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Team-Based Care Design

Tools and resources leaders can use to help support the review, design or redesign of team-based care models.

Patient Care Needs

The composition of a care team should be driven by the typical patient population and associated care needs of the specific unit/service. This information enables leaders to identify the key care providers needed, based on their optimized scope of practice, and the core competencies team members will be required to demonstrate to safely provide person-centred, team-based care.

Collecting and analyzing key data points that describe the characteristics of the typical patient population is the first step in determining required team members. These data points will enable you to:

  • determine the typical patient cohort for the specific practice environment to determine the acuity, complexity and intensity of care needs.
  • identify similar internal and/or external comparator practice settings.
  • identify trends with key patient indicators (e.g.: patient falls with injury, pressure ulcer prevalance, sitter costs etc.)
  • provide the foundation for determining required provider competencies and the most appropriate care team members.

 

Unit-based information (Tableau)

To locate unit-based patient information pertaining to CMGs, ADT, co-morbidity levels, length of stay data, etc., please use the Tableau server (linked below).

Instructions:

  • For inpatient units to obtain a specific inpatient unit profile change all filters at top of page to "ALL", then select or type in the Cost Centre Number. Example: Zone - All/Type- All/# of Beds- All/Cost Centre- 123456.
  • Please Note: To obtain specific data for an ICU, IMCU or ED, please refer to the associated links within Tableau. ICU, IMCU and ED data are grouped in Tableau based on levels. Example, Level 1 ED.

Required Patient Information

While there may be specific, context-based patient information that requires assessment, at a minimum the following information is required:

  • Demographics (for example, age, sex, co-morbidities, top CMGs)
  • Risk management reports, e.g.:
    • Patient falls rates with injuries
    • Pressure ulcer prevalence rates
    • Medication errors
  • Medication utilization
  • Service-specific patient data collection (See patient care tools based on practice environment context)
  • Internal and external benchmarks (TBD)
  • Review and application of definitions - intensity/acuity/complexity (See Intensity/Acuity/Complexity Tool)
  • Sitter use trends
  • Medication utilization trends, e.g.:
    • High-alert medications
    • Narcotics and other controlled-substance use
    • IV medications

Resources include:

  • Physician Leaders
  • Providers
  • Patients/Clients
  • Quality Leads
  • Program/Service Data Analysts

Assessment Tools

The following context-specific tools have been used to assess patient care needs as part of a care team design review. Many of the tools have undergone validation processes by the content author. They have also been used in similar practice settings across various hospital sites, regions and countries.The Acute and Subacute Inpatient Units section contains tools developed by IPPL to inform team-based care design at Nova Scotia Health. These tools have been validated with end users to ensure the care needs reflected in the tool adequately highlight typical care needs.

Emergency Departments

Inpatient Mental Health Units

Acute and Subacute Inpatient Units

Additional Acute Inpatient Unit Tools

Critical Care

Stay tuned: To be determined.

Primary Health

PrimaryHealthCare@nshealth.ca 

Stay tuned: To be determined.