At the Brigham, nurses play a pivotal role in care coordination, especially for patients who will require post-acute care services or rehabilitation placement. Daily care coordination rounds, also known as interprofessional huddles, are one of several strategic initiatives launched in recent years to improve collaboration, enhance quality of care and ensure coordinated and efficient discharge preparation for patients.

During the rounds, which take place every day on several inpatient floors at the Brigham, members of a patient’s care team – including the charge nurse, resident, care coordinator, physical therapist, social worker and unit coordinator – gather to review and facilitate patient progression. This proactive planning enables the team to operate more cohesively and to collectively track completion of key activities or documents.

One example of how these rounds led to improved care involved a patient with a serious brain injury who spent one year at the Brigham as an inpatient.

Following the daily huddle, each member of the patient’s care team was responsible for following up on specific action items that came out each huddle, such as collaborating with Financial Services and care coordination nurses to explore discharge options. While the planned discharge date for the patient was pushed back on several occasions, per the family’s request, the interprofessional team continued to work with the family toward the shared goal of discharging the patient to his home with hospice care.

The patient’s wife later contacted the care team to inform them of her husband’s passing and express her gratitude for the services arranged by clinical nurse care coordinators, which enabled the patient to be at home with his family before he died.

Daily care coordination rounds ensure all members of an interdisciplinary team are brought up to speed on a patient’s care plan and goals, said Jane Grana, RN, of Care Coordination.

“We often each know something a little different, or see it from a different point of view, so it’s important that we collaborate,” Grana said.

Farah Abellard, MSN, RN, a nurse on Tower 10AB, agreed that improved multidisciplinary collaboration results in higher-quality, safer care: “Everyone plays a vital role in providing family-centered care.”