Transcript Slide 1

Geriatrics, Inter-professional Practice and Inter-organizational
Collaboration (GiiC): Primary Care Lessons
David Ryan, PhD, Regional Geriatric Program of Toronto, University of Toronto
Cheryl Cott Ph.D. William Dalziel MD, Dr. Iris Gutmanis PhD,
David Jewell MSW, Mary Lou Kelley PhD, Barbara Liu MD & John Puxty MD
What is frailty?
Complex bio-psychosocial and
functional difficulties co-occur.
Risk of adverse health events is high
Independence and self-worth are
easily compromised
Risk of institutionalization is high
A fast growing demographic
Frailty brings increased need for
health care services and demands
high levels of teamwork and intersectoral collaboration.
“Go to where the puck is going to be”
Wayne Gretsky’s Dad
Articles on Teamwork in the Journal of Orthopsychiatry by Decade,
since the Journal began in 1930
25
20
15
# of
Articles
23
10
16
5
8
5
6
30s
40s
50s
The trinity
won the
right to treat
Sociotherapy
and
broadening of
the mental
health team
5
4
80s
90s
0
From moral
treatment to
mental
hospitals
The medical
model and the
orthopsychiatri
c trinity
60s
Community
mental health
and
sociotherapy’s
democracy
Decades
70s
Hospitals
emptied and
community
mental health
funding
dwindled
DRG’s,
managed care
and mental
health
fragmentation
Integrated
care and
inter-team
collaboration
The framework for health systems renewal in Ontario 2007
Funding supported 90 interprofessional research & development projects
Regulatory Colleges formed an interprofessional care working group
Investment in Academic Interprofessional Education & Training eg:
interprofessional coaching
interprofessional mentoring
interprofessional preceptorship
stand alone and embedded interprofessional curricula
Investment in interprofessional development in the practice environment eg:
Interprofessional care of the diabetic foot
Accountability Framework for Regulated and Unregulated Health Care
Providers in Long Term Care
Interprofessional prevention of delirium in the Emergency Department
Geriatrics, Interprofessional Practice & Inter-organizational Collaboration
(GiiC) Initiatives
What we wanted . . .
Health professionals still aren’t being sufficiently trained in geriatrics
Help us to build the health human resources needed for an aging population
Going to where the puck is . . .
“Just putting people to together to work doesnt necessarily produce effective
teamwork let us help build your 200 new family health teams”
“Teamwork is the traditional method of service delivery in geriatrics. Let us use
geriatrics as a clinical focus through which we can train family health teams”
“We are in the integration era but no-one is trained let us add our interorganizational collaboration skills into the mix”
“Then let us help the entire circle of care work from a common toolkit”
. . . Suddenly the puck was on our stick
GiiC: Family Health Teams/Community Health Centers
GiiCPlus: Community Care Access Centers, Public
Health and Community Support Agencies
GiiC Plus: Patients Families and Health Care Teams
GiiC Hospitals: Seniorfriendlyhospitals.ca
Geriatric Practice in FHTs
Clinical Focus
Never
Only if
symptoms
Routinely
every 6
months
Continence
Screening
Drive Safe
Protocol
12%
68%
0%
12%
73%
5%
12%
Polypharmacy
Reviews
Cognitive
Screening
5%
35%
19%
41%
3%
85%
0%
13%
92%
Delirium
Screening
24%
73%
0%
2%
32%
ADL/IADL
Assessment
Depression
Screening
11%
74%
0%
78%
2%
20%
74%
Falls Risk
Assessment
13%
64%
0%
23%
29%
Abuse
Screening
20%
63%
3%
2%
Routinely
every year
Use of
Standardized
Tools
25%
9%
18%
15%
26%
18%
41%
25%
When is a family health team not a high performance team?
When it is an organization – some family health teams have 250 people
When it is a network - some family health teams have docs in their
offices and a new building in the middle of town for allied health folks
When it doesn’t take on the qualities of team – one manager had a
“closed door policy”
When its roles are fixed, leadership hierarchical and everyone does their
own thing.
When is a family health team not a
high performance team?
When it excludes unregulated
employees from making
credible contributions
When is a family health team not a high performance team?
When the “shadow workforce” is not incorporated in team proceedings
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 crossing
Continuing medical education students
(From Brookman & Harrington: 2007)
‘Edumetrics” and the Knowledge-To-Practice Process
In the continuing health professional education world a new model has
emerged in the pursuit of practice change outcomes
Knowledge translation, knowledge transfer, implementation science and the
knowledge-to-practice process emerged as guiding constructs
Central to all, is the idea that practice change is more likely to the extent that
researchers engage ‘subjects’ more actively in the development of research
questions and the dissemination of findings.
GiiC researchers wanted to understand the performance of
family health teams, standardize a Dimensions of Teamwork
Survey (DTEAM) for use by Family Health teams and compare
DTEAM surveys with social network analyses, and improve
interprofessional practice.
Fifty-five participating Family Health Teams wanted
information on the quality of their teamwork and how they
stood with regard to other similar teams.
The distribution of high performance teamwork in a sample of 55
family health teams using the Dimensions of Teamwork Survey
Level of Inter-professional Teamwork
Dimension of
Teamwork
Below Average
Levels of
Teamwork
Teams at Average
Levels
of Teamwork
(One standard
deviation below the
group mean )
(Within
+/- one
standard deviation of
the group mean )
High Performance
Teamwork
(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%)
When environments require
complex interdependency
the quality of collaborative
alliances may predict
outcomes better than the
internal processes of
individual teams (Pfeiffer, 86)
And then we started working on the “community care” side of the
health system where the world is different and so are teams
On Emergence in Community Based Shared Care
Initial conditions
Health professionals don’t own the space
Co-caregivers may not know each other
Care providers are inter-organizational
Practice Jazz
Regulated and unregulated providers
Lots of surprises
Unpaid “shadow workforce” prevails
No standardization
Interactions are non-linear
Improvisational
Self-organizing
Sense-making
Local ecology and regional diversity
Local Adaptations
Strength of ties is variable
Co-evolving
No single agent knows everything
Patient
Focused
Community
Based
Teamwork
Questions for the Interprofessional Academies
Are we responding to emerging conditions?
Does it matter how the word ‘team’ is used?
Are we developing the essential skill sets?
What is the relationship between teams and the shadow workforce?
How are regulated and unregulated health professionals working together
Is ‘knowledge-to-practice process’ in the curriculum?
Is ‘team’ the right concept for community based health care collaboration?
Are we heading to where the puck is going now?
Economic Recession
Integration
Quality Management
Safety
That’s all for now
Goodnight Irene
http://giic.rgps.on.ca
[email protected]