Guidelines Collaborative Care

 

GLOSSARY

• Collaborative Care: a style of care that involves a team of health providers and a client who work in a participatory, collaborative and coordinated approach to share decision-making around health and social care.

• Collaborative Care Team: clients and their healthcare providers work together to achieve the optimal health outcomes. It could refer to situations where the team is located in the same practice setting and interact closely, or it could refer to providers who work independently and/or externally, but are providing care to the same client.

• Collaborating: an active ongoing partnership based on sharing, co-operation and coordination in order to solve problems and provide a service, often between people from very diverse backgrounds.

• Interprofessional: more than one health care profession on a health care team who work together and learn from each other.

• Interprofessional Care (IPC): is the provision of comprehensive health services to clients by multiple health caregivers who work collaboratively to deliver quality care within and across settings.

• Interprofessional Collaboration: the process of developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/ families and communities to enable optimal health outcomes.

Introduction

The purpose of the Collaborative Care Professional Practice Guidelines for Registered Dietitians in Ontario (Guidelines) is to set out the knowledge and behaviours that a dietitian must demonstrate when working in Collaborative Care Teams and in Collaborative Care environments. The Guidelines also help dietitians integrate knowledge, skills, attitudes and behaviours in utilizing their professional judgement when working with interprofessional colleagues, participating in and contributing to decisions that affect the wellbeing of clients.

Much of this Guideline document provides suggestions for enhanced or best practices and relates to clinical and other care-based contexts with clients. However, many of the concepts can be applied to other interprofessional areas of dietetic practice. The Guideline statements are interrelated; each informing and qualifying the other statements. They are not intended to be applied in isolation, nor are they intended to provide an exhaustive or definitive list of collaborative behaviours required of members. Rather, they are to be used in combination with other College documents such as the Code of Ethics and Standards of Practice and relevant legislation, policies and any other applicable organizational guidelines or policies in the workplace.

Approved by Council  December 7, 2018

Dietitians must have an understanding of their role and responsibilities in collaborative care-based contexts that enable respect, trust, shared decision-making, and partnership, including the following:

1.1 Collaborative Care should be Client and Family Centred

i.  In addition to the professional members of the collaborative health care team, clients and family members are integral as active participants across the spectrum of care.

ii.  The client/substitute decision-maker is a key participant in the collaborative care team.

iii.  Whenever possible, the client should be treated as a member of the team.

iv.  Based on context, if the client is capable, and has expressed the desire to, they may even act as the team leader to become an active participant in their own care.

1.2 Clarify Team Members’ Roles and Responsibilities as Part of Each Client’s Care Plan

i.  Understand who is capable and authorized to perform which aspects of treatment is the starting point for role clarity in a team. In many cases, there may be more than one provider sharing roles and tasks (including authority mechanisms) to best service clients.

ii.  Members of a collaborative care team should clearly understand: who is on the team; the team members’ roles and responsibilities; and which task(s) each team member will perform (this is especially important when there is overlapping scope or shared authority for the performance of controlled acts).

iii.  Dietitians recognize that the authorities, roles and responsibilities in the team may differ depending on the specific needs of the client, the practice setting, or other relevant factors.

iv. Dietitians exercise professional judgment within the limits of individual competence and collaborate with others, seek counsel, and make referrals as appropriate.

v. There should be mutual respect and trust in the team, based on a clear understanding of each team member’s competencies.

vi.  It may be beneficial to document team members’ roles and responsibilities as part of each client’s care plan. This will include members in the circle of care such as dietitians in food-service, community, public health, management etc.

1.3 Dietitians Are Accountable for Dietetic Services Delivered in Collaborative Environments

i.  Dietitians have a professional obligation to maintain individual accountability when practising dietetics within collaborative environments.

ii.  Dietitians should use critical thinking, problem-solving skills and good judgement when practising dietetics in diverse collaborative care environments. 

iii.  Dietitians must ensure that a comprehensive client health record is maintained when individual nutrition assessments and treatment/intervention are provided (this can include shared appointments whereby another provider documents nutrition services that were provided which are then verified and signed by the dietitian).

iv.  Records provide clear accountability of what was done and by whom. Keeping appropriate records is important for client care and is critical to ensuring accountability for services. The quality of a dietitian’s records can be a good barometer of the quality of their practice.

1.4 Shared Evidence-Informed Decision-Making for Safety and Quality Care

i.  Dietitians are encouraged to work in a participatory and coordinated approach when providing collaborative care. This includes evidence-informed decision-making through the use of best practices and resources to support the safe delivery of collaborative care. An evidence-informed decision-making approach should enable the separate and shared knowledge and skills of care providers to synergistically influence the client care provided.

ii.  Decisions should be made based on the client’s informed choices and health care professionals working together to ask, access, appraise and act on the research evidence.  

Dietitians must have an understanding of how to work effectively in teams, including the following:

2.1  Effective Collaboration Requires Effective Communication

i.  The team should establish a clear process for communicating within the team, and have a shared language/lexicon.

ii.  Being an effective communicator means being acutely aware of whether your professional communication is done well. Are you getting through? It also means being aware of the various forms of communications — interpersonal, interprofessional and intrapersonal communication — and how they impact dietetic practice.

iii.  Communication is an essential dietetic practice competency, so it is an important area for continuous learning and reflection.

iv.  Sometimes the only form of communication between health care providers is through the client health record. The team should develop both a process and format of how record keeping will occur in the team.

v.  Timely and clear record keeping not only facilitates communication between the health team members, it helps to prevent gaps, errors and duplication, and enhances collaboration and coordination to optimize safe, effective and efficient health care.

vi.  Sometimes communicating with our colleagues can be more difficult than speaking with clients. Dietitians do not have the sole responsibility for successful communication; all healthcare professionals have a mutual and shared duty to communicate effectively.  Dietitians have a duty to be collegial.

vii.  Active listening skills facilitate information sharing, seeking and decision-making.

2.2 There Should Be a Strategy for Conflict Management

i. The team should establish a clear process for conflict resolution and decision-making.

ii. Team members should be able to identify conflict when it occurs.

iii. In the interest of client-centred care, dietitians should strive to work collaboratively with the other health professions caring for their clients. If dietitians have concerns about the safety of a nutrition treatment recommended by another dietitian or practitioner from another health profession, address these concerns with the individual practitioner and collaborate to find the best course of action for the client.

iv. Dietitians have the obligation, in serving their clients’ interest, to manage conflict and advocate for the client’s best interest. To support interprofessional collaborative practice, dietitians need to consistently address conflict in a constructive manner as discussed in How do you know you are communicating well? (p. 7): 

i.  Collaborative care does not happen automatically. In addition to any formal team leader, the “collaborative leadership” model means that team members understand and can apply leadership principles that support a collaborative practice model.  Together the team determines who will provide group leadership in any given situation. The leader may change or alternate from time to time based on the client’s priorities and model of care. The leader helps the team develop synergy and engage in client-centred practices to ensure that it facilitates effective collaborative care. To do this, a collaborative leader has two functions: task orientation and relationship orientation. 

ii. The team should consider when it would be beneficial to document who is the team lead as part of each client’s care plan.

iii. The team leader can be a dietitian or another member of the team.

2.4  Team Functioning and Evaluation  

i. Teams that respect the definition of collaboration should establish clear group expectations and a clear process to evaluate whether the team is meeting its goals, and how well the team is functioning.

ii. An evaluative measure can be formal or informal, and should be based on context and the best interests of the health care system. Given that resources are constrained, how best can collaborative environments maximize productivity of each team without increasing costs (human or financial) or sacrificing safety and quality?

iii. Team functioning is enhanced when team members learn about, from and with each other to practise in the interest of client-centred care.

iv. Team functioning should reflect standards of respect and civility so as to enable collaborative teamwork, effective conflict management, andshared decision making.

v. Teams function best when they have shared team values (e.g. integrity, compassion, stewardship, safety)

2.5  Education and Training

i.  Collaborative care includes continuous individual and collective learning and training. Where relevant, dietitians can reflect on their practice and professional competence to identify any gaps and develop plans for professional development which can include education and training for how to work effectively in a team.

ii.  Each profession brings its own set of competencies through education, training and experience. Health-care professionals working in collaborative environments should seek out opportunities to learn from each other in ways that can enhance the effectiveness of their collaborative efforts.

iii.  There may also be opportunities for team members to connect with and educate each other based on their respective knowledge bases and expertise to enable the best possible outcomes.

• World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice. Geneva: Author. Retrieved from http://whqlibdoc.who.int/hq/2010/WHO_HRH_HPN_10.3_eng.pdf
• Canadian Interprofessional Health Collaborative: National Interprofessional Competency Framework (2010).

The College has developed several resources to assist dietitians and others in enhancing IPC within their professional practice. Refer to the following resources:

• Enhancing Interprofessional Collaboration
• Effective Use of Knowledge in Interprofessional Teams
• Interprofessional Collaboration e-learning module
• Interprofessional Collaboration Addressing Conflicts Between Health Care Professionals