Collaborative Care Standard

    The public can expect coordinated care focused on their interests, delivered by licensed healthcare professionals who communicate effectively and work together collaboratively.

    This Practice Standard applies to all licensed healthcare professionals working in conjunction with other healthcare providers, support personnel, patient families, and community members to coordinate or deliver care.

    A licensee must:

    1. Provide person-led care, which means to:


      1. Engage the patient and, where applicable, other team members and individuals identified by the patient—including advisors and family members—in collaborative decision making.
 
      2. Communicate in a clear, respectful, and timely manner with healthcare providers and others involved in the patient’s healthcare.
 
      3. Recognize and respect the roles of all team members and acknowledge distinct perspectives and expertise.
 
      4. Seek clarification when roles within a healthcare team are unclear, and clearly explain their own role if necessary.
 
      5. Participate actively in the patient’s care planning by contributing relevant knowledge and engaging in shared goal setting and treatment planning, where possible. 

      6. Inform the patient about, or facilitate access to, appropriate healthcare providers or services when the patient’s care needs are beyond the licensee’s scope of practice or competence. 

      7. Provide health services concurrently with other healthcare providers, with the patient’s consent, when it contributes to more effective service delivery, enhances safety, and supports the patient’s goals. 
    1. Share information appropriately, which means to:

      1. Ensure that team members have access to the relevant clinical information necessary for safe and effective service delivery while complying with privacy and confidentiality requirements.
      2. Provide records and test results to other team members, including the referral source and any other team member, as appropriate. 

      3. Provide records and information to third parties only with the consent of the patient or individual being assessed, or as required or authorized by law.
    1. Support continuity of care, which means to:

      1. Make reasonable efforts to identify appropriate referral options for patients and ensure that follow-up for test results is arranged where necessary.
      2. Communicate with other healthcare providers to facilitate continuity of care for the patient, including during periods of transition, at cessation of services, and when services are shared.

    Glossary

    Consent: a voluntary, informed, and capable person’s agreement to receive a specific health service. Consent is valid only when:

    • The person is capable of making the decision;
    • The person receives the information that a reasonable person would require about the nature, purpose, benefits, risks, and alternatives to the proposed service;
    • The person is given an opportunity to ask questions and receive answers;
    • The decision is voluntary, not obtained through coercion, fraud, ormisrepresentation; and
    • The consent relates to the specific health service proposed.
      Consent may be expressed orally or in writing, or inferred from the person’s conduct, and may be withdrawn at any time.

    Healthcare team: a group of healthcare providers from the same and/or different disciplines who work collaboratively to provide health services to a patient. Team members may include regulated healthcare professionals, unregulated care providers, support staff, and others involved in the planning, delivery, coordination, or evaluation of health services, including the patient, their family, or community representatives.

    Health service: any service or activity provided by a licensee in relation to healthcare, including collecting information; assessing, diagnosing, preventing, monitoring, treating, or managing a person’s health or health-related condition; or providing health-related information to an individual or the public, whether or not treatment is provided.

    Individual being assessed: an individual who is the subject of an evaluation, examination, or report prepared by a licensee for a third party (such as an employer, insurer, court, or agency).

    Patient: a person to whom health services are provided. Throughout the Ethics and Practice Standards, “patient” includes substitute decision-makers, parents, and guardians where applicable.

    Person-led care: an approach to healthcare that prioritizes the needs, values, preferences, knowledge, life experience, and autonomy of patients receiving care to ensure a respectful and collaborative professional relationship. Person-led care: (a) facilitates informed decision making; (b) recognizes the patient as an active partner in decisions concerning their care; and (c) takes into account the patient’s social, cultural, and emotional context to ensure care is responsive, equitable, and tailored to their needs.

    Record: includes patient information, books, documents, drawings, photographs, letters, vouchers, papers, and any other thing on which information is recorded or stored by graphic, electronic, mechanical, or other means, but does not include a computer program or any other mechanism that produces records.

    Third party: an individual or organization other than the patient or the licensee who is involved in or affected by the provision of health or related services. Third parties may include employers, insurers, educators, regulators, service providers, or other persons or entities.

    Related standards and legislation

    Communications


    Consent

    Discontinuing Health Services and Ensuring Continuity of Care