Chronic disease management can be complex as care coordination throughout the team presents many challenges such as fragmented care, isolated data, and a lack of interoperability between health systems. Patients with diseases such as chronic kidney disease (CKD) often have multiple providers in addition to kidney doctors, including primary care providers, endocrinology and cardiology professionals, social workers, nutritionists, nutritionists and pharmacists. Although there are many benefits to the holistic approach provided by many experts, a lack of consistency and coordination among these professionals can lead to dispersed care and poor outcomes.
Interdisciplinary coordination is a model that encourages a comprehensive approach to care for healthcare professionals across the continuum to ensure optimal treatment for patients with chronic diseases. This model is supported by sharing innovative technologies and collaborative mechanisms such as electronic health records (EHRs) in health systems, thereby enhancing communication and decision-making. By focusing on the entire patient and coordinating all aspects of their treatment plans, providers can personalize care for individuals, increase engagement to promote improved disease management and lead to longer, more affluent lives.
Interdisciplinary care is associated with increased patient safety, decreased hospitalization rates and reduced medical errors. As far as renal care is concerned, it enables nephrologists to focus on managing CKD and ESKD rather than coordinating other aspects of care.
Here are some of the benefits of using an interdisciplinary approach to chronic disease management:
Promote holistic approach to care
Nearly 40% of the American population, patients with chronic diseases require complex treatment plans involving several specialized elements. This care can be time-consuming, with chronic patients taking an average of 828 hours per year – 3.5 hours per day – a physician time limit is usually prohibited. Furthermore, patients experience more frequent, longer hospitalizations when these conditions are not treated in tandem and inter-team coordination. In the interdisciplinary care model, providers adopt a patient-centered approach to achieving a unified goal of ensuring the program and meet countless needs.
When providers are able to address care more comprehensively, they can identify trends in different areas of personal health to better manage chronic disease symptoms. This is especially important because physical, mental and emotional well-being are all interconnected and everyone affects overall well-being. For example, people with severe mental illnesses are at a higher risk of CKD, partly due to higher prevalence of risk factors such as smoking, cardiovascular disease, type 2 diabetes, and food insecurity. In this case, connecting points across mental and physical health can help identify risk factors and drive more attention to prevention.
Enhance holistic health care communication
Because providers can share decisions in real-time in interdisciplinary nursing models, communication is more effective, resulting in better, more consistent care for patients. Doctors, pharmacists, and other caregivers can share and access patient information in a centralized location to ensure that all providers, patients and families are on the same page about treatment plans and that everyone has the same comprehensive, up-to-date health information. In kidney care, interdisciplinary models bear the burden of kidney doctors that determine all the elements of patient care, reducing their administrative responsibilities and the responsibility to become a channel for patient information. This allows them to focus on the kidneys while still being able to observe the patient’s development throughout the care continuum.
EHR sharing allows providers to easily access a complete view of the patient’s medical history and facilitates this real-time communication. Especially for people with chronic illnesses who may often visit several hospitals and clinics, EHR sharing is an important step towards better continuity of care, ensuring everyone has faster access to patient information for more timely and comprehensive care. Although 84% of hospitals often share EHR, only 42% of hospitals send a summary of care to external hospitals. This may be a sign of inconsistent care and clearly sends room to improve provider communication.
Improve the quality of care
Interdisciplinary models also help improve care efficiency and prevent medical errors that are unfortunately common in chronic disease care. Patients with a large number of prescription medications and comorbidities (often among patients with chronic diseases) have an increased risk of medical errors. Patients with chronic diseases may prescribe several drugs from various experts and providers. CKD patients take an average of 9 pills, ESKD patients take ESKD dialysis daily, and about 21 pills per day. Juggling these medications can make it difficult for many patients to follow, and if everyone is not on the same page, it can cause confusion for the provider.
Without proactive communication and interdisciplinary coordination, patients may get prescribed medications that interfere with each other, receive contradictory information or send repeated tests. The kidneys are dealing with many medications, so taking certain medications increases risk levels and safety issues for people with CKD. For example, some painkillers or antibiotics that make the body pass through the kidneys can lead to further kidney damage. Therefore, it is crucial that healthcare professionals communicate about the patient’s health and ensure they are safely prescribed with the patient’s other conditions or professional care.
Ensure optimal care for patients with chronic diseases
Chronic disease care is complex and not only requires patients to be navigated and understood, but also for the provider to coordinate and promote. Interdisciplinary care is designed to ensure that everyone, from providers to patients to families, is on the same page in terms of patient care. This holistic approach can improve outcomes while focusing on slowing down the progress of the disease when serving some of the most vulnerable and diseased patient populations. Adopting interdisciplinary approaches and leveraging technologies to improve monitoring and cross-team communication can help to obtain better personalized treatments and achieve better patient outcomes.
Photo: Edwin Tan, Getty Images
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