With the massive shift towards models of interprofessional collaboration (IPC) to provide integrated care for patients with complex health needs, role clarification is a central enabler for true collaboration to occur and yet, it is consistently documented as a very challenging process due to the constant flux of people caring for the patient, both the healthcare side (Health Team) and family/caregiver side (Support Team).

We introduced tiered role based access into our Patient Success Platform from the start, enabling “need to know” so everyone can respect privacy legislation and patient preferences. Everyone can see who is who and what level of access they are granted.

Based on user feedback, we are now formalizing another important aspect - achieving greater clarity on who is the lead on the Health Team and Support Team sides, including making it possible to confirm who has the legal right to make decisions on behalf of the patient. 

This builds on the abundant research evidence that there are three key elements that are essential in order for team-based care to ensure patient safety and quality:

1. Clear and known roles and tasks for team members
2. Clear specifications regarding authority and accountability
3. Clear and known decision-making procedures

Read more about these two key functionalities, how our latest product enhancements work, and the benefits for both Health and Support teams alike.

Identifying the Most Responsible Provider (MRP)

Health Team members using Careteam can now assign one healthcare provider as the Most Responsible Provider / Practitioner / Physician (MRP), the regulated health professional who has overall responsibility for directing and coordinating the care and management of a patient at a specific point in time. 

Traditionally, the MRP has been a physician, but increasingly legislation and practice changes now make it possible to have any regulated health practitioner such as nurse practitioners, nurse, therapists and social workers as the MRP. With the rapid changes to who is on shift or service,  or absences due to vacations or illness and also due the changes in patient status, it can be difficult for both the Health Team and the Support Team to see who is the current MRP for the patient. 

Being able to know who is the current MRP enables safer patient handoffs and transfer of care, as well as allows for everyone to know who they should communicate with if there are any questions or concerns regarding the patient. There is strong evidence that this practice enhances care quality and safety, as well as increases patient satisfaction and for providers, increases capacity to collaborate while decreasing burnout. Increasingly, the ability to identify an MRP for every patient is a requirement for quality of care scores and accreditation.

It is also important to note when there is a change in the MRP for a particular patient known as a ‘transfer of care”, This can take place with movement of patients between health care locations, providers or different levels of care within the same location as their conditions and care needs change. Careteam keeps log of such transfers and makes it very easy to modify who is the MRP at any given time.

Health Team members can assign the MRP, using the following three steps:

1. Go to the ‘Team’ page
2. Click on the Health Team member that you would like to assign as ‘Most Responsible Provider’
3. Click ‘Assign as Most Responsible Provider’ and confirm this decision in the subsequent pop-up

Assigning a Substitute Decision Maker (SDM)

Knowing who is the ‘Substitute Decision Maker’ or ‘Surrogate Decision Maker’ (SDM) not only saves time and effort to ensure the right person is involved, but is a must to meet medicolegal and ethical obligations. Too often making assumptions as to who that is for a given patient leads to inefficiencies, negatives care outcomes or legal action. Knowing who the SDM is helps health providers to know who is involved in the patient’s care at a decision making level and they can better meet privacy and legal rules as to what they are allowed or obligated to disclose.

An SDM can help make healthcare decisions on the patient’s behalf at any time they can't make these decisions for themselves. Ideally a patient can identify their own SDM and give them Power of Attorney (POA) for Health care/ Personal care (ie, health care proxy, health care representative or agent).

When patients have not done so, there is a hierarchy that determines which individual has priority, and this is usually based on locally applicable laws that vary. The prioritized list usually starts with a legal guardian, spouse, adult child, parent, sibling, or another family member. Some jurisdictions allow for someone not on the specific hierarchy of surrogates (eg, an uncle, niece, close friend) to serve as an authorized SDMif there is no one else available and they can demonstrate that they know the patient and can represent their best interests.  Finally, although a court-appointed guardian could usually be appointed, in practice, this process is often costly and time consuming and impractical for time-sensitive decisions.

SDMs are obligated to make health care decisions for a patient in accordance with what the patient would want and are encouraged to include the patient in the decision-making process to the extent of the patient's abilities and interest, which is possible within the Careteam platform as the patient can continue to be a “co-pilot” of their own care, if so able and if so desired.

Both Health Team members and Support Team members can now assign a SDM among the patient’s Support Team. This feature formalizes and organizes the Support Team member role, highlighting which Support Team member can make decisions on behalf of the patient if they are unable to do so. There can be multiple SDMs assigned with users having the option to further clarify their role by selecting, either POA for Health care/ Personal care or Guardian/ Trustee.

As a the patient or a Support Team member, follow the following three steps to assign an SDM: 

1. Go to the ‘Team’ page
2. Click on the Support Team member you would like to assign as an SDM
3. Click ‘Assign as Substitute Decision Maker’ and confirm this decision in the subsequent pop-up with the correct legal designation for the person

A health professional may also assign an SDM when creating an Action Plan and inviting Support Team members.  

Key takeaways

Knowing who the MRP and SDM are for a patient is important for several reasons:

1. Continuity of care, care quality and safety: The MRP is the primary practitioner responsible for coordinating and managing the patient's overall care. They are familiar with the patient's medical history, ongoing treatments, and specific healthcare needs. Knowing the MRP ensures that there is continuity in the patient's care, especially when multiple healthcare providers are involved or as health professionals change due to shift, service coverage or absences due to vacations or illness. 

2. Effective communication, information access and sharing: Identifying the MRP allows for efficient communication between healthcare providers. It ensures that important medical information and treatment plans are accurately conveyed, reducing the risk of miscommunication or misunderstanding. This is particularly crucial during care transitions or when different specialists are involved in the patient's treatment. It ensures that the right individuals are involved in conversations related to the patient's care and maintains patient privacy and confidentiality.
   
   
3. Decision-making and patient advocacy: The SDM is an individual designated to make healthcare decisions on behalf of a patient who is unable to do so themselves. It could be a family member, legal guardian, or someone appointed by the patient in an advance directive. Knowing the SDM is essential to involve them in medical decision-making, especially in critical situations or when consent is required for certain procedures or treatments. This helps ensure that the patient's rights, preferences, and wishes are respected. It allows healthcare providers to engage in shared decision-making with the patient and their SDM, considering their values and goals of care. This promotes patient-centered care and helps align medical decisions with the patient's best interests.

Feedback?

We are always looking for ways to improve. If you have questions for feedback on these enhancements, or thoughts on future developments, we would love to hear from you! Reach out to us at support@getcareteam.com.