Transcript Slide 1

Emergent, inter-organizational, senior
sensitive teamwork in the community
Prepared by
Dr. David Ryan, Director of Education & GiiC Initiatives
Regional Geriatric Program of Toronto
July, 2010
Objectives
Examine senior sensitive care from a communications perspective
Examine senior sensitive care from a psychological perspective
Reflect on the role of family caregivers
Examine a model of families and health care
Explore the circle of care and teamwork in the community
Understand ‘emergence’ as it applies to community based care
Communication at the heart of senior sensitive health care
No matter what we say or do, even if we say
or do nothing we cannot not communicate
We all know this but still:
1. Miscommunication is the rule rather than the exception and
2. A major source of complaints and dissatisfaction with care
First some general observations on seniors,
health care providers and communication
What Seniors Like in Health Conversations
(Greene et al, 1994)
Questions & support about their concerns
Questions worded positively
Information after questions on their topics
Orientations to each step of the visit
Longer visits
Sharing laughter
Satisfying us
Communication Patterns of Primary Care Physicians (Roter et al., 1997)
Frequency of
occurrence
Physician
Satisfaction
Patient
Satisfaction
(1 = most satisfying 5 = least)
1. Narrowly biomedical
32%
5
5
2. Expanded biomedical
33%
3
4
3. Bio-psychosocial
20%
3
3
4. Psychosocial
7%
3
1
5. Consumerist
8%
1
2
Biomedical patterns were used more often with more sick, older, and lower income
patients by younger, male physicians.
Being on the same page (Christensen et al, Journal of General Internal Medicine 2010)
Symmetrical attitudes about health locus of control between patients and
providers promote adherence, and symptom management
Symmetrical attitudes occur about 38% of the time
Seniors Contribute to the Communication Dilemma
Seniors are likely to have ageist attitudes towards medical interventions.
Older patients are less likely to challenge authority
Less likely to ask questions
Less inclined to take a participatory or controlling role in the health care process
Less effective in getting their physicians to attend to their concerns
Less likely to acknowledge psychological issues
Now some notes on health communication in general
Communication is such a complex process
2. Non-verbal Behavior
3. The situation
4.Cultural diversity
Proxemics & Posture
Controllable
Preferences/expectations
Prosody
Predictable
Practices
Facial Expression & Gaze
Sound/light
Language
Turn-taking
Safety
Drugs
5. Individual Difference
1.The words we use
Self efficacy
Medspeak
Control beliefs
Everyday language
Reaction to novel stimuli
Linguistic Relativity
Emotional expressiveness
The communication gap
Perceived Meaning
1. Just saying what we mean can be a challenge
Doctor: “Do you have a history of cardiac arrests in your family?”
Patient: “No, we have never had any trouble with the law”
Nurse: “Do you have varicose veins?”
Patient: “ I have veins, but I don’t know how close they are”
“If you think our staff are bad you should see our manager.”
Preferred distance for conversation
2. Non-verbal communication is a message about the message
Far
Near
Young Adult
Middle Age
Old-Old
Adult
The relationship between age and personal space usage is curvilinear (Ryan et al., 1986)
3. Health situations present different challenges
Consider the following differences
Seriousness
Disease controllability
Illness predictability
Symptom visibility
Cognitive demand
4. Cultural diversity presents a double jeopardy
“Handicapped by losses in physical and cognitive functioning, the
inability to use their native language doubles the risk” of not
having health care needs met. (Saldov & Chow, 1994)
5. Individual difference: where adherence is moderated by:
Cognitive Processes
Age related changes in information processing
Understanding and valuing the outcomes promised
Temperament:
Reaction to change
Emotional expressiveness
Social Learning:
Self-efficacy and the expecting to be able to achieve goals
Control beliefs, particularly health control beliefs
The "So simple you can't make a mistake and if you do its no big deal
Guide to Understanding Reactions to Practically Everything”
React quickly and hate to wait
J
DRIVERS prefer to
move ahead calmly,
watching results,
staying organized
and asking “what’s
next”
Stay cool
calm and
collected
no matter
what
C
4
3
2
4
3
2
1
1
0
ENTHUSIASTS like
to jump into new
things, sets everyone
on fire by “just doing
it” and asking “Why
not?”.
1
2
3
4
1
ANALYSTS like to
hear the details,
see facts and
figures and asks
“How is this going
to work?”
2
3
4
S
HARMONISTS like to
give everyone the
opportunity to express
themselves and their
opinions often asking
“how is everyone
feeling?”
Wait, watch, hear all sides
E
Let
feelings
and
emotions
show
Like to get on with things
When our patients
are Drivers
Like to see results
Like everything to be organized
Most frequent question: “What's next”
Want to face the problem and put a plan in action
Want timelines, goals, precision and specifics
We do not want any delays
We want information and we want to see results
We like handouts
We prefer one to one rather than a group
Like to set people on fire with new ideas
When our patients
are Enthusiasts
Jump in and lead by doing
Like to explore new possibilities
Most frequent question “Why not”
Likely to quickly become frustrated if professionals ask too many questions
Specific information on things they can do right away
They want to be able to see results quickly
We will probably already have gathered information
But we can easily get frustrated if people don’t move fast enough
More likely to appreciate a group approach
Open to new approaches and do not need evidence base to use new therapies
Likely to look for help from different sources
Like to hear the details
When our patients
are Analysts
Like to see facts and figures
Likes to have a clear plan
Most frequent question: “ How is this going to work”
We want the facts “just the facts”
We like written information preferably with statistics
We want predictable outcomes and a clear plan to achieve them
We want evidence based information
We want to be able to compare approaches and benefits.
We want to know everything about the illness
Don’t expect us to follow your recommendations without a lot of thought
Wants to avoid conflict and be friendly
When our patients
are Harmonizers
Likes to talk things through and hear all sides
Most frequent question: “How does every one else feel?
We want to know everything
We want to know how it will affect our families
We will not be rushed
We need time to ask lots of questions
Our emotions will be much more visible
We will need time to talk about how we feel about it all .
We will want to know if it is going to hurt
We might need more than one session
A Psychological Structure for Patient Engagement
Control Beliefs
Patient Autonomy
Adherence
Self-efficacy
Informed Choice
Temperament
Symptoms
managed
Opportunities for
behavioral control
Satisfaction
Value outcome
Preferences
Focus on Control Beliefs, Self-Efficacy and Controllability
Control and Health
(Adapted from Schultz 1976, Schultz & Hanusa 1978)
Control
Predict
Random
7
No treatment
Health status ratings
4
6
5
4
10
24
30
42
Time elapsed in Months
Mean health status ratings by treatment conditions presented at four points in time
Control and Well-Being
(Adapted from Schultz 1976, Schultz & Hanusa 1978)
Control
Predict
Random
7
No treatment
zest for life ratings
6
5
4
4
10
24
30
42
Time elapsed in Months
Mean zest for life ratings by treatment conditions presented at four points in time
Optimizing Patient Focused Care in More Controllable Health Situations
Sense of Self-Efficacy
Control Beliefs
Internal
External
High
Low
Self Management
Information and behavioral control
Participatory control
Reliance on higher power
Support Dependency
Optimizing Patient Focused Care in Less Controllable Health Situations
Sense of Self-Efficacy
Control Beliefs
Internal
High
Control over reaction,
Low
Depression
Control through predictability
Control through information
External
Challenge to faith
Support Dependency
Who is the “shadow workforce”?
Why are they in the shadow?
Are they part of the team?
How can we think about families?
Family Caregivers: the shadow workforce and team player
The distinction between “formal” and “informal” care giving does not reflect
the reality of the work of many family caregivers who are often:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Geriatric Case Managers
Mobile medical records
Service gap fillers
Continuous care providers
Acute change of condition monitors
Paramedic service providers
Quality Control experts
Inter-organizational boundary crossers
Continuing medical education students
An understanding of this work should prompt us to seek joint action
(From Brookman & Harrington: 2007)
Family Caregivers: why the shadow workforce and team player
The focus has been on decision making largely in the context of mental capacity
Less about mentally capable older persons working together with their families
“The autonomy model of a lone individual . . . stems chiefly from experience in
acute care settings” (Kapp 1991)
Paternalistic professionalism
We underestimate the amount and value of family care giving - $90 billion (Brown
2010) .
We underestimate the sophistication of family care giving that is required
(Brookman & Harrington, 2007)
We understate the quality of family caregivers contributions. Instead of saying “two
thirds are correct” we say “Surrogates incorrectly predict patients’ treatment
preferences in one-third of cases” (Shalowitz et al 2006, cited in Kirchoff et al 2010)
Family systems are complex and in the context of stressful
health care encounters the characteristics of these family
systems are sometimes dramatically revealed and often
quite challenging. .
Yet our clinical encounters with families is often unguided
by systemic thinking and each situation is encounter
appears as if it were the first.
What follows is one simple model of many that are
available to help us think about and engage families in our
work.
A family’s sense of order and controllability in the outside world
moderates its ability to seek and use new information
High
Low
High
Environmentally
Enriched Family
A family’s
ability to
coordinate
itself
Achievement
Focused Family
Consensus Sensitive
Family
Disorganized
Family
Low
A Model of Family Adaptation: Adapted from David Reiss (1980)
The family meets the hospital, Archives of General Psychiatry, 37, 141-154.
The Environment Sensitive Family:
Able to ask for and use new information
Able to coordinate action both within the family
and with a treatment team
Normal adjustment process
Prescription: Move ahead normally
The Consensus Sensitive Family
Perceives the environment as threatening
Avoids conflict and seeks agreement
May disagree but is unable to voice concerns
Has difficulty making hard decisions and resists passively
Clinicians are surprised when plans go awry
May be threatened by other families
Often one family member has the role of communicating
with the outside world and if that person is the patient the
family can become quite disabled
The Consensus Sensitive Family: Prescriptions
Assign a team member to be the families ally
Stage the delivery of stressful information
The ally can give voice to the families hidden disagreements
Avoid precipitous involvement of family members in family
support groups and etc.
The Achievement Sensitive Family
Usually all family members are high achievers
Family members are status oriented
If special relationships develops between a family
member and team members others may undermine it.
Often family members compete with the team
regarding who is the best caregiver
Consensus may be very difficult as each family
members asserts the value of their own opinions
Illness/injury may mean failure
The Achievement Sensitive Family: Prescriptions
Recognize high achievement
See coping with illness as a success
Talk to the family as a group to avoid unbalancing the
family power structure. Avoid assigning one person as a
family spokesperson
Be sensitive to care-giving competitions
Maintain control by giving it away
Pose arriving at consensus as a challenge. This will
prompt motivation to meet the challenge.
The Disorganized Family
The family is unable to problem solve together despite
being highly enmeshed
Often each member is involved with their own social agency
Although well-meaning the family is unable to followthrough with family plans
Family members are often vigilant for signs that the team
sees the family as disorganized
The Disorganized Family: Prescriptions
Getting the family together is often a struggle and is best
avoided.
Do not rely on apparent family agreements to translate into
follow-through especially if the plans are complex.
Often finding the strongest person and making them the
family contact person is best.
Like the achievement sensitive family, these families need
explicit recognition though for different reasons.
Informal care giving and volunteerism
(Choi et al 2007)
Seniors who are informal care givers are more likely to volunteer and
the more intense the care giving the greater the amount of
volunteering
Care giving brings them into contact with volunteer opportunities
Formal volunteering provides a less guilt free break from care giving
Volunteering seems to balance the stress of care giving and enhances
health and well-being
On our teams and inter-organizational teamwork
Management Teams
Emergent Inter-organizational Senior Sensitive Shared Care Teams
Continuing care and Rehabilitation teams
Acute Care Teams
Specialized Geriatric Services Teams
Primary Care Teams
Customer
Focused
Outcomes
Internal
Focused
Outcomes
Financial
Focused
Outcomes
Innovation
Focused
Outcomes
Customer
Needs &
Interteam
Issues
Team
Member
Skills &
Strengths
Communication
&
Conflict
Management
Roles &
Interdependence
Clarity/
Coherence
of Goals
Decisions
Authority
Accountbility
THE DIMENSIONS OF TEAMWORK
A framework for examining teamwork
Perceived
Support from
Organization
On the distribution of high performance on co-located health care teams
Level of Inter-professional Teamwork
Dimension of
Teamwork
Below Average
Levels of
Teamwork
(One standard
deviation below the
group mean
)
Teams at
Average Levels
of Teamwork
High
Performance
Teamwork
(Within +/- one
standard deviation of
the group mean )
(One standard
deviation above the
group mean )
Patient and Inter-team focus
5 (9%)
40 (73%)
10 (18%)
Team members strengths
and skills
7 (13%)
40 (73%)
10 (18%)
Communication and Conflict
Management
9 (16%)
39 (71%)
7 (13%)
Roles and Interdependence
9 (16%)
35 (64%)
11 (20%)
Clarity of Team Goals
11 (20%)
35 (64%)
9 (16%)
Decision-making and
leadership
9 (16%)
36 (68%)
10 (18%)
Organizational Support
12 (22%)
38 (69%)
5 (9%)
Total teamwork
9 (16%)
37(68%)
9(16%)
Dorothy
86 year old woman living alone. Widowed from a 62 year marriage 24 months ago.
No children. A niece (PofA) lives in the west and visits every few months to take care of
finances. Neighbors do shopping.
Both veterans of WWII, her husband was an enthusiast she an analyst and careful
planner. Traditional, Dorothy asserted influence indirectly and despite a continuing sense
of loss, she has also experienced some increased freedoms since the death of her
husband.
Resourceful and humorous, she laughs at adversity. Picking up dropped blueberries with
her grabber on berry at a time is hilarious for her. She is hardy: in control, committed and
unfazed by challenge.
Medico-Functional Status
Severe osteoarthritis arthritis in hips and knees. Ambulates in-house within her home
with a walker. She has an elevator chair, stair-glide and a front porch elevator.
She has high blood pressure and cardiac insufficiency
Independent in ADLs except footcare
IADLS compromised by mobility and pain
Meds include pain killers, blood thinners, celebrex, stool softeners,
A network analysis of
Dorothy’s circle of
care: Is it a team?
Line color legend
Aware
Send
Information
Discuss
Emergent Inter-organizational teams
for Dorothy and Mrs X
Line color legend
Aware
Send
Information
Discuss
Community care giving is unique
Care givers are not typically co-located
Care giving is typically inter-organizational
Care givers include both professionals and non-professionals
Care givers are both paid and unpaid
Unpaid care givers do a lot of the work
Different subsets of paid caregivers convene for each client
On Emergence
Initial conditions
Health professionals don’t own the space
Co-caregivers may not know each other
Multiple organizations with distinct cultures
Practice Jazz
Interactions are non-linear
Lots of surprises
Self-organizing
No standardization
Co-evolving
Improvisational
Local ecology and regional diversity
Sense-making
Strength of ties is variable
Local Adaptations
No single agent knows everything
Patient
Focused
Care
That’s all for now
Goodnight Irene
http://giic.rgps.on.ca