Collaborative Care: It Takes a Village

Imagine a fictitious scenario: The receptionist at a retirement community takes a telephone call from a family member who lets the receptionist know that her mother, Mrs. Jones (pseudonym), has fallen inside her apartment. The receptionist asks nursing staff to go to Mrs. Jones’ apartment. Nursing staff assess the resident and determine it is safe to help her up using a lifting chair. Further investigation into the cause of the fall reveals several findings: Mrs. Jones appears disoriented, her cat seems thirsty, and she does not seem to know what medications she has taken. After a discussion with dining and nursing staff, it is discovered that Mrs. Jones has not been going to the dining room for meals and has not been seen at any recent social activities.

Having gathered this information, the nurse phones Mrs. Jones’ daughter and primary care physician (PCP) and tells them about the incident as well as Mrs. Jones’ care needs. The PCP orders physical and occupational therapy. The nurse puts in a referral for a social worker to evaluate Mrs. Jones for signs and symptoms of depression. Mrs. Jones’ neighbor invites her to “happy hour,” and Mrs. Jones’ housekeeper is told to monitor whether the cat is being fed and given water. Mrs. Jones appreciates and accepts these efforts in regard to her care needs and is now on her way to a healthier and safer life due to her “village” and the coordination of care within it.

In this scenario, each individual played an important part in the collaborative care of Mrs. Jones: her daughter, the front desk receptionist, resident assistant and nurse, dining team, housekeeper, activities staff, and Mrs. Jones herself. This care would not have been possible without Mrs. Jones’ consent and recognition that she needed and wanted help. More individuals will enter Mrs. Jones’ world as her story and collaboration of care continue.

There are many links in the chain of collaborative care. Every link adds value and can impact final outcomes in terms of cost, quality of care, and timeliness of care. It is hoped that health care workers embrace the “it takes a village” concept in delivering quality care to older adults.

To read more, visit the full academic journal written by Era Living employees Danielle Parkins, BA, Associate Executive Director and Albert Munanga, DBH, MSN, RN, Regional Director of Quality Improvement: http://bit.ly/2M0QIjq