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Assessment 01
Collaboration and Leadership Reflection Video
For this assessment you will use Kaltura to create a 5–10 minute video reflection that addresses
either an interprofessional collaboration you experienced or the case study on interprofessional
collaboration presented below.
If you choose to reflect on the interprofessional case study presented below, imagine that you
are a nurse on the team and you have been assigned to interview members of the team prior to
making the video reflection that you will share with the team and leadership where you will make
recommendations to improve interprofessional collaboration.
After you have thoroughly reviewed the case study below, return to the detailed instructions in
the courseroom to complete your assessment. Feel free to refer back to this case study as you
complete your assessment.
Case Study:
Interprofessional Collaboration for Chronic Disease Management
in a Community Health Center
Chronic diseases such as diabetes and hypertension are prevalent in the United States and
require ongoing management to prevent complications and improve health outcomes.
Interprofessional collaboration is essential to ensure that patients receive comprehensive and
coordinated care. This case study explores the interprofessional collaboration experience for
chronic disease management in a community health center.
The community health center in this case study serves a diverse population of patients with
chronic diseases. The interprofessional team includes physicians, nurses, pharmacists, social
workers, and community health workers who work together to develop and implement a patient-
centered care plan. The team provides ongoing care to patients with chronic diseases, including
regular check-ups, medication management, and lifestyle counseling.
The following are the responses when you asked each provider where the team could improve
its interprofessional collaboration.
DR. JOHN LEE, a physician who specializes in internal medicine and leads the
interprofessional team for chronic disease management. He is responsible for diagnosing and
treating patients with chronic diseases, prescribing medications, and coordinating care with
other team members.
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“We are all trying our best to provide quality care to our patients with chronic diseases,
but we also face some challenges that we need to overcome as a team. Communication
is really important for interprofessional collaboration, but we fall short sometimes.
“The pharmacy once changed the medication regimen of a patient without informing me
or the nursing staff. The pharmacist thought the patient was taking too many pills and
decided to switch some of them to a combination drug, but he didn’t consider the
potential interactions or side effects of the new drug, and the patient developed a rash
and nausea.
“Another time, a team member didn’t show up for a team meeting because she didn’t
receive the email invitation that Ms. Smith sent. She said she checked her spam folder
and did not find it there either. She missed an important discussion about a patient’s
psychosocial needs and resources, and we had to reschedule the meeting for another
day, but I don’t think it ever got rescheduled.
“A patient once received incorrect information about a community program that he
thought would help the patient with his diet and exercise. Our community health worker
didn’t verify the information with the program coordinator or update the patient’s records,
and the patient went to the wrong location and time for the program. He wasted his time
and money, and it hurts a patient’s trust in the whole team when miscommunications like
this happen.”
CONNIE JONES, a nurse who works in the community health center and provides direct care to
patients with chronic diseases. She is responsible for performing physical assessments,
administering medications, monitoring vital signs, and educating patients about self-care and
lifestyle changes.
“Thanks for doing these interviews! Interprofessional collaboration is so important for our
team to work well together, especially for our patients with chronic diseases.
“I’d say one of our biggest problems is with goal alignment. We don’t always have a
shared vision and mission for patient care. We have different or conflicting goals for
each patient, and sometimes we don’t even know what they are. We don’t communicate
and negotiate our goals with each other all the time or with the patient and family. We
just do what we think is best, because we have a lot on our plates, but we need to
consider the impact on the whole team and on the patient’s satisfaction and outcomes.
“The other day, I had a patient who had diabetes and hypertension. He was overweight
and had poor diet and exercise habits. His physician wanted him to lose weight and
lower his blood pressure by following a strict diet and exercise plan. The pharmacist
wanted him to take more medications to control his blood sugar and blood pressure
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levels. His social worker wanted him to join a support group for people with chronic
diseases. The community health worker wanted him to enroll in a community program
that offered healthy meals and physical activities.
“But none of them asked me what I wanted for the patient, or what the patient wanted for
himself. They just gave me their orders and expected me to follow them. They didn’t
care if the patient was willing or able to do what they asked him to do. They didn’t care if
the patient had any preferences or concerns about his care plan. They didn’t care if the
patient had any other needs or goals that were not related to his chronic diseases.
“I felt like I was caught in the middle of a tug-of-war, and I didn’t know who to listen to or
what to do. I tried to balance their demands and accommodate their requests, but it was
impossible. I ended up doing too much or too little, or doing something wrong or different
from what they wanted me to do. The patient was confused and unhappy, and so was I.”
DR. VIRAJ PATEL, a pharmacist who works in the community health center and provides
medication management services to patients with chronic diseases. He is responsible for
reviewing medication histories, dispensing medications, counseling patients about medication
use and adherence, and identifying and resolving medication-related problems.
“I’m glad someone’s going to help track what’s going on with our interprofessional
collaboration. There’s so much need, we can all get stretched really thin, and we need to
find some new strategies to better support our patients when we’re working together to
provide care.
“One of the major problems is our knowledge deficits. I need to know more about
everyone else’s knowledge, skills, and scope of practice. I think sometimes I assume
what other people on the team are doing or what they know, and I probably get it wrong
sometimes. These knowledge gaps limit our ability to collaborate effectively and provide
the best patient outcomes.
“The other day, I had a patient who had diabetes and hypertension. He was taking
several medications for his conditions, but he was not adhering to them properly. He was
skipping doses, taking wrong doses, or mixing up his medications. He was also
experiencing some adverse effects from his medications, such as dizziness, fatigue, and
dry mouth. I tried to help him with his medication management, but I faced some
challenges from other team members. The physician didn’t consult me before
prescribing new medications or changing the dosage of existing ones. He didn’t consider
the patient’s ability and willingness to take them. He just wrote the prescriptions and
expected me to dispense them.
“Someone should have referred the patient to me for medication counseling, but no one
recognized the importance of medication education and adherence for chronic disease
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management. Everyone else was just focusing on whatever they thought they were
supposed to be doing.”
LENORE GARCIA, a social worker who works in the community health center and provides
psychosocial support to patients with chronic diseases. She is responsible for assessing
patients’ social and emotional needs, providing counseling and referrals, facilitating access to
community resources, and advocating for patients’ rights and welfare.
“Thanks for talking to everyone so we can get a big picture view of our collaboration
efforts—they’re so important to patient care.
“One of the main problems is our language or cultural barriers. We have a diverse
population of patients and team members who speak different languages or come from
different cultures. We have difficulties communicating, understanding, and respecting
each other’s languages or cultures. We have language or cultural misunderstandings,
conflicts, biases, or stereotypes that affect our interprofessional collaboration and patient
care.
“For example, the other day, I had a patient who had diabetes and hypertension. He was
an immigrant from Somalia who spoke limited English and had different health beliefs
and practices. He had difficulty communicating and trusting the health care system and
the team members.
“I tried to help him with his administrative and financial needs, but I faced some
challenges from other team members. His physician didn’t use an interpreter or a
translator when he talked to the patient. He didn’t understand the patient’s language or
culture. He just used medical jargon and assumed that the patient understood him.
“There were issues with the social worker. She didn’t ask the patient about his dietary or
religious restrictions. She just gave him food and medication that weren’t compatible with
his culture. The pharmacist didn’t acknowledge the patient’s health beliefs or practices.
He didn’t explore the patient’s use of traditional or alternative medicine. He just
dismissed them as unscientific or harmful. The community health worker didn’t
coordinate with me to link the patient to community resources or services. He didn’t
consult me about the patient’s eligibility or availability for community programs or
support. He just provided outreach and education to the patient, without facilitating
access to community resources or services.
“We need to overcome our language and cultural barriers by developing more
intercultural competence and sensitivity across the whole team. We also need to use
appropriate communication methods and tools to enhance our intercultural
communication and better coordinate how we’re collaborating.”
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WILLIAM NGUYEN, a community health worker in the community health center who provides
outreach and education services to patients with chronic diseases. He is responsible for
conducting home visits, providing health education and coaching, linking patients to health care
and social services, and collecting data on patient outcomes and satisfaction.
“Hi, thanks for interviewing me. I think it’s wonderful that you’re doing this report on
interprofessional collaboration. I think it’s very important for our team to work well
together, especially for our patients with chronic diseases. But I have to say, we have
some problems that we need to address.
“One of the main problems is our organizational silos. We are separated or isolated from
different departments, units, or professions within the healthcare organization. We have
barriers to information sharing, resource allocation, and decision making. We have a
culture of individualism and territorialism that undermines teamwork and innovation.
“For example, the other day, I had a patient who had diabetes and hypertension. He was
also depressed and anxious because of his chronic conditions. He had difficulty coping
with his emotions and managing his stress. He also had financial and social problems
that affected his health and well-being. I tried to help him with his psychosocial support,
but the patient’s physician didn’t refer the patient to me for counseling or assessment.
He didn’t recognize the importance of psychosocial factors for chronic disease
management. He just focused on the patient’s medical needs and treatments.
“Ms. Jones did not collaborate with me on providing patient education and self-care. She
did not include me in the patient’s care plan or daily goals. She just followed Dr. Lee’s
orders and instructions, without considering the patient’s emotional and behavioral
needs.
“Mr. Patel did not inform me about the patient’s medication regimen or adherence. He
did not share any information or data on the patient’s medication use and outcomes. He
just dispensed the medications and counseled the patient about medication use, without
addressing the patient’s psychosocial issues or concerns.
DR. ADRIANA SMITH, an administrator who works in the community health center and
oversees the operations and finances of the interprofessional team for chronic disease
management. She is responsible for managing the budget, staff, equipment, and policies of the
team, as well as evaluating the quality and effectiveness of the team’s performance.
“Thanks for tackling this project. I think it’s amazing that you’re doing this work to help us
perform better as a team.
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“You know what I’m going to talk about: limited resources. We have a shortage of staff,
equipment, space, and time in the health center that lead to difficulties providing
comprehensive and coordinated care to all our patients.
“The other day, I was helping a patient who had diabetes and hypertension. He needed
regular check-ups, medication management, and lifestyle counseling from the team. He
also needed some lab tests, imaging studies, and referrals to specialists. I tried to help
him with his financial questions, but our physicians have a long waiting list of patients
and a heavy workload. They don’t have time to provide more than a brief consultation
and maybe some prescriptions.
“The problem just carries through across the team. Our nurses don’t have enough space
or equipment to care for all our patients with chronic health care needs. Our pharmacy
doesn’t always have enough hours or staff to schedule comprehensive med counsels for
every patient or follow up if someone else on the team forgets to make that referral. Our
social workers and community health workers don’t have enough access or availability to
provide all the support our patients need to assure the best outcomes. There’s a limited
network of community resources and services with long waiting times and eligibility
criteria. We do the best we can with what we have, but I wish we had some new
strategies our interprofessional approaches that could stretch what we do have to better
support our patients.”
