Teams and Teamwork in Cancer Care Delivery: Shared Mental Models to Improve Planning for Discharge and Coordination of Follow-Up Care

Abstract

This article discusses the potential for shared mental models to improve teamwork during discharge planning and follow-up care. A 58-year-old inpatient on the hematology care unit of an academic medical center was discharged to his community after initial treatment of acute myeloid leukemia, without a clear plan for either discharge or follow-up. This case highlights the challenges faced by the primary oncology care team, the patient's community health-care team, the patient, and his caregiver, because a formal plan for follow-up care after discharge was not in place. The lack of communication within the oncology care team and between the medical center and community care teams that leads to the gap in continuity of care between inpatient and outpatient oncology settings could be addressed at least in part by establishing a shared mental model. This model would require all individuals involved in patient care to recognize they are part of a team. Furthermore, all members of the interdisciplinary discharge team need to understand their own roles and responsibilities as well as those of the other team members, including the need for communication and how their roles and activities affect those of other team members. Tools such as huddles, checklists, and patient education could be used to help the team recognize and achieve its goals. Ideally, this shared mental model could be extended to include the community health-care team, leading to a more fluid transition between inpatient and outpatient care, improving patient satisfaction, and likely improving patient outcomes.

Does emotional talk vary with fears of cancer recurrence trajectory? A content analysis of interactions between women with breast cancer and their therapeutic radiographers

“…This has been recognised as a major transition from treatment to home [42]. The topic of this transition is a prominent one for many patients and has been recognised in oncology services [42,43].…”

Improving Nurses’ Hand-off Process on Oncology Setting Using Lean Management Principles

“…These complaints cause many negative consequences such as delay in care; inadequate treatment, adverse events; increased length of stay, avoidable readmissions, costs, work inefficiency, and other patient harms which have negatively affect patient outcome and caregiver satisfaction including nurses Patients in oncology setting are struggling with the complexed disease including complicated signs and symptoms such as an immobility, decrease in blood counts, electrolyte discrepancies which have significant impacts on their well-being; and various types of long and intensive treatment options such as chemotherapy, radiotherapy, surgeries; and expensive treatment which put the patients and their family in financial crisis (Petersenet al, 2015;Zapka et al, 2012). This increase the patients' needs for more care and support, proper coordination, effective hand-off between health providers including nurses, education, and engagement in their care plan (Gupta et al, 2007;Page et al, 2016;Zapka et al, 2012). For this reasons, the effective hand-off between nurses is considered an essential as treatment management strategy because of its role to safe, effective, appropriate care (Azzani et al, 2014;Gupta et al, 2007).…”

Development and psychometric evaluation of a questionnaire to measure cancer patients’ perception of care coordination

“…Importantly, this study has illuminated notable differences between the existing literature and actual CC approaches used in cancer care. Although a multidisciplinary, team-based approach to cancer care in the US is extensively studied and recommended [3,4,8,25], patient-reports of actual care indicated that many do not perceive receiving a team-based care and some patients receive oncology care from nononcology providers (e.g., urologists, primary care). It is possible that these differences are in part due to that many prior studies on cancer CC were based on systems or providers' perspectives of CC or focused on specific systems of care.…”

“…Although the importance of CC is well-recognized, existing evidence demonstrates that cancer patients often receive poor, fragmented care across multiple settings and providers [1][2][3][4]. Poorly coordinated care has been linked to numerous adverse outcomes including medical errors, patient dissatisfaction, higher health care costs, excessive use of health services, and increased morbidity and mortality from the disease [5][6][7][8]. Further, the critical need to improve the quality and value of health care delivery has been highlighted by a recent report that demonstrated that failure in care coordination costs $27.2 to $78.2 billion annually in the U.S. health care system [9].…”