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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