Barbara Tofani Outlines Best Practices and Mistakes of Care Coordination

Using technology and collected data can greatly improve care coordination, but some low-tech options, like better team communication and involving the patient are also important, explained Barbara Tofani, RN, MSN, NEA-BC, administrative director of the Hunterdon Regional Cancer Center.

What are some best practices for setting up a program for care coordination?
I think having an enterprise-wide electronic health record would help tremendously. I think really educating providers not only in the input into the electronic health records, but also how do they manage the output? How do they manage the information that’s in there? How do they access the information? So, how does a primary care provider access the information from the medical oncology chart, so that when the primary care provider is seeing Mary Smith come in for her annual well visit, but he knows that she’s been diagnosed with breast cancer 4 years ago, how does the primary care physician know what he should be looking for, for Mary Smith? What are the most common side effects of the drug that she got? And what are the most common latent long-term effects of the drug that she got? So, that the primary care doctor knows what it is to look for. I think that’s number 1, being able to set up the electronic health record, and utilize the electronic health record to its fullest potential.

I think, we need to look at data a little bit more. Again, we put a lot of information in, we don’t do a good job of looking at it and saying, “What story is it telling us?” And, then, where does that story lead us? We put a lot of improvement projects in place, but, often, they’re not grounded in the data that, you know, the American College of Surgeons now requires anybody who is accredited to do studies of quality before you do a quality improvement, because what they want us to do is look to see: where are our problems? Then, address what are the appropriate solutions. But don’t just start throwing stuff against the wall and seeing what sticks.

Then, the third thing I think we need to do is we need to really recognize that care coordination is everybody’s responsibility. It’s not the responsibility of 1 person. It is not the responsibility of the nurse. It is not the responsibility of the care coordination department. It is everybody’s responsibility to coordinate the care of the patient. And that means improving your communication, asking questions, involving the patient in their care.

Actually, I said there was 3, but I think the fourth mistake we make is that we don’t involve the patients nearly as much as we should. The patients can give us a wealth of information and we don’t always talk with them. We talk at them. We make the decisions of what they need and we don’t often ask the patients: what is it that you need? How can we best help you coordinate your care?
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