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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: Critical Analysis

Once you have collected the relevant patient care data elements, you should analyze the data to assess for:

  • patient care needs trends.
  • potential individual role and team required competencies to support patient care needs.
  • missing or additional data to obtain to inform patient care needs, care competencies or team-based design considerations.

The following questions were developed to help guide the patient care needs analysis. This is not an exhaustive list, but a starting point to support critical analysis. 

Critical Analysis Questions

Ask:

  1. What are the 'typical' care needs required for the patient population given the age cohorts? What CMGs and/or co-morbidities require resources/treatments to support while in the hospital? Has there been a trend up or down since the last review? Do care needs remain consistent?
  2. What are the typical barriers to discharge? How can these barriers be managed and by whom (which team members need to be involved)?
  3. Does the 'typical' patient population require support of more than one team member to assist with activities of daily living?
  4. Are acute delirium and/or responsive behaviours areas of focus within the practice setting? Which team member should have a lead role in helping to address these care needs by performing a comprehensive assessment of contributing factors (for example, medication or pathology related causes, etc.) and by determining and performing treatment interventions? Which team members could have supportive roles in helping to meet care needs once the plan has been established?
  5. Has there been an increase in complex drug therapies?
  6. What are the risk management reports telling you? What might be possible contributing factors leading to the reported issues/area?
  7. How would you categorize the patient care need? (For example, is there a subset of patients that are acute? Is there a subset that have complex-chronic care needs?) What are the considerations for team design, patient assignment practices, etc.? See the Acuity/Intensity/Complexity tool linked below.
  8. Which units/practice settings within Nova Scotia Health are similar?