Research suggests that collaboration between various departments leads to better health outcomes at nursing homes, but that has been a difficult principle to follow, often because of time and regulatory constraints placed on staff already stretched thin.

However, team-based care is the name of the game and sticking to it is important for the future of quality clinical care and the vitality of the sector, clinical leaders told Skilled Nursing News.

Teamwork will ultimately reduce the unnecessary utilization of health care resources even as nursing homes maintain their profitability, according to Dr. Arif Nazir, who serves as chief medical officer for Signature HealthCARE and chief medical officer for primary care at BrightSpring Health Services, both based in Louisville. Signature is one of the largest U.S. skilled nursing operators, with 75 locations across eight states, while BrightSpring is a major provider of home- and community-based care.

Nazir is a proponent of a “Care Hub” model that has proven to reduce unnecessary hospitalizations by 30%, he told SNN. Such results are critical particularly as more managed care organizations continue to become more prominent payers for skilled nursing.

The Quality Assurance and Performance Improvement process is one area of focus as nursing homes look to improve clinical teamwork, according to Nazir and GAPS Health CEO Dr. Jerome Wilborn. GAPS Health provides the sector with medical directorship and clinical services.

And a particular goal has to be involving clinicians across departments and at all levels — from certified nursing assistant (CNA) on up. To this end, Brickyard Healthcare Chief Compliance and Strategy Officer Wanda Prince recommends identifying and empowering influential team members. Indiana-based Brickyard operates 23 nursing homes in Indiana.

While it is not easy, creating better clinical teamwork is an imperative as nursing homes position themselves for the future. And this means overcoming the “inertia” of the status quo.

“It’s in our convenience that we continue the inertia of a traditional model, which is devoid of meaningful teamwork,” Nazir said. And so, the move has to be away from the old ways of working in silos, he said.

Creating a care hub

Nazir and his teams are implementing the “Care Hub model,” which includes a teamwork huddle that requires practitioners to review outcomes and polypharmacy cases with nursing colleagues and consultant pharmacists. This allows the whole clinical team to discuss such issues as medication history and its correlation with side effects.

Under the huddle model, Nazir explains, the mantra is: “Right off the bat, we work as a team so we make the best possible decisions, rather than just one person being seen as solving all the problems.”

Nazir said his organization has taken steps to coach and train nurse practitioners, doctors and pharmacists to become better team members and improve patient and staff satisfaction with health care outcomes. Better clinical teamwork has allowed for more efficiencies as well as improvement in turnover and retention of staff.

Referring to Quality Assurance and Performance Improvement (QAPI) meetings, Nazir said. “We are really looking at all those frameworks so that quality improvement, learning, use of data and teamwork becomes a regular part of the job … It just does not become an activity that happens every 30 or 60 days and then people just move on and do their own silo-based work after that.”

However, implementation of better teamwork models is also time consuming in the interim.

“It’s not that easy. It is taking us hours and hours and months and months and years and years of figuring things out about how humans interact and how we can redesign things so that we do not disrupt any regulatory framework. It’s very hard to accomplish all of that, but not impossible,” Nazir said.

And of course the proof is in the pudding, or rather the cake, as Nazir explained it.

“I think the cake needs to be baked well and that involves basic teamwork processes,” Nazir said.

The success of teamwork at facilities with the care hub model was evidenced by two “big markers,” according to Nazir. Avoidable hospitalizations dipped by 30% while on average at least two medications were removed from the typically long list of meds being taken by a long-term care resident.

Nazir proposes posing simple questions at the QAPI meetings. He believes these improve communication among different clinical team members and other departments. Examples include engaging staff with questions on whether they are aware of adverse outcomes on a weekly basis, or have knowledge of the number of medications an average resident takes in the facility, as well as names of consulting pharmacists and medical directors.

Beyond the attentiveness of the clinical staff, Nazir said family members and non-clinical staff such as dietitians, nutritionists and housekeeping professionals can provide valuable insights and close observation in their day-to-day interactions with patients. In fact, he said, “Every nurse practitioner, physician assistant or every physician actually should start their day with the help of an aide who knows the patient really well.”

First rule of teamwork is respect for all levels of care

A spirit of respect will go a long way to support these new data-driven teamwork models in addition to technology and organizational methods, leaders said.

Wanda Prince, chief compliance and strategy officer for Brickyard Healthcare, says that it’s imperative to look for individuals who can bring positivity to the workplace.

The aid of such personalities whose positivity is contagious helps break down silos, said Prince.

“Maybe it’s someone with informal power and influence, who can engage everybody, enthuse everybody, champion everybody and get everyone on the same team,” Prince said. “Those individuals are so valuable and incredibly important in getting everyone together, as far as doctors and nurses (and) treating individuals on the team as valuable team members.”

During her decades of experience in skilled nursing facilities, Prince has noted the work of maintenance and environmental services’ staff, for example. They can even lend overarching insights on how to transform the whole whole organization, she said.

“Everyone has great ideas. We need to brainstorm, we need to problem solve,” Prince said. “We need to ensure that organizational learning occurs and everyone’s voice is important and is being heard.”

The pandemic helped organizations such as Brickyard become more resourceful with manpower by allowing staff crossover between departments. One of the ways in which Prince’s organization broke down the barriers between departments was staff crossover, including a top-level staff member working as a temporary nurse’s aide.

“For a certified nurse assistant to see their executive director come out of their office, go out to the floor and work alongside them is incredible,” Prince said.

For Nazir too, instilling respect for all levels of care is extremely important because it empowers people to lead, he said. And sharing of knowledge across departments only makes employees more confident and willing to engage.

Nazir suggests administrators at nursing homes should frequently ask their employees: “Are you a nurse’s aide empowered to work closely with your nurse practitioner, [and] physicians? Do you have respect in your building? Those are just examples of key questions you can ask as an administrator.”

Improving physicians’ involvement at SNFs

Better clinical coordination is important, but physicians should be shepherding clinical care, in the view of GAPS’ Wilborn. Like Nazir, he zeroed in on QAPI meetings as a focus. Typically, these meetings are led by an administrator or director of nursing, but Wilborn is pushing for that to change.

“(The physician) has got to be the quarterback for that,” Wilborn said. “The doctors need to discuss what the issues are, and they hold people in those meetings accountable to making sure that we’ve made progress from one month to the next.”

As an example, Wlborn said that only a doctor can determine the correct correlation between the number of falls a patient has suffered and the medication history.

“Nurse practitioners who work in a solo manner are not the cure-all for taking care of the sickest people in our health care continuum, and (while) they have the ability to be on site, they can be more present, the correct model is to have supervision and collaboration of that nurse practitioner by the doctor,” he said.

And while it might require more investment to have a doctor be more present, Wilborn believes that physician involvement will bear profits and better care over time with fewer mistakes and greater adherence to regulations.

“If the physician is running the interdisciplinary team, it’s going to make a huge difference in regards to the silos being broken down,” Wilborn said.

Coordinating schedules is one of the biggest challenges in implementing more team-based nursing home care, particularly given physicians’ schedules.

Nazir said, “It’s nobody’s fault. It’s just how the system is set up to expect that of (physicians).”

But teamwork, including more structured input from physicians, works to everyone’s benefit.

It doesn’t help that both long term care and geriatric care are put under rigorous regulatory scrutiny and often portrayed in a negative light by the media. This leads caregivers, including physicians, to be overcautious and preoccupied with bureaucratic work.

These distractions, of course, aren’t limited to physicians, Nazir said. Pharmacy consultants are also prone to this work in this manner. The expectation is that the pharmacy consultant will appear once a month and leave behind recommendations without any expectations for follow up. So a better tag teaming between physician and pharmacists would prevent delays related to beneficial medication changes.

But things are at the tipping point given the hurdles facing nursing homes in the aftermath of the pandemic.

“This requires us to take a break, retune, refigure all these things, and I think the new system would actually offer more value, more fun, more satisfaction and better outcomes,” said Nazir.