By Melinda Young

EXECUTIVE SUMMARY

Collaborative care teams can use interdisciplinary plan of care rounds to improve communication and facilitate smooth transitions.

• The plan of care round team can give patients a brief overview and answer patients’ questions or concerns.

• Consistency is essential to success. These rounds can be conducted at the same time each day for every floor of a hospital.

• Another method is to keep the patient bedside visits brief and time them to maintain efficiency.


Interdisciplinary plan of care rounds, attended by nurse case managers, social workers, and others, can help improve communication within the collaborative care team.

Plan of care rounds are instrumental for case management, says Ashley Cannady, BSN, RN, CCM, manager of case management at Cleveland Clinic.

“We have interdisciplinary plan of care rounds — collaboration between the case management department, nursing staff, and usually a nurse case manager and social worker, bedside nurse, nurse practitioner, and the patient,” Cannady explains. “We’re able to see the patient day to day. We have continuity and the ability to stay on that particular floor.”

With rounding, case managers watch patients progress and can answer any patient concerns. “It gives us a heads-up on any issues they have at home,” Cannady says.

For example, a patient might ask questions about medication. With plan of care rounds, case managers can suggest a pharmacy consult to address those concerns.

“It allows us to put together various pieces of the puzzle and have smooth transitions home,” Cannady says.

There is evidence to suggest the rounds have helped increase communication scores on the patient satisfaction survey, she notes.

“Patients see team members communicate. The rounds allow them to provide feedback on what they need at home,” Cannady explains. “It provides for a smoother transition home or to the next level of care.”

Cannady explains how the plan of care rounds work:

• Make an introduction. The case manager’s introduction to patients might follow a script similar to this:

“Hi, Sally. My name is Ashley, your case manager. We’re here for your bedside rounds. Our social worker Kristen is here, along with the rest of the team. We’re here to review your plan of care for today,” Cannady explains. “I see you were admitted with chronic obstructive pulmonary disease. We have our pulmonary team, and the plan is for you to go home with home care. Do you have any questions about what is going on with your care?”

The patient then has a little time to ask questions or make a comment.

“It’s collaborative and gives each team member the potential to voice their goals and what input they may have as far as medical care,” Cannady says.

The bedside round ends with a brief comment, such as: “Thank you for your time. If there’s anything you can think of going forward, please let us know. We’re here,” she says.

• Provide consistency. “Every floor has the same team,” Cannady says. “We start the rounds at 10 a.m. for most floors, although some floors vary. Typically, the case manager or bedside nurse leads the round. Each member goes to each patient room. We identify ourselves, introduce ourselves, and discuss the plan of care for the day.”

Each bedside meeting takes around three minutes. The plan of care team visits each patient, every day.

“It’s very important to do this every day, for every patient,” Cannady stresses.

Each time the team visits a patient during the plan of care round, they can reinforce the previous day’s discharge information.

“We round on patients the same day as discharge,” Cannady explains. “We might say, ‘This is the plan: The nurse will come in, and we have home care set up for you. We also have a follow-up appointment set for you on this day.’”

This reinforces everything the team has discussed with the patient.

• Include patients. The plan of care round team gives patients time to provide feedback, ask questions, and plan goals.

“The nurse or case manager gives a brief overview of what the patient is hospitalized for and what is going on with treatment,” Cannady says. “If they’re confused about what’s going on with their plan of care or have any questions about what medications they might need at discharge, they can ask.”

When patients need more time with their case manager, he or she can return later to sit with the patient and troubleshoot issues, she adds.

• Adjust on day two. The second day of rounding serves as reinforcement of the patient’s education and plan of care.

“We provide an update on what is going on today, as opposed to yesterday,” Cannady says. “If the patient needs a higher oxygen level or additional medication, that’s the time to discuss any differences between the days and any differences in the care.”

The second day is an update in the care plan, she adds.

• Maintain efficiency. The bedside rounds are timed to keep them quick and efficient. Nurses provide clear-cut instructions for follow-up care, Cannady says.

“Patients shouldn’t have any delays with discharge,” she notes. “The bedside rounds are not meant to hold up discharge. If patients are unable to leave and are medically cleared, then they will leave the hospital — as long as nurses have provided them with discharge instructions.”

The plan of care round team does not carry devices with them. At the most, someone might have a clipboard with the patient’s name and notes, she says.

“Sometimes, when patients have a higher acuity or additional questions, then the plan of care team might stay longer — up to six minutes in the room,” Cannady says. “If the patient requires longer plan of care rounds or explanation, then we continue on and stop back at the patient’s room when we complete the rest of the rounds. This provides more one-on-one time with that patient.”

The scripting for rounding is flexible, but efficient. A case manager might say, “I see you have additional questions. These are our bedside rounds. As soon as we get done with the remainder of the patients, we’ll circle back to have one-on-one with you and answer your remaining questions,” Cannady says.

When caregivers are present, the team encourages them to be part of the plan of care round.

Physicians are not part of the rounds, but a nurse practitioner is available on the floor to participate, she notes. “There is someone from the medical team there to answer questions and provide feedback on any medical issues,” Cannady says.