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The role of teams in delivering medical care has risen to prominence, with increased attention on team dynamics, the role of communication on patient safety, and the potential for teamwork to improve clinical outcomes. Yet, while it is easy to admire, or even envy, high-performing teams from afar, figuring out how they work is not so easy.
Individual teams in physical medicine and rehabilitation (PM&R), also called physiatry, care for some of the most medically complex and vulnerable patients following severe injuries, all while maintaining an inclusive focus on medical management, quality of life, and long-term goals for community participation.
In my own clinical practice as a physiatrist at Spaulding Rehabilitation Hospital in Boston, I focus on caring for people with disabilities that are the result of spinal cord injuries and neurologic disorders across the care continuum. Providing high-quality care for individuals with multiple complex medical conditions and functional impairments can pose unique challenges, and involves close collaboration and teamwork across different specialties and sites of care within the community.
While I am incredibly fortunate to work in a system where collaboration across settings is the norm, I have long admired two peer institutions that have seemingly bridged the divides of geography and discipline to accentuate the value of rehabilitation medicine and effective teamwork — not only for specific teams, but for entire organizations in very different environments.
At the University of Washington, physiatrists care for patients with complex brain and spinal cord injuries from across the greater Northwest, a region that spans Washington, Wyoming, Alaska, Montana, and Idaho. Given that these are high-need patients from geographically disparate communities, care coordination is particularly challenging.
Jennifer Zumsteg, MD, a physiatrist at the University of Washington, says that physiatrists coordinate with rehabilitation nursing teams, remote care providers, and community organizations to develop comprehensive contingency plans for patients who may live 4–5 hours away. A dedicated nursing team provides updates via EMR on whether patients need to make adjustments in their care plan to be closer to home or require expedited follow-up with a specialist. Physical medicine and rehabilitation specialists at the University of Washington are also available to providers in rural communities via a 24/7 toll-free telephone consultative service called Medcon, which links physicians in remote areas with tertiary center expertise.
Collaboration across the care spectrum between physiatrists at the University of Washington and remote primary care providers is crucial for supporting patients with severe injuries, who often have complex medical and social needs, and helping them reintegrate into their communities after acute hospitalization and inpatient rehabilitation. Dr. Zumsteg underlines the “substantial buy-in” needed across health systems to support such teamwork, making it clear that these patient services are made possible not only by the diligence of individual rehabilitation care teams, but also through collective support from communities and regional academic clinical and administrative leadership. For example, the Medcon program is sponsored by the University of Washington, but draws upon professional contacts and the collaboration of diverse care teams across the greater Northwest to allow patients to remain in their home communities as they continue rehabilitation and treatment.
Another example of teamwork that transcends boundaries has less to do with geography than with making cross-disciplinary collaboration between clinicians and researchers a day-to-day endeavor. Earlier this year, clinical teams at the Shirley Ryan AbilityLab in Chicago underwent a transformative move by transferring to a new hospital where clinicians and biomedical researchers share the same space, clustered into what are called Innovation Centers.
By intentionally coupling research and clinical care in the same setting, Shirley Ryan AbilityLab aims to revolutionize the model of care for inpatient rehabilitation and accelerate rehabilitation research focused on innovative technologies and neurologic recovery, with the goal of achieving improved patient function, independence, and clinical outcomes.
David Chen, MD, who directs the Spinal Cord Injury Rehabilitation Program at the Shirley Ryan AbilityLab, explains that the decision to co-locate clinicians and researchers grew out of a pilot program on one of the floors at the old hospital. Despite apparent differences between the daily routines of clinicians and researchers, Dr. Chen says the “two groups weren’t as different as people think they are,” and that communication and collaboration between clinicians and researchers has proceeded with relative ease since the pilot and recent hospital move. While it is still too early to tell the long-term effects, the model promises to promote transparent communication among teams and foster routine teamwork between disciplines.
Great teams often rally around a shared mission. A behind-the-scenes look at teams from two institutions making innovations in the field of physical medicine and rehabilitation demonstrates that team performance depends upon a shared sense of purpose as well as deliberate planning and buy-in — not only from other disciplines, but also from larger health systems and communities. In different ways, teams at the University of Washington and Shirley Ryan AbilityLab are bridging traditional boundaries to transform collaboration within their institutions and across the care continuum.
Effective collaboration by care teams in acute, post-acute, and ambulatory settings alike undoubtedly contributes to patient care improvements. Collaborative relationships across settings are critical to optimizing care, yet they are very difficult to achieve. This is where physiatrists play a key role in integrating care for patients with severe injuries and complex medical needs, by maintaining a focus on improving function and helping patients return to their communities. Commitment to making collaboration with physiatrists and rehabilitation specialists across geographic and disciplinary boundaries a shared mission, and a daily reality for health systems and organizations that span the care continuum, may help scale these improvements to an even greater reach.
Acknowledgments: I would like to acknowledge Dr. Jennifer Zumsteg from the University of Washington Department of Rehabilitation Medicine in Seattle, WA, and Dr. David Chen from the Shirley Ryan AbilityLab in Chicago, IL, for contributing their thoughtful insights to this piece.
This blog post originally appeared in NEJM Catalyst on October 10, 2017.