Partnerships in collaborative care

This chapter describes frequently encountered roles that are required to support the delivery of contemporary practice in the care of individuals with a chronic illness and/or disability. The provision of contemporary practice necessitates a team approach being adopted which brings together in partnership a range of health professionals and other agencies and services. The nature of this partnership is one of collaboration and goal-setting to see that optimal outcomes a re achieved for the individual and their family. Determination of these outcomes is based on the use of evidence-based practice and the collective learnings of each of the team members to see what might be possible; to consider new ways of doing or set up innovative ways to manage. The complexity of need that exists for many people experiencing a chronic illness or disability is significant and changing. This may mean that the lead of the team changes and that it is not necessarily medically driven. However, it is recognised chat most care in this con text is coordinated through the nurse, who frequently is the constant in the lives of the individual. It also recognises that the composition of the 'team' may need to change as the needs of individuals with a chronic illness and/or disability also change, requiring different professionals, agencies or services co be involved. Working collaboratively and drawing on the skills and expertise of others offers the capacity to respond to the changing needs of a person with chronic illness and/or disability and their family. The partnerships created between the person and their family with the various members of the team, enable the person and their health needs to be the central priority. The team seeks to resolve issues for the person and their family by determining a shared goal of care, involving a number of strategies that are not discipline-specific, but rather conceptualised from knowledge and experience to best suit the needs of the individual. The delivery of high-quality care uses team meetings and patient/family conferences to share information and discuss possible ways of achieving an optimal outcome for the person requiring care and their family (Pierce & Lutz 2013). Effective communication is key to achieving the goals determined by the team in collaboration with the person. The nurse is equal to all other members of the interdisciplinary/multidisciplinary team and is most likely to be the primary carer in the majority of health or home settings. As a result, the nurse will often assume a coordination role within the team to bring together the other health professionals. Having the primary carer assume this coordination role directly benefits the person and their family by bringing together the wealth of knowledge, experience and skills in the planning of a range of interventions to manage the issues arising for people with chronic illness and/or disability. This role is also pivotal in ensuring that the interventions and solutions implemented are evaluated on an ongoing basis and to recognise that as people's needs change so does the plan of care. This ch apter aims to describe the scope of practice undertaken by these frequently encountered roles and their contribution to supporting a person with a chronic illness and/or disability. This chapter begins therefore with a description of the nurse's role followed by the dietitian, exercise physiologist, general practitioner, occupational therapist, paramedic, pharmacist , physio therapist, social worker and speech pathologist. In this chapter the terms 'interdisciplinary' and 'multidisciplinary' are used interchangeably by the various authors to en able both approaches to care to be illustrated and contextualised depending upon the needs of the person and their family