Evolution & experience in geriatrics

1. Interdisciplinary Teams:
Evolution & Experience in
Geriatrics

2. 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

3. Preparing the Workforce
Five 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. 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 Workforce
Five Skills

5. 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

6. Pressure for Enhanced Teamwork
 Cost-effective care models
Hospice
ACT Teams
Visiting Nurse
Day Treatment Programs
Senior Community Centers
Gero-psychiatric Centers
Others……….
 Emphasis on health
promotion
 Emphasis on disease
prevention
 Community based services

7. 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)

8. 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)

9. Evolution Team Approach
From historical perspective teams have evolved
 Consultative approach
 Multidisciplinary
 Interdisciplinary
 Trans-disciplinary

10. 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

11. 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)

12. 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

13. Team Evolution
What event(s) propelled the move to develop and
initiate multidisciplinary teams in health and mental
health settings?

14. Team Approach
Courts and mental health care
Accreditation regulations
De-institutionalization within mental health
Mandatory insurance regulations

15. Mental Health Teamwork
Do you know which NC Hospital is pictured?
Community Mental Health Programs 1970s
Referrals from state hospitals
Case review and assignment
Case consultations and reviews
Consultation & Education Initiatives

16. Health Care Team Work
Mandatory regulations and accreditation
End-Stage Renal Disease Program 1972
Social Security Act Amendment P.L. 92-603
Medicare coverage for renal transplants and home dialysis
Referrals from state hospitals

17. Geriatric Team Development
On 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

18. 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

19. Retired August 1993, October stocked 39-foot
sailboat, on-board black Labrador, and tacked
out into the Pacific from San Francisco.

20. Expansion of On Lok Model
1986 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

21. Veterans Administration
Application across health
and mental health facilities
Acute Care Hospitals –
treatment and
rehabilitation, out-patient
clinics, specialty clinics,
patient and family
education, support groups

22. Veterans Administration
Mental Health In-
patient and Out-patient
Drug/Alcohol programs
Homeless programs
Vocational – work
readiness
Residential community
homes

23. Mental Health
Assertive Community Team (ACT)
 Principles
 In vivo services
 Primary responsibility for service delivery
 Team approach – shared caseload
 Flexible service provision
 Time unlimited

24. 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

25. Juvenile Offenders
Multisystemic 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.

26. 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.

27. Team Advantages
For 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

28. Team Advantages
For 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

29. Teamwork Advantages
For 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

30. Teamwork Advantages
Mental health needs --
Better management
depression
Decreased depression
scores
More adherent medications
Fewer symptomatic days
Increased work days
Less panic and anxiety
attacks

31. Team Advantages
For 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

32. 12 C’s of Team Process
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)

33. 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)

34. Experiences
Were 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)

35. Where is future with interdisciplinary
teamwork?
 Informatics – increased technology
 Computer based services
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