0:00

Are you working with a team and looking for new ways

0:02

to work together? Are

0:04

you looking for innovative ways to improve cognitive

0:06

care across your team? Yeah,

0:09

me too. Sarah,

0:49

we're getting into stage three of the pathway

0:51

for team based care. This is where

0:54

the team is really developing and starting

0:56

to gel as a team, isn't it?

0:58

Right. So in this stage, team

1:00

members are already working together.

1:03

They're getting to know each other. And they're

1:05

kind of starting to establish new ways

1:07

of interacting. Really,

1:09

I think a key piece here is

1:11

thinking about, you know, not just who's doing

1:14

what, but also how are we sharing

1:16

leadership decision making and maybe

1:18

working a little bit differently to really,

1:21

draw in kind of team strengths.

1:23

And Sarah, when you get into that kind of shared

1:25

leadership or distributed authority

1:28

that you need to have a lot of trust in who you're

1:30

working with. So I think that's, that's a

1:32

part of this, isn't it? It's that understanding

1:35

about who you're working with, knowing

1:37

them and, and having that trust for

1:39

the shared leadership to be effective.

1:41

Exactly.

1:42

Yeah. And at this stage, I think also.

1:45

And this is my bias, but you're going to start thinking

1:47

about continuity as well.

1:49

It's not just here's a task for somebody else

1:51

to do and I'm going to get the answer back.

1:53

But now thinking about if there is

1:55

that shared leadership, that shared care

1:58

that's really happening, how do you ensure

2:00

continuity across the team? And that's particularly

2:03

true if you're growing up in a larger team.

2:05

And Morgan, I know this is a passion

2:07

area for you. You've done a lot of work

2:09

It is. Yeah.

2:11

if we think about one of the main concerns that we've

2:13

heard when we think about team based care and

2:15

how patients are understanding

2:17

what's happening in this space, both

2:19

patients and provider concern actually. is

2:22

really this idea that team based care

2:24

is going to decrease continuity of care because all

2:26

of a sudden as a provider You

2:28

might not have as close a relationship with The

2:30

patient that you're seeing all the time the patient

2:33

now has a team rather than one person

2:35

that they're connecting with There's a lot of

2:37

concern here about you know, does

2:39

this mean that I'm gonna have less continuity

2:41

of care?

2:42

And it, doesn't mean that if you do it

2:44

well. And I think understanding the different

2:47

kinds of continuity then helps you understand how

2:49

to do it. but also for a patient

2:51

who, who as part of the relationship

2:54

needs to feel part of the team and

2:56

connected, understanding how

2:59

relationship continuity happens across a team

3:01

is also really important. So, if

3:03

I can get a little academic, I think of

3:05

continuity myself in four ways. And

3:08

the first one is about information. So,

3:11

you know, the classic thing here really

3:13

is, do we all have access to the same

3:16

record if we're part of a team? Are

3:19

we able to see the same information

3:21

or is, are there barriers to that?

3:24

And if, if that continuity is broken,

3:26

that makes it hard to see what's happening. Second

3:29

one's a little different. And, that's

3:31

more about management continuity. And some

3:33

people think of this as care plans, so we all have, okay, this

3:35

is our protocol, we're going to run the protocol. it's

3:38

partly that, but it's also, why

3:40

are we here, and what's our philosophy

3:42

for work?

3:43

Right.

3:44

So that purpose of, like, are we

3:46

taking a harm reduction approach, for example,

3:48

in my practice? If one of us

3:50

is not taking a harm reduction approach, it's very

3:52

hard to be consistent in our management. one

3:55

person, a patient sees one member of the team and

3:57

versus another, that can be tricky. So

3:59

you have to have that sort of general philosophical

4:02

alignment,

4:03

I'm guessing that, you know, the management

4:06

continuity could also be really tricky when

4:08

you think about how a patient's needs

4:10

might evolve over time and how

4:12

that, could change over time and

4:14

needing to really loop back to that idea of,

4:17

okay, do we all have the same framing

4:19

for our work? Do we all have that same philosophy?

4:22

Does that management continuity continue

4:24

even when the team changes

4:26

and adjusts,

4:27

And sometimes the, the, goal of different parts

4:29

of care shift. So having

4:32

the informational continuity helps with the management.

4:34

So it kind of builds on it. So you can say, we're changing

4:36

the plan and there's a way to share that plan.

4:39

and that's So interesting because I think when I, kind of think

4:41

about continuity, all I really think about is the relational

4:44

continuity side, which I think

4:46

as a patient, that's, yeah, and sometimes

4:48

you think, well, it's a given, isn't it? That everyone

4:50

has the information. I think that's a lot of it. I remember

4:52

my mom years ago saying, well, the hospital

4:54

didn't have my doctor's records. And

4:56

I said, well, mom, where did the doctor write

4:59

the records? So in the paper. And

5:01

then, and where does the paper go afterwards?

5:04

On the shell. Oh, right. It

5:06

goes on the shelf, so obviously nobody

5:09

has access to it. Now, with electronic records,

5:11

it's a little bit different, but still. relational

5:13

continuity, though, coming back to that, I

5:15

think it's about getting that connection

5:18

so people understand being,

5:21

connected. The patient knows who

5:23

they're talking to, so that small teams are actually

5:25

really good for this, because you build a

5:27

relationship, patient to team members.

5:30

I think with a team, too, You

5:32

actually can spend a bit more time as a,

5:34

family doctor or any team member, you can spend more

5:36

time getting to know the patient Understanding

5:38

what matters to them.

5:40

And actually, there's a tool for that, isn't there?

5:42

HQBC, Health Quality BC,

5:44

has a great resource, that's built

5:47

out around asking patients explicitly,

5:49

what matters to you? And I think we're going to

5:51

come back to that later today.

5:54

Yeah, absolutely. I think that's an important thing

5:56

to think about and it definitely helps

5:58

build relational continuity. I'm

6:00

almost done my academic piece. Let me do

6:02

one more type of continuity. And this is my, my

6:04

favorite one. Cause this is part of what I learned

6:06

through my own work is this idea

6:09

of, what I call inter

6:11

provider relationships.

6:14

So the, relationships

6:16

between team members across

6:19

the team and this inter

6:21

provider connectedness really

6:23

is about how much we trust. So coming back to that idea

6:26

of trust. How much we trust each other

6:28

and how closely we work together means

6:30

we're more likely to share all the other pieces,

6:33

and patients really feel that. they

6:35

just, they get that sense, and, and also

6:37

it's not so much, you know, I want

6:39

you to see one of our nurses about

6:42

such and such. It's actually, you know

6:44

what, I want you to see Ann, and

6:46

let's go down, down the hallway and just double check with Ann,

6:48

or, you know, it, it becomes

6:50

so much more personal. And then

6:53

there is that personal attention that is felt

6:55

by the patient, so that builds that relational

6:57

continuity as well. So that last

6:59

part, I think, when you think about how

7:02

the team provides that continuity,

7:04

becomes really important. And it happens across

7:06

team members.

7:07

And, you know, as you're saying this, I'm thinking, Morgan, you

7:09

know, so many, so much of the pathway

7:12

that's been designed is really to support

7:14

this Interprovider connectedness,

7:17

build this trust and then kind

7:19

of extend that interprovider connectedness

7:22

to the relational continuity and include

7:24

the patient. Right. So really thinking

7:26

about, all of these stages

7:28

of the pathway, the getting started, the team building,

7:31

the team development. And then

7:33

as you move ahead, you know, thinking about quality

7:35

improvement and what do you want to do better? So

7:37

much of that, I think, yeah. It really needs that

7:39

kind of foundation of trust to

7:42

work well.

7:43

Yeah. Absolutely.

7:44

And I think patients feel this, right? They see when a

7:46

team works well together, they, they, they

7:48

can tell when, something is, is, you know,

7:51

well supported.

7:52

Yeah. Absolutely. Even if it's not directly

7:54

with them, one thing I've noticed

7:56

is if, Sam, I'm walking a patient out

7:58

of, out of a visit out to the waiting

8:01

room and one of the other team members is walking

8:03

a patient in the other direction, you

8:05

know, just even, acknowledging the, the

8:07

nurse that's going the other direction, patients see

8:10

that and they see how connected we are. And

8:12

that makes a big difference as opposed to sort of cold

8:15

and clinical, don't know who that is,

8:17

kind of. walking the other direction down the hallway.

8:19

So patients definitely pick it

8:21

up.

8:22

And it's, I mean, I know I always come back to this, but

8:24

it's that culture piece, right? That team culture.

8:26

How do you, how do you build that out?

8:28

Yeah.

8:29

Thinking about kind of this team development

8:31

stage that we're now. And in the pathway,

8:34

and you know, what jumped out to me when we think about

8:36

an interesting activity, I really

8:38

wanted to come back to the what matters

8:41

to you, resources that have been included

8:43

here you can think that they're really

8:46

sort of not as team focused. It

8:48

really is more about how a provider

8:50

is connecting with a patient individually.

8:52

But I think it's one of those pieces. If you can

8:55

bring that back into the philosophy of how

8:57

you're all working together. and

8:59

make it so that, you know, across the team, everyone

9:01

is really reflecting on this question of,

9:04

what matters to you to keep care sort of patient

9:06

centered and to keep patients engaged

9:08

in the team. I just think there's a lot

9:10

of, great kind of team development that can

9:12

happen through the use of, of

9:14

that tool.

9:15

Yeah, I think so. Now this, we're going to put some links

9:18

down to the, what matters to you

9:20

tool down below in the show notes.

9:23

And what I like about this tool is I agree with you.

9:25

It, it comes back to that question of how do we

9:27

keep the relational continuity

9:29

going? it's a very easy

9:31

thing to also implement. And I like that. It

9:34

makes you think in a patient centered manner

9:36

and it's something that all the team members can do

9:38

from the front staff to nursing

9:41

team members to nurse practitioners

9:43

family doctors Any team member

9:45

can take this approach and it it

9:48

really does help shift our thinking.

9:50

And I mean, as far as an example of

9:53

the kind of questions and resources that are in

9:55

this kind of host of, tools, there's a series

9:57

of, checklists that you can work through

10:00

and we'll post the links below. But one

10:02

of the things is, before an appointment and a checklist

10:05

of things to make sure, has been communicated

10:07

to a patient. And when we were building out the,

10:09

the idea for this episode, I thought, Oh, like I,

10:12

that would be great if I got a, before

10:14

the appointment sort of check in with my provider. I don't,

10:16

I don't get that at all. But then I

10:18

realized, no, actually, if I think about how

10:21

in the team that I'm part of, my, the team works,

10:24

it's not the primary care provider who

10:26

reaches out to me, but it's the MOA. and

10:28

I absolutely do get all of those

10:30

things that are in that checklist. But

10:33

through, through the MOA, reaching out to me

10:35

and, and confirming, demonstrating

10:37

the flexibility and scheduling, setting

10:39

out what can be expected. Am I connecting,

10:41

over a phone or is there a

10:44

kind of virtual platform that we're using? and

10:46

I realized, Oh, I do get everything in this checklist,

10:49

but I immediately had jumped

10:51

to, Oh, my provider doesn't connect

10:53

with me at all about this.

10:54

Right.

10:55

So I just think it's a really, interesting

10:57

reframe when you think about the team

10:59

and how can the team fit into, these

11:02

sort of what matters to you questions.

11:04

I think that's a really good point and it might be

11:06

helpful to share that

11:08

approach with the patients in your practice

11:11

so people understand, oh yeah, we're all working together,

11:13

as a team. And so the things

11:15

that the MOA might be asking, I'm

11:17

going to know about. And, that extends

11:19

the relationship across

11:22

team members for the person.

11:24

the simple idea of just asking

11:27

somebody in a visit what matters to

11:29

you or what's important for you right now or, you

11:31

know, what, what are you worried about?

11:34

Simple questions like that can change

11:36

the conversation so dramatically. somebody

11:38

comes in, you know, I work in a shelter as, as

11:40

people have listened to this now. it might be

11:42

for a medication refill is what I, what I'm initially

11:45

understood as the question, but then as we

11:47

start to talk, you know, what is it that's,

11:50

important for you right now that I can help with? And it might

11:52

be something unsurprisingly to do with

11:54

housing or, finances.

11:57

And some of those things are out of my scope. but

12:00

because I'm connected into a team, I'll say, you know, what I'll do

12:02

is I will talk to one of the social workers

12:04

here or the client support worker here. And

12:07

and just help to advocate a little bit, and even if

12:09

it's a, a little bit of advocate, you

12:11

know, that, that could be important for,

12:13

for a patient to hear that that's

12:16

happening, and if I don't ask the question what's important,

12:18

I don't, I don't know that that's what they really

12:20

want to know about. a classic example

12:23

is, something that I think is completely

12:26

benign. It might be, a sprained

12:28

ankle or it might be a cough,

12:31

but somebody thinks it's cancer. And if

12:33

you don't ask and then all

12:35

of a sudden like, well, do you think I'm going to die

12:37

from this? And you know, wait, wait, it's.

12:39

All you have is, you know, it's just a sprained

12:42

ankle. There's nothing that, and, but

12:44

for some part of their

12:46

history there's a reason they think

12:48

that, and then you can unpack that and reassure them.

12:50

and so those things are important

12:53

little questions that really suddenly change

12:55

the conversation and then change the relationship.

12:58

And I think so, really learning what matters

13:01

to a patient I think is just so important

13:03

throughout their sort of care journey.

13:06

And there's a lot of questions on people's

13:08

plates and that's when I think these kind of checklist

13:10

sort of tools can at least be a good

13:12

prompt to, to review and, and

13:14

think about. One other thing that kind

13:16

of comes to mind here is if this kind of

13:19

resource is of interest to you, and

13:21

if you specifically have a nursing

13:23

role on your team, we actually did

13:25

some work at the beginning of the pandemic times,

13:28

about, uh, our end virtual visit tool,

13:30

very similar to the, what matters to you tools,

13:33

kind of checklists when you think about how you're

13:35

connecting as a team and with your patients.

13:37

Yeah, I think those are excellent things to start

13:39

looking at. you know, the other thing in

13:42

terms of the, relational continuity

13:44

and thinking about how your team is structured,

13:46

I think the team let is,

13:49

is something that I often come back to is if you have

13:51

a, if you have a large clinic,

13:53

and a potentially a large team or a

13:55

large group of members that are potentially working together

13:57

in different ways, trying Shrink

14:00

down into smaller teams that

14:02

work more consistently with a panel of

14:04

patients, obviously there's going to be some

14:06

shifts on certain days or when people are available

14:08

or certain skills, but if you

14:10

generally try to have a smaller collaborative

14:13

group, patients are going to feel that

14:15

continuity. They're going to feel more

14:17

listened to across a smaller team than if it's

14:20

just, different people every single time.

14:22

And that goes for all the different roles. So I think that

14:24

that's one thing to structure your team. The

14:26

other thing that I'll, I'll highlight as a possible

14:29

thing to try to implement if you

14:31

have a team is just communicating with your

14:33

patients about how you're

14:35

communicating across the team. and

14:37

it can be as simple as I'm writing

14:39

a note here so that, that,

14:41

your nurse will know, you know, or Ann will

14:43

know next week. I've written something

14:45

specially for Roz here and

14:48

the patient will realize that you're communicating even

14:50

if it's asynchronously through

14:52

the EMR note.

14:54

And I think the, the side benefit is. Your patient

14:56

is being reminded of these other people that

14:58

are on their team and what their names are

15:00

and that you're working together and all of

15:02

those questions. I think it can be really concerning

15:05

for folks when all of a sudden they don't

15:07

have maybe their one provider that they're going

15:09

to see all the time. All of those concerns

15:11

get mediated by the fact that you're really

15:14

open about how you're connecting and communicating,

15:16

which is one of the biggest areas of feedback

15:18

that we heard when we reached out to patients about, you know

15:20

what they need To be better supported in team

15:23

based care, I guess before we

15:25

wrap up, I'm looking at this kind of stage

15:27

three of the pathway and thinking about the other

15:29

sort of really interesting tools in this space.

15:32

there's a relational continuity change package

15:34

that has been highlighted in the

15:36

learning pathway. This comes from Alberta

15:39

and does some really interesting sort of

15:41

resource linking, identifying actions and

15:43

tools for teams, to try

15:45

out when they're thinking about different aspects of continuity.

15:48

Some of it is really Alberta, specific

15:51

and we are going to be working on building out some

15:53

more of these resources. So this is another

15:55

kind of check this space, uh,

15:57

note for, for our listeners, come

15:59

back to this and, and check in and we'll

16:01

continue to update it. to wrap

16:03

up, what do you think Morgan

16:06

is an action to try in practice?

16:09

I'm going to keep it super simple and very

16:11

actionable, and that is, as you're

16:13

writing up your care plan, just tell patients how

16:15

you're sharing them across your team. I

16:17

think any team can just start to embed

16:19

that into their practice very

16:21

simply, and it's a nice way to wrap up a visit

16:24

as well.

16:24

Great. Well, and while doing that, you're,

16:27

you're developing your team here. You're

16:29

moving forward kind of through this journey.

16:32

So invite you also to check out some of the other

16:35

resources in stage three. We've highlighted

16:37

a couple here, but there's so much more, and

16:39

thanks so much for listening. If you've heard

16:41

anything that's really interesting today, if

16:43

you have feedback for us, we'd love

16:46

to hear from you. Reach out to

16:48

info at teambasedcarebc. ca. The

16:52

Innovation Support Unit is a distributed

16:54

multidisciplinary team. We work

16:56

mostly remotely from communities across

16:58

the Lower Mainland and Vancouver Island in

17:01

British Columbia.

17:02

Sarah and I are both recording from our offices

17:04

in the territories of the Lekwungen speaking peoples,

17:07

the Songhees and Esquimalt First Nations.

17:09

And recognizing the colonial history

17:11

and the ongoing impacts of colonization

17:14

and healthcare systems and in Indigenous

17:16

communities in Canada and around the world, as

17:18

we move through the season, we'll work to bring an equity

17:21

lens to this work. And we really

17:23

encourage you, our listener, to reflect

17:25

on your past, present, and future participation.

17:28

On the indigenous lands where you are situated.

17:30

Thanks for listening.