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 WorkforceFive Skills

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

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

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

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

Preparing the WorkforceFive Skills

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 modelsHospiceACT TeamsVisiting NurseDay Treatment ProgramsSenior Community CentersGero-psychiatric CentersOthers……….

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

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 1970sReferrals from state hospitalsCase review and assignmentCase consultations and reviewsConsultation & Education Initiatives

Health Care Team Work

Mandatory regulations and accreditation

End-Stage Renal Disease Program 1972

Social Security Act Amendment P.L. 92-603Medicare coverage for renal transplants and home dialysisReferrals from state hospitals

Geriatric Team DevelopmentOn 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 Model1986 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

PACE

Veterans AdministrationApplication across health and mental health facilities

Acute Care Hospitals – treatment and rehabilitation, out-patient clinics, specialty clinics, patient and family education, support groups

Veterans AdministrationMental Health In-patient and Out-patient

Drug/Alcohol programs

Homeless programs

Vocational – work readiness

Residential community homes

Mental HealthAssertive 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

It is not a brokering model of case management

One person on the team can substitute for another

Philosophy is not to use facilities – not to use structured programs

The team itself provides the needed services

Flexibility if there is a needed service that would augment the person’s service array – the team might access that service

Juvenile OffendersMultisystemic 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 AdvantagesFor 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 AdvantagesFor 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 AdvantagesFor 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 AdvantagesMental health needs --

Better management depression

Decreased depression scores

More adherent medications

Fewer symptomatic days

Increased work days

Less panic and anxiety attacks

Team AdvantagesFor 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

12 C’s of Team Process1. Communication

2. Cooperation (empowerment of team)

3. Cohesiveness (team sticks together)

4. Commitment (investing in team process)

5. Collaboration (equality in team)

6. Confronts problems directly

7. Coordination of efforts (actions support common plan)

8. Conflict management

9. Consensus decision making

10. Caring (patient, client, consumer centered)

11. Consistency (with one another an environment)

12. Contribution (feeling this is being made)

(Heinemann & Zeiss, 2001)

Experiences What has been your experience?

What type of teams have you been member?

1. Communication

2. Cooperation (empowerment of team)

3. Cohesiveness (team sticks together)

4. Commitment (investing in team process)

5. Collaboration (equality in team)

6. Confronts problems directly

7. Coordination of efforts (actions support common plan)

8. Conflict management

9. Consensus decision making

10. Caring (patient, client, consumer centered)

11. Consistency (with one another an environment)

12. Contribution (feeling this is being made)

ExperiencesWere these present?

1. Communication

2. Cooperation (empowerment of team)

3. Cohesiveness (team sticks together)

4. Commitment (investing in team process)

5. Collaboration (equality in team)

6. Confronts problems directly

7. Coordination of efforts (actions support common plan)

8. Conflict management

9. Consensus decision making

10. Caring (patient, client, consumer centered)

11. Consistency (with one another an environment)

12. Contribution (feeling this is being made)

Where is future with interdisciplinary teamwork?

Informatics – increased technology

Computer based services

Contact

Inquiry

Service

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