How often have you asked yourself, “What’s the plan?” You may ask the question when you’re caring for a patient, as a leader, or even in your personal life. Over the past few months, I’ve recognized a growing trend — patients don’t know their options and their plan of care. It’s grown more common with each passing month since the COVID-19 pandemic ended. During the pandemic, it was straightforward — try to keep the patient from decompensating and dying. Now as we get back to focusing on wellness and managing patients’ different diagnoses and prognoses, it’s time to refocus on collaboration and communication.

What’s changed over the past year?

Healthcare providers and caregivers are busier than ever and have less time with their patients, let alone time to speak with consultants or review their recommendations. In outpatient settings, patients often must wait weeks or months for an appointment with a specialist, further delaying diagnosis and the plan of care. Why should a patient have to wait months to get an MRI or an appointment with a cardiologist, neurologist, or oncologist? Why is it so difficult to get pharmacologic therapy approved that isn’t on formulary?

Many of these issues are due to lack of healthcare professionals, time, access to care, and healthcare costs. There has been an increased turnover of physicians, nurses and other healthcare professionals leaving the bedside, along with limited appointment opportunities and not enough time in the day. In addition, the complexity of patient care has increased due to pandemic-related disruptions to care for disease prevention and chronic disease management which have led to complications. Healthcare expenses continue to rise adding on another complex layer to the equation. The result is poor patient/provider communication and poor patient outcomes, which is a recipe for disaster!

Collaboration: the key to coordinating the plan

Nurses are known for their ability to coordinate patient care and foster collaboration among the disciplines. Case managers do this regularly in acute care, and there are nurse navigators or nurse care coordinators in some specialty areas. They’re able to negotiate the “politics” of working collaboratively with specialties and with 3^rd party payers so a collaborative plan that includes patient input and agreement can be implemented. Primary care practices need to consider hiring these patient advocates (or training current staff) to facilitate timely diagnostics, consults, and interdisciplinary, patient-centered plans of care.

Nurse navigators: facilitating collaboration and informed patient care

True collaboration in healthcare means all members of the interdisciplinary team are open to other points of view and are willing to change course to address the most critical issues first. One cannot forget the patient is at the center of the team and needs evidence-based information to make informed healthcare decisions. Nurse navigators are responsible for working directly with the patient, providers, and 3^rd party payers to facilitate the collaborative plan of care in a timely manner.

We need to improve communication and collaboration in healthcare. Our workforce issues and lack of access to care are not going to end anytime soon. Focusing on interdisciplinary collaboration and navigation through the system will only improve patient outcomes and access to care.