I had a patient who had diabetes and hypertension. He was taking several medications for his conditions, but he was not adhering to them properly. He was skipping doses, taking wrong doses, or mixing up his medications. He was also experiencing some adverse effects from his medications, such as dizziness, fatigue, and dry mouth. I tried to help him with his medication management, but I faced some challenges from other team members. The physician didn’t consult me before prescribing new medications or changing the dosage of existing ones. He didn’t consider the patient’s ability and willingness to take them. He just wrote the prescriptions and expected me to dispense them.

 

“Someone should have referred the patient to me for medication counseling, but no one recognized the importance of medication education and adherence for chronic disease management. Everyone else was just focusing on whatever they thought they were supposed to be doing.”

 

LENORE GARCIA, a social worker who works in the community health center and provides psychosocial support to patients with chronic diseases. She is responsible for assessing patients’ social and emotional needs, providing counseling and referrals, facilitating access to community resources, and advocating for patients’ rights and welfare.

 

“Thanks for talking to everyone so we can get a big picture view of our collaboration efforts—they’re so important to patient care.

 

“One of the main problems is our language or cultural barriers. We have a diverse population of patients and team members who speak different languages or come from different cultures. We have difficulties communicating, understanding, and respecting each other’s languages or cultures. We have language or cultural misunderstandings, conflicts, biases, or stereotypes that affect our interprofessional collaboration and patient care.

 

“For example, the other day, I had a patient who had diabetes and hypertension. He was an immigrant from Somalia who spoke limited English and had different health beliefs and practices. He had difficulty communicating and trusting the health care system and the team members.

 

“I tried to help him with his administrative and financial needs, but I faced some challenges from other team members. His physician didn’t use an interpreter or a translator when he talked to the patient. He didn’t understand the patient’s language or culture. He just used medical jargon and assumed that the patient understood him.

 

“There were issues with the social worker. She didn’t ask the patient about his dietary or religious restrictions. She just gave him food and medication that weren’t compatible with his culture. The pharmacist didn’t acknowledge the patient’s health beliefs or practices. He didn’t explore the patient’s use of traditional or alternative medicine. He just dismissed them as unscientific or harmful. The community health worker didn’t coordinate with me to link the patient to community resources or services. He didn’t consult me about the patient’s eligibility or availability for community programs or support. He just provided outreach and education to the patient, without facilitating access to community resources or services.

 

“We need to overcome our language and cultural barriers by developing more intercultural competence and sensitivity across the whole team. We also need to use appropriate communication methods and tools to enhance our intercultural communication and better coordinate how we’re collaborating.”

 

WILLIAM NGUYEN, a community health worker in the community health center who provides outreach and education services to patients with chronic diseases. He is responsible for conducting home visits, providing health education and coaching, linking patients to health care and social services, and collecting data on patient outcomes and satisfaction.

 

“Hi, thanks for interviewing me. I think it’s wonderful that you’re doing this report on interprofessional collaboration. I think it’s very important for our team to work well together, especially for our patients with chronic diseases. But I have to say, we have some problems that we need to address.

 

“One of the main problems is our organizational silos. We are separated or isolated from different departments, units, or professions within the healthcare organization. We have barriers to information sharing, resource allocation, and decision making. We have a culture of individualism and territorialism that undermines teamwork and innovation.

 

“For example, the other day, I had a patient who had diabetes and hypertension. He was also depressed and anxious because of his chronic conditions. He had difficulty coping with his emotions and managing his stress. He also had financial and social problems that affected his health and well-being. I tried to help him with his psychosocial support, but the patient’s physician didn’t refer the patient to me for counseling or assessment. He didn’t recognize the importance of psychosocial factors for chronic disease management. He just focused on the patient’s medical needs and treatments.

 

“Ms. Jones did not collaborate with me on providing patient education and self-care. She did not include me in the patient’s care plan or daily goals. She just followed Dr. Lee’s orders and instructions, without considering the patient’s emotional and behavioral needs.

 

“Mr. Patel did not inform me about the patient’s medication regimen or adherence. He did not share any information or data on the patient’s medication use and outcomes. He just dispensed the medications and counseled the patient about medication use, without addressing the patient’s psychosocial issues or concerns.

 

DR. ADRIANA SMITH, an administrator who works in the community health center and oversees the operations and finances of the interprofessional team for chronic disease management. She is responsible for managing the budget, staff, equipment, and policies of the team, as well as evaluating the quality and effectiveness of the team’s performance.

 

“Thanks for tackling this project. I think it’s amazing that you’re doing this work to help us perform better as a team.

 

“You know what I’m going to talk about: limited resources. We have a shortage of staff, equipment, space, and time in the health center that lead to difficulties providing comprehensive and coordinated care to all our patients.

“The other day, I was helping a patient who had diabetes and hypertension. He needed regular check-ups, medication management, and lifestyle counseling from the team. He also needed some lab tests, imaging studies, and referrals to specialists. I tried to help him with his financial questions, but our physicians have a long waiting list of patients and a heavy workload. They don’t have time to provide more than a brief consultation and maybe some prescriptions.

“The problem just carries through across the team. Our nurses don’t have enough space or equipment to care for all our patients with chronic health care needs. Our pharmacy doesn’t always have enough hours or staff to schedule comprehensive med counsels for every patient or follow up if someone else on the team forgets to make that referral. Our social workers and community health workers don’t have enough access or availability to provide all the support our patients need to assure the best outcomes. There’s a limited network of community resources and services with long waiting times and eligibility criteria. We do the best we can with what we have, but I wish we had some new strategies our interprofessional approaches that could stretch what we do have to better support our patients.”