Interdisciplinary Teams: Evolution & Experience in Geriatrics

Present State of Health Care

Crossing the Quality Chasm (Institute of Medicine, 2001)

- Notes present health care system frequently harms patients and routinely fails to deliver potential benefits - In chapter Preparing the Workforce, outlines new or enhanced skills required for professional to function in changing health [health & mental health] environment --- 5 skills

Preparing the Workforce

Five Skills 1.

Informatics – Communicate, manage knowledge, and support decision making using information technology

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Interdisciplinary Teams – standardize care to make services patient-centered, continuous, and reliable

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Evidence-Based Practice – Integrate best research with clinical expertise and patient values

Preparing the Workforce

Five Skills 4.

Patient-Centered Care – Inform and involve patients and their families in medical/treatment decision making and self management; coordinate and integrate care, apply principles of disease prevention and behavioral change appropriate for diverse populations

5.

Quality Improvement – Continually understand and measure quality of care in terms of structure, processes, and outcomes, design and test interventions to change processes and systems of care

Pressure for Enhanced Teamwork

Healthcare system  Organizational changes – mergers, acquisitions, closings  Financial changes incentives, reimbursement models  Priorities – shorter in patient days, out-patient services, home based services

Pressure for Enhanced Teamwork

 Cost-effective care models  Hospice  ACT Teams  Visiting Nurse  Day Treatment Programs  Senior Community Centers  Gero-psychiatric Centers  Others……….

 Emphasis on health promotion  Emphasis on disease prevention  Community based services

Teamwork: Health & Mental Health

Outcomes  Teams fall short of expectations of members, leaders and managers (Pearson, 2001)  Suboptimization – lack of care continuity, redundant and wasteful processes, excess costs, miscommunication (Larson, 1999; Institute Medicine, 2001)

History of Interdisciplinary Education

 Professionals trained and socialized in isolation  Organizations are hierarchical in structure  Professionals have their own “speak”  In 1995 less than 25% nursing and medical schools had any interdisciplinary programs  Accreditation speak to ability to practice in interdisciplinary settings but silent in terms of training environment  Limited research on the impact interdisciplinary training, practice and patient care (Greiner, 2007)

Evolution Team Approach

From historical perspective teams have evolved  Consultative approach  Multidisciplinary  Interdisciplinary  Trans-disciplinary

Evolution Team Approach

 Consultative approach – one practitioner retains central responsibility and consults with others as needed  Multidisciplinary – each team member implements a specialized part of a care plan  Interdisciplinary – each team members put forth their knowledge individually and collectively to the care plan  Trans-disciplinary – members are jointly responsible for implementing an integrated plan

Evolution in Terminology

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Multidisciplinary – as disciplines

working in parallel, with diverse goals 

Interdisciplinary – is most common in

literature today, each team members put forth their knowledge individually and collectively to the care/treatment plan 

Interprofessional is gaining presence

(Institute of Medicine, 2001)

Of the Four Team Approaches

Trans-disciplinary “Cadillac” Model

Trans-disciplinary – training and legal parameters may shape practice - tasks among team members based in individual patient problems and needs than on traditional role definitions

Team Evolution

What event(s) propelled the move to develop and initiate multidisciplinary teams in health and mental health settings?

Team Approach

Courts and mental health care Accreditation regulations De-institutionalization within mental health Mandatory insurance regulations

Mental Health Teamwork

Do you know which NC Hospital is pictured?

 Community Mental Health Programs 1970s  Referrals from state hospitals  Case review and assignment  Case consultations and reviews  Consultation & Education Initiatives

Health Care Team Work

 Mandatory regulations and accreditation  End-Stage Renal Disease Program 1972  Social Security Act Amendment P.L. 92-603  Medicare coverage for renal transplants and home dialysis  Referrals from state hospitals

Geriatric Team Development

On Lok Senior Health Services

 Community leaders wanted to build nursing home in Chinatown North Beach area  Marie Louise Ansak, social worker and others advocated home based services to allow elderly to remain in their own homes/family  Used the British concept of “home and community services”  Focus transporting frail elderly people to center for health and support services 

On Lok Senior Health Services

1971 (Cambodian - Peaceful, happy abode)  1983 obtained Medicare & Medicaid waivers

All Inclusive Care

 On Lok Model is pooled capitated financed scheme for integrated acute and long-term care  Program becomes her primary physician  Interdisciplinary team coordinates provision of services – specialists outside program, home service, contracted services, hospitalization  800 participants – term used  Manage risk by preventive care

Retired August 1993, October stocked 39-foot sailboat, on-board black Labrador, and tacked out into the Pacific from San Francisco.

Expansion of On Lok Model

 1986 Robert Wood Johnson Foundation & HCFA funding for Program of All Inclusive Care the Elderly (PACE)  Established as demonstration project  @ 24 sites today  Carrying full-risk for health care of their participants  1997 PACE established Medicare provider  Interdisciplinary team core of health care management

Veterans Administration

Application across health and mental health facilities Acute Care Hospitals – treatment and rehabilitation, out-patient clinics, specialty clinics, patient and family education, support groups

Veterans Administration

 Mental Health In patient and Out-patient  Drug/Alcohol programs  Homeless programs  Vocational – work readiness  Residential community homes

Mental Health Assertive Community Team (ACT)

 Principles  In vivo services  Primary responsibility for service delivery  Team approach – shared caseload  Flexible service provision  Time unlimited

ACT Team

 “The primary responsibility for care” means that the team provides the majority of the services the consumer needs  Philosophy is not to use facilities – not to use structured programs  The team itself provides the needed services  It is not a brokering model of case management  One person on the team can substitute for another  Flexibility if there is a needed service that would augment the person’s service array – the team might access that service

Juvenile Offenders Multisystemic Therapeutic Model

Multisystemic Therapy (MST) is a family-focused, home-based program focuses on chronically violent, substance-abusing juvenile offenders [age 12 17] at high risk for out-of home placement. Family therapist collaboration allows family to take the lead setting treatment goals, therapist helps them to accomplish their goals. Intensive family and community-based treatment addresses multiple determinants of serious antisocial behavior. Therapist teams provide services in home and school and are available around the clock. costs approximately $5,800 (in 2007 dollars) per youth treated.

Hospice & Palliative Care Teams

Hospice care is provided through an interdisciplinary, medically directed team. This team approach to care for dying persons typically includes a physician, a nurse, a home health aide, a social worker, a chaplain and a volunteer. Hospice care program tries to provide the best quality of life for dying patients by providing a holistic approach. That means giving spiritual, mental, emotional and physical comfort to the patients, their families and their other caregivers.

Team Advantages

For educators and students  Offers multiple health care approaches to study  Appreciation and understanding of other disciplines  Models strategies for future practice  Promotes student participation  Challenges norms and values of each discipline

Team Advantages

 For delivery systems [health & mental health]  Potential for more efficient delivery of care  Maximizes resources and facilities  Increased preventive care to reduce burden of acute care [health & mental]  Facilitates continuous quality improvement efforts

Teamwork Advantages

For patients  Improves care by increasing coordination of services, especially complex problems  Integrates care for wide range of problems and needs  Empowers patients to be active partner in care decisions  Support cultural diversity  Uses time more efficiently

Teamwork Advantages

Mental health needs - Better management depression Decreased depression scores More adherent medications Fewer symptomatic days Increased work days Less panic and anxiety attacks

Team Advantages

For professionals  Increases professional satisfaction  Facilities shift in emphasis from acute, crisis care to long-term preventive care  Enables professional to learn new skill and approaches  Encourages innovation  Allow providers to focus on individual specialize expertise

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12 C’s of Team Process

Communication Cooperation (empowerment of team) Cohesiveness (team sticks together) Commitment (investing in team process) Collaboration (equality in team) Confronts problems directly Coordination of efforts (actions support common plan) Conflict management Consensus decision making Caring (patient, client, consumer centered) Consistency (with one another an environment) Contribution (feeling this is being made) (Heinemann & Zeiss, 2001)

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Experiences

What has been your experience?

What type of teams have you been member?

Communication Cooperation (empowerment of team) Cohesiveness (team sticks together) Commitment (investing in team process) Collaboration (equality in team) Confronts problems directly Coordination of efforts (actions support common plan) Conflict management Consensus decision making Caring (patient, client, consumer centered) Consistency (with one another an environment) Contribution (feeling this is being made)

Experiences

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Were these present?

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Cooperation (empowerment of team) Cohesiveness (team sticks together) Commitment (investing in team process) Collaboration (equality in team) Confronts problems directly Coordination of efforts (actions support common plan) Conflict management Consensus decision making Caring (patient, client, consumer centered) Consistency (with one another an environment) Contribution (feeling this is being made)

Where is future with interdisciplinary teamwork?

 Informatics – increased technology  Computer based services Contact Inquiry Service  ???