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True collaboration
How patient advisers are working with Region
staff to improve the delivery of care
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By Mike Daly
Jan/Feb 2019

Paula Orecklin is not a nurse or a doctor.

In fact, the 31-year-old Winnipeg woman has no medical training at all.

But she does have experience with the health-care system, having received years of ongoing treatment for a chronic condition called complex regional pain syndrome. As a result, Orecklin possesses something that is in high demand these days: a patient's view on how to improve the delivery of care.

It's a perspective that the Winnipeg Regional Health Authority went looking for when it recently decided to revamp the way it organizes its collaborative care training teams.

Traditionally, collaborative care training teams are made up of a cross-section of health-care providers who work together to solve problems and identify ways to improve care.

Research shows that collaborative care creates better health outcomes for patients, clients, and residents, and positively impacts their experience and satisfaction with their care. Health-care providers also benefit through healthier work environments and increased job satisfaction.

But the Region decided last spring to revitalize its approach to collaborative care training by adding patient advisors to the mix. The move was part of the Region's ongoing effort to elevate and emphasize the role of patients and their families in the delivery of care.

Orecklin, for example, was asked to sit in with a collaborative care team that was working to improve care for patients at Health Sciences Centre Winnipeg's spinal cord rehabilitation unit. The team also included a physiotherapist, an occupational therapist, a social worker, and a clinical resource nurse.

The new approach paid immediate dividends, according to Kristyn Ball, Physiotherapy Clinical Services Leader at the cord injury rehabilitation unit and a member of the collaborative team.

Photo of Paula Orecklin and Tracy Thiele
Tracy Thiele (right) says advisers like Paula Orecklin are helping to improve the delivery of care.

"This is the future," says Ball, in reference to the idea of including former patients on collaborative care teams. "This is where health care is going."

As Ball explains, discussion among collaborative care team members centred on improving communication between health-care providers, and between the health-care team and patients. Health-care providers agreed that they weren't always on the same page when it came to discussing issues with patients and families.

Orecklin contributed to the group's deliberations by reflecting on her experiences as a patient and by reminding them of the importance of seeking out input from patients and their families.

Those words of advice resonated with Ball.

"Even though (Orecklin) wasn't a patient on our unit, she told us what she would want as a patient, and about her frustrations and experiences in health care, and what would have made it better," says Ball.

Orecklin, who also serves as a volunteer with one of the Region's patient advisory committees, says she's pleased the team took her input to heart.

"Working with the (Region) and some of its teams has been pretty awesome," she says. "They really listened."

Collaborative care training has been a cornerstone of the Region's efforts to enhance the delivery of care throughout the Region since 2012, according to Tracy Thiele, Nursing Initiatives Manager, and the person who oversees training for the Region.

"Health-care professionals have been collaborating for years, of course, but not always as successfully as we could be," says Thiele. "We wanted to achieve a good base of education so that we could support the teams that were doing well and to push some teams to do a little better."

In order to meet those goals, collaborative care training has evolved over time.

"When we started and collaborative care was still a new concept for most staff, the training was very didactic," Thiele says. "Now, many of the professionals who are coming already understand the basic concepts, are asking better questions, and challenging us in different ways. We're able to dive into the topic a little deeper."

The format of the course has also changed, evolving from a one-time, five-day education session, to a more interactive format spread out over several months. Among other advantages, the change allows teams to start the course with a hands-on, real-life project aimed at improving collaboration at their work site or program.

Photo of Cara Windle
Time Well Spent
Deer Lodge Centre team says time spent on collaboration will lead to better care. Click here to read more

"Teams come for three days in the spring, a half-day in September, and then another half-day in November, where teams can showcase the work they've done," Thiele says.

The decision to place patient advisors on the collaborative care teams adds a new dimension to the concept.

At first glance, not having that input from the outset of the training back in 2012 might seem an odd omission, but Thiele says it had to wait until the program gained sufficient traction within the Region.

"I would say we probably just weren't ready yet," Thiele says. "It was a new concept to teach collaboration. Person-centred care was one of the competencies we taught, but I don't think we were ready to integrate direct patient involvement into the training. Now, we have it structured well, we did a developmental evaluation, the content is set, and now that we have all that, we can get into the meat and potatoes of involving the patient. We are ready to challenge teams a little more."

This year, all eight participating teams had the benefit of hearing from patient advisors whose life experience has brought them into close contact with the health-care system.

For Ball and the other members of HSC Winnipeg's spinal cord injury rehabilitation team, that input was a valuable piece of the team's goal-setting project.

"Spinal cord injury is a complex diagnosis, and it's often catastrophic," Ball says. "Patients and their families are dealing with life-changing injuries, and it takes them time to come to terms with these changes. We struggle with patient engagement because they come to rehab and feel like we're taking their hope away by saying things like, 'We're going to put you in a wheelchair' when they are saying, 'No, I want to walk again.' It's a hard time when we're trying to help them build these new skills and they're trying to cope, and our team saw an opportunity to improve how we communicate rehabilitation goals to the patients and to each other."

In addition to hearing from Orecklin, the collaborative care team also sought input from spinal cord injury patients and their families to get a feel for how they felt about the rehab team's current processes, and to provide a baseline to help measure the success of their goal-setting initiative going forward.

The result, the team believes, is a project that much more effectively involves patients and their families.

"It's a hard thing for our team members to say, 'No, I don't believe you will ever walk again,' or 'I don't think you will regain control of your bowels or your bladder," Ball says. "We realized we weren't doing a good enough job of approaching it as a team and being on the same page about where the patient is going to progress. And the patient receiving mixed or unclear messages wasn't helping the situation. So we tried to make a process for communicating to patients about their goals and (for engaging) them in their rehab."

The new process has been in use on the unit for the past two months, she says.

"First of all, we're having a formal meet-and-greet, which is a new thing for our team. Within two weeks of admission to the unit, the patient and their family have a chance to sit with the whole team to hear the prognosis of their injury and what it means." Patients get an initial introduction to rehab, and a "heads up" that the team will be talking about necessities such as wheelchairs.

Photo of HSC Winnipeg collaborative care team members
HSC Winnipeg collaborative care team members, from left: Kristyn Ball, Kevin Stewart (physiotherapist), Lea Grant (occupational therapist), Bridget Gallagher (clinical resource nurse).

"We let them know that we understand that this is going to be really hard, and that they are included in the team and we're here to answer their questions. We introduce them to the members of the team and their roles, so they know who to talk to about wheelchairs, about transferring from bed, and about issues like pressure relief. It makes the various roles on the team very clear to the patient and their family members. And then we give them some time to process the information. They often have a lot of questions, and we get off to a slow start."

The process also involves a form for capturing goals.

"We use this process during rounds," Ball says. "The unit's entire team is represented in the rounds, including the doctor, physiotherapists, occupational therapists, social workers, recreational therapists, home-care specialists, nurses, and, at times, members of the Canadian Paraplegic Association as a community support.

"We set one or two goals for the patient every two weeks," Ball says, adding that patients can stay on the ward anywhere between eight weeks and a year, depending on the severity of their injury. The average stay is somewhere between four and five months.

"Everyone has input, and we document the goals in a couple of bullets. Then the social worker and the nurse take those goals to the patient and say, 'This is what we need you to work on in the next two weeks, are you on board? Does this sound okay to you?' They are given a chance to provide feedback so that they don't feel like it's just people telling them what to do. We're engaging them in helping to set their own goals."

Goals are then placed on the patient's bedside board as a reminder to staff and family, and are closely monitored.

"If we aren't achieving them, we can come together as a team to ask ourselves why we're not being successful, evaluate what we're doing, and identify the barriers to success. It creates accountability."

Additional discussions with the patient and families can also take place as necessary.

Though the project was implemented only weeks ago and is still being refined, early indications are that it's making a difference for health-care staff, their patients, and families.

"Initial feedback indicates that staff feel they have a better idea of what message is going to their patients," Ball says. "They're able to reinforce a message the whole team supports, and they feel like we're acting more like a collaborative team. They feel more confident in their dealings with the patients and their families."

Patients have also been appreciative.

"If you're not getting consistent messages, you're not going to have confidence in the team that's providing care for you," Ball says. "With such a life-changing event, we need to give patients that confidence. The families are also very much a part of the team and we need their support. A lot of these patients need physical and emotional support when they go home, so the caregivers are as much a part of our team as the patient."

Like many advocates volunteering with the Region's many patient advisory committees and local health improvement groups, Orecklin's observations and eye for detail have been developed through extensive experience with the health-care system.

"I have complex regional pain syndrome. It basically means that one of my legs is hurting and won't stop hurting. It's known as one of the most painful conditions out there. In March, I'll have had it for 18 years."

Orecklin says she has first-hand experience dealing with health-care professionals who don't collaborate as well as they should.

"Trying to make sure the professionals are all on one page is a wonderful idea," she says. "I can tell you that personally I've gotten completely confused by different professionals saying very different things. These are the people you have to trust, and if they can't figure it out, how am I supposed to figure it out as a patient or family member?"

She says that she's happy that the spinal cord rehabilitation team has taken the time to get the patient perspective.

"I had no idea they'd come up with a meet-and-greet and a goal-setting form, but I think it's excellent because a huge issue seems to be the disparity between the patient and family's expectations and the expectations of the professionals. I'm incredibly honoured that they were able to take my input to help make something wonderful that's going to benefit patients and families. I'm honoured to take part in that."

Mike Daly is a communications specialist with the Winnipeg Regional Health Authority.


For more information about Collaborative Care, click here.

Collaborative Care's six core competencies:

1. Person-Centred Care
Each person is the expert in their own health experience. Health providers recognize that people are at the centre of their health-care story. A patient's family members can also provide valuable insight into a loved one's health. Involving individuals and their families in the creation, implementation and evaluation of the health-care plan helps ensure the best outcome.

2. Role Clarification
When creating their own roles, health providers also consider the roles of others as part of the larger health-care team. Along with understanding and describing their own roles, health providers/students are able to describe the roles of other health providers.

This understanding helps avoid duplication and gaps in service. In turn, this improves teamwork, frees up time for health providers to work to their full scope of practice, and ensures more effective planning, implementation and evaluation of services.

3. Team Functioning
It starts with the belief that whether a team is formal or informal, there is an opportunity for health providers to work together in a way that ultimately benefits the patients/clients/residents they care for.
Health providers develop teams by establishing and maintaining effective working relationships with everyone on the team applying team practice processes to informal working groups as well understanding the process and dynamics of team development.

4. Collaborative Leadership
Collaborative leadership occurs when health providers work together as a team with the patient and his/her family to plan, introduce and evaluate care and services. Each member of the team shares responsibility for their role in the process toward creating positive healthy outcomes.

5. Interprofessional Communication
Interprofessional communication occurs when health providers communicate with each other, with patients and their families, and with the community in an open, collaborative and responsible manner. This type of communication builds trust amongst patients, their families and team members.

An environment of mutual respect is essential for interprofessional communication. Respect helps facilitate a positive environment in which to set shared goals, create collaborative plans, make decisions and share responsibilities.

6. Interprofessional Conflict Resolution
Interprofessional conflict resolution happens when health-care providers work as a team that actively engages in addressing disagreements and responds effectively to all types of conflict.