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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 areeasily 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 inter-
sectoral 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
# of Articles
The medical model and the orthopsychiatric trinity
The trinity won the right to treat
Sociotherapy and broadening of the mental health team
Community mental health and sociotherapy’s democracy
Hospitals emptied and community mental health funding dwindled
DRG’s, managed care and mental health fragmentation
Integrated care and inter-team collaboration
From moral treatment to mental hospitals
Decades
5 6
16
23
85 4
0
5
10
15
20
25
30s 40s 50s 60s 70s 80s 90s
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 inter-organizational 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
Ge
ria
tric
Pra
cti
ce
in F
HT
s
32% 2% 0%73%24%Delirium Screening
92%13% 0%85% 3%Cognitive Screening
18%41%19%35% 5%Polypharmacy Reviews
26%12% 5%73%12%Drive Safe Protocol
9%25% 0%68%12%Continence Screening
Use of Standardized Tools
Routinely every year
Routinely every 6 months
Only if symptoms
Never Clinical Focus
25%15% 2%63%20%Abuse Screening
29%23% 0%64%13%Falls Risk Assessment
74%20% 2%78% 0%Depression Screening
41%18% 3%74%11%ADL/IADL Assessment
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 it excludes unregulated employees from making credible contributions
When is a family health team not a high performance team?
The distinction between “formal” and “informal” care giving does not reflect the reality of the work of many family caregivers who are often:
1. Geriatric Case Managers2. Mobile medical records 3. Service gap fillers 4. Continuous care providers 5. Acute change of condition monitors6. Paramedic service providers 7. Quality Control experts 8. Inter-organizational boundary crossing9. Continuing medical education students
(From Brookman & Harrington: 2007)
When is a family health team not a high performance team?
When the “shadow workforce” is not incorporated in team proceedings
‘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.
9(16%)37(68%)9 (16%)Total teamwork
5 (9%)38 (69%)12 (22%)Organizational Support
10 (18%)36 (68%)9 (16%)Decision-making and leadership
9 (16%)35 (64%)11 (20%)Clarity of Team Goals
11 (20%)35 (64%)9 (16%)Roles and Interdependence
7 (13%)39 (71%)9 (16%)Communication and Conflict Management
10 (18%)40 (73%)7 (13%)Team members strengths and skills
10 (18%)40 (73%)5 (9%)Patient and Inter-team focus
High Performance Teamwork (One standard deviation above the group mean )
Teams at Average Levels of Teamwork (Within +/- one standard deviation of the group mean )
Below Average Levels of Teamwork (One standard deviation below the group mean )
Level of Inter-professional Teamwork
Dimension of Teamwork
The distribution of high performance teamwork in a sample of 55 family health teams using the Dimensions of Teamwork Survey
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
Health professionals don’t own the space
Co-caregivers may not know each other
Care providers are inter-organizational
Regulated and unregulated providers
Unpaid “shadow workforce” prevails
Interactions are non-linear
Self-organizing
Local ecology and regional diversity
Strength of ties is variable
No single agent knows everything
Practice Jazz
Lots of surprises
No standardization
Improvisational
Sense-making
Local Adaptations
Co-evolving
Initial conditions
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
