Team Form & Functions: From Multi-Disciplinary to Interprofessional Collaborative Geriatric Teams-...

Team Form & Functions: From Multi-Disciplinary Team Form & Functions: From Multi-Disciplinary to Interprofessional Collaborative Geriatric Teams- to Interprofessional Collaborative Geriatric Teams-

Assessment & Educational ModelsAssessment & Educational Models

Debra Fromm Faria

V. Associate Professor, Social Work

Co-Director Center for Excellence in Gerontological Social Work

College at Brockport, State University of New York

[email protected]

Marla Berg-Weger

Professor, School of Social Work

Executive Director, Geriatric Education Center

Saint Louis [email protected]

Webinar October 23, 2012

The Presenters also wish to acknowledge a collaborative input for some of the health care slides by Assistant Professor Thomas Caprio, MD,MPH, FACP, University of Rochester Medical Center , School of Medicine, Division

of Geriatrics

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Objectives

1. Define types of teams Multidisciplinary Interdisciplinary Interprofessional Transprofessional

2. Understand the roles of interprofessional team members

3. Describe the value of interprofessional geriatric assessment

4. Introduce model of using interprofessional education in clinical settings and courses to prepare the next generation of interprofessional team members

5. Provide resources for future use

What are the differences and similarities with types of teams?

The terms multidisciplinary, interdisciplinary, interprofessional and transdisciplinary often are used interchangeably.

It is useful to understand definitions, and assess how our teams are functioning

www.asha.org/uploadedFiles/aud/TeamApproaches.pdf

Multidisciplinary Team Approach

Professional Silos are common “A multidisciplinary approach to service delivery means

that persons from several disciplines are involved in the delivery of services.

The approach, however, is discipline-oriented with each team member responsible only for the activities related to his or her own discipline (Melvin, 1989; Rothberg, 1981).

One team member is affected very little by the efforts of the other team members..”

Melvin, J. L. (1989, April). Status report on interdisciplinary medical education. Archives of Physical Medicine and Rehabilitation, 70, 273–276.Rothberg, J. (1981, August). The rehabilitation team: Future direction. Archives of Physical Medicine and Rehabilitation, 62, 407–410.as cited in Catlett, C. & Halper, A. (1992, Summer). Team Approaches: Working Together to Improve Quality ASHA Quality Improvement Digest. http://www.asha.org/uploadedFiles/aud/TeamApproaches.pdf

Interdisciplinary Team

An interdisciplinary approach to service delivery requires Interaction among the disciplines. Not only are individuals from several disciplines working

toward a common goal, but the team members have the additional responsibility of the group effort (Rothberg, 1981).

Effective communication is required among those involved (Melvin, 1989).

The team includes the patient/client and his/her family

Melvin, J. L. (1989, April). Status report on interdisciplinary medical education. Archives of Physical Medicine and Rehabilitation, 70, 273–276.Rothberg, J. (1981, August). The rehabilitation team: Future direction. Archives of Physical Medicine and Rehabilitation, 62, 407–410.

as cited in Catlett, C. & Halper, A. (1992, Summer). Team Approaches: Working Together to Improve Quality ASHA Quality Improvement Digest. http://www.asha.org/uploadedFiles/aud/TeamApproaches.pdf

Transdisciplinary Team Model

“A transdisciplinary model includes the following components:

• one person can perform professionals’ roles by providing services to the patient/client under the supervision of the individuals from the other disciplines involved.

• Disciplines work together in the initial evaluation and care plan, but only one or two members actually provide the services.

• Professionals are still accountable for areas related to their specific discipline and for training the team member delivering the service” (e.g., ACT).

Bailey, D. B., & Wolery, M. (1989). Assessing Infants and Preschooler With Handicaps. Columbus, OH: Merrill Publishing Co.Connor, F. P., Williamson, G. G., & Stepp, J. M. (1978). Program Guide for Infants and Toddlers With Neuromotor and Other Developmental Disabilities. New York: Teachers College Press.

as cited in Catlett, C. & Halper, A. (1992, Summer). Team Approaches: Working Together to Improve Quality ASHA Quality Improvement Digest. http://www.asha.org/uploadedFiles/aud/TeamApproaches.pdf

Example of Transdisciplinary Team in Behavioral Health

Assertive Community Team (ACT) Evidence–Based Practice Model designed to provide treatment,

rehabilitation and support services to individuals diagnosed with a severe mental illness whose needs have not been met with traditional mental health services

ACT team: psychiatry, nursing, psychology, social work, substance abuse & vocational

rehabilitation.

Based on respective areas of expertise, team members collaborate to deliver integrated services of the recipients' choice,

assist in making progress towards goals, adjust services over time to meet recipients' changing needs and goals.

www.socialworkleadership.org

NYS Office of Mental Health, Assertive Community Treatmenthttp://bi.omh.ny.gov/act/index

Definition of Interprofessional Team Collaboration

“ Interprofessional collaboration is a ‘partnership’ between a team of health providers and a client in a participatory collaborative and coordinated approach to shared decision making around health and social issues.”

Canadian Interprofessional Health Collaborative. A national interprofessional competency framework. February 2010. Available from: http://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf

Interprofessional Collaborative Practice Principles

A process by which professionals: Reflect on and develop ways of practicing that provides an integrated and

cohesive answer to the needs of the client/family/population. Involves continuous interaction and knowledge sharing between professionals. Organized to solve or explore care and social issues while seeking to optimize

the patient’s participation.

Morrison S. Working together: why bother with collaboration? Work Bas Learn Prim Care. 2007;5:65–70.

Sources: Core Competencies for Interprofessional Collaborative Practice . Report of an Expert Panel, May 2011, Sponsored by the Interprofessional Education Consortium, p 8 . http://www.aacn.nche.edu/education-resources/ipecreport.pdf

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Benefits of an Interprofessional Team Approach

Interprofessional approaches to health and social care are linked to improved clinical services and enhanced problem-solving

(Mitchell, Parker& White, 2010)

Characteristics of Effective Collaborative Interprofessional Teams

Belief that the team is important to the outcome Open communication Equality of resources Respect Shared decision making All members feel valued

Meet Mrs. C.

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Mrs. C. Social History Data

92-year-old woman lives alone Widowed 14 years ago; daughter lives locally and

son lives in Arizona Worked for 15 years as an executive secretary at a

local company Active in her faith community all her life Volunteers in a children’s reading program at the

local library

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Case Presentation - Mrs. C. Health History

Multiple chronic health problems (Cardiac, Pulmonary, Diabetes, Arthritis)

Hospitalized for shortness of breath and chest pain twice in the last 3 months

Acute Incident

Falls at home paramedics arrive and

find her with right leg pain and unable to walk

Taken by ambulance to the hospital

Diagnosed with Hip Fracture

Admitted for surgery and day #2 develops worse shortness of breath, complaints of pain, nausea, and

constipation

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Mrs. C. - Discharge Planning

Fearful of falling, hard time using walker

Discharged to a skilled nursing facility for rehabilitation

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Mrs. C. - Rehab Update

4 weeks of rehabilitation: family is concerned about her returning home alone

They report Mrs C. has a history of several falls at home without injury

Family is concerned she is “taking her medications wrong” sometimes they notice “she is wearing

clothes that have stains and appear dirty”

Mrs. C. - Rehab Discharge Outcome

Discharged back home after 6 weeks Plan includes:

Home Care Aids 4 hours per day

Weekly nursing visits

Referral to outpatient PT

Daughter plans on shopping weekly and setting up mediset

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Mrs. C. - Five days later…..

Family brings Mrs C back to hospital Emergency Department Increased confusion, not eating/drinking Found on the floor where it appeared she

had been for many hours after aide left in morning and daughter visited at night

Admitted to the hospital with pneumonia, dehydration, and “failure to thrive”

With which health care teams did Mrs. C. interface?

Hospital: Multi-Disciplinary? discipline-oriented with each team member responsible only for the

activities related to his or her own discipline. Communicate with one another through chart documentation and unit reports.

Rehabilitation Nursing Home Stay? Likely interdiscplinary / perhaps interprofessional

Discharge Home? Multi-Disciplinary

PCP for medical Care Home Care agency Outpatient PT clinic Family

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Mrs. C.’s Story: Important to Assess how team function can improve across service sectors

Next steps in management? How could this have been prevented? How can the team think about?

Prior level of function at home Hospital management Rehabilitation course in nursing home Home Care Plan and safeguards

What about: Cognitive & psychosocial strengths and challenges Family caregiving & interface with the formal care system Functional & Environmental Factors

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Why the need for interprofessional collaboration and effectiveness?

Population is Aging:

Largest increase in Age > 85

Older adults are seen as patients/clients in all health care settings

Source: Administration on Aging, January 2004

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Where are older adults interfacing with service providers?

Home (independent in the community) Home (with Home Care Services) Independent or Senior Housing Assisted Living Facilities Adult Day Care Programs Long-Term Care Facilities (Nursing Homes) Rehabilitation Centers Hospitals Community Retail Providers (Pharmacy )

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What challenges do older adults experience as they age?

Disability (loss of function)

Comorbidity (chronic medical conditions)

Frailty (vulnerability)

Multiple Losses (compounding effect)

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Why is assessment important?

Goal: decrease disabilityand dependence

Identify “pre-clinical” disability

Majority older adultslive independently

50% Lifetime Risk of nursing home placement

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Geriatric Syndromes

Broad categories of signs and symptoms common in the geriatric population Vision impairment Hearing loss Incontinence Falls/Mobility Depression Memory disorders

HELP!

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What is geriatric assessment?

Method to identify problems/challenges early

Goal to maintain or improve FUNCTION

Screen for common problems of aging (geriatric syndromes)

Identifies the strengths/resilience of the individual and family system

Performed by interdisciplinary/interprofessional team

Focus on chronic disease management and effective resource utilization to enhance quality of life

*

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Geriatric Assessment:Interprofessional Team Interface

Comprehensive assessment is performed by an interdisciplinary/interprofessional team

Each team member’s professional domain knowledge is recognized. Collaborative team practices are central to the model. Allowing for contextual understanding of complex issues.

Geriatricians Social Workers

Patient/Family

Nurses

Neuropsychologists

Pharmacists

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Addressing Complexities Through an Interprofessional Approach

Interface of

Geriatric

Competencies

Functional

Assessment

MedicineAssociation of American Medical Colleges / John A. Hartford Foundation, Inc. July 2007 Consensus Conference on Competencies in Geriatrics EducationAcademic Medicine. 84(5):604-10, May 2009.

NursingJohn A. Hartford Foundation

Institute for Geriatric Nursing,2002

Social WorkGeriatric Social Work Competency Scale II with Life-long Learning in Relationship to Leadership Skills

Assess & describe baseline and current functional abilities in an older patient (ADLs/IADLS) by collecting historical data and performing a confirmatory physical exam

Demonstrate within care plan appropriate intervention to promote function in response to change in ADLS and IADLS

Conduct a comprehensive biopsychosocial-spiritual assessment identifying older adults strengths and problems, social supports, social functioning, ADL and IADLshttp://www.pcssprimarycare.org/nsw/competencies/competencies.php#http://www.pogoe.org/sites/

default/files/Minimum%20Geri%20Competencies%202.0%20w%20narr%20AcademMed%203-9-09_0.pdf

http://hartfordign.org/uploads/File/competencies.pdf

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Interface of Competencies

MedicineAssociation of American Medical Colleges / John A. Hartford Foundation, Inc. July 2007 Consensus Conference on Competencies in Geriatrics Education Academic Medicine. 84(5):604-10, May 2009.

PharmacistMedication Management Therapy in Pharmacy Practice, (2008). http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf

NursingGeriatric Social Work Competency Scale II with Life-long Learning in Relationship to Leadership Skills

Explain impact of age-related changes on drug selection and dose based on knowledge of age related changes in renal & hepatic function, body composition & CNS sensitivity

Perform basic elements of geriatric pharmacotherapy assessments, interpret physical, laboratory and diagnostic test results, monitor drug therapy, provide medication counseling

Assess barriers, drug interactions, … that impact patients’ understanding of information, following directions and making needs known.

MedicationManagement

http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdfhttp://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdfhttp://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf

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Components of Geriatric Assessment

Medical Functional Psychological

Cognitive Social Economic Family

Dynamics

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Dimensions of Geriatric Assessment: Medical Assessment

Past Medical and Surgical Histories

Family History Physical Exam Review Medications:

Polypharmacy “Bad Drugs”

Geriatric Syndromes: Vision & Hearing Incontinence Falls/Mobility Memory/Mood Nutrition Pain

*

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Medication Review: Medicine, Nurse Practitioners and Pharmacy

Drug distribution and metabolism altered with aging

Adverse Drug Reactions & Drug-Drug Interactions

Number of medications OTC and herbal/dietary “Inappropriate” Meds:

falls, urinary problems, delirium, hospitalizations

While Social Workers are not the primary profession dealing with medication review, observations from home assessments, knowledge of environmental issues such as finances can inform the interprofessional team

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Functional Assessment:Activities of Daily Living (ADL)

Dressing Eating Bathing/Hygiene

(personal care)

Toileting(+/- continence)

Mobility Ambulating Transferring

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Instrumental Activities of Daily Living (IADLs)

Shopping Housekeeping (cleaning, laundry) Finances Cooking Using telephone Medications Transportation (driving, buses, etc.)

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Psycho-Social

Social History Contextual understanding of who the patient is

Presenting Challenges & Goals Patient perspective Family perspective

Mental Health Assessment Coping skills, stressors, risk factors,

depression screen Social Functioning Assessment

Social skills, social activity level, social supports

Caregiver Needs/Levels of Stress *

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Assessment Cognitive Function

Alzheimer’s Disease

Normal Aging

Mild Cognitive Impairment

Dementia

DEMENTIA

Cognition

Behavior Function

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Geriatric Assessment

Assessments depend on context and location:

Hospital – discharge planning Clinic/office – comprehensive assessment Nursing Home – improve or maintenance Home – mobility and safety Rehabilitation – improve function

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Core Areas

Functional assessment (observations) Areas of concern (mobility impairment,

weakness, ROM, falls, etc.) Medical Conditions (dementia, CHF, etc.) Rehabilitation tolerance and potential Psycho/Social Assessment

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Establishing Goals with Older Adults

Individualized and person-centered Maintain independence longer Reduce stress or burden on caregivers Gradual or stepwise loss of function common

in patients Some older adults’ function may “plateau”

after an illness or injury Small improvements in physical function go a

long way (high “investment payoff”)

*

Time

Fun

ctio

nIllness

Hospitalizations

Rehab

Nursing HomeDisability

Good Health

Functional Impairment

Functional Decline:

Threshold

Family & Caregiver Stress

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Summary

Interprofessional team collaboration improves communication and patient/client outcomes Geriatric assessment emphasizes

functional status and the goal of maximizing independence and quality of life

Loss of function is common but small improvements go a long way

Person-Centered Approach

Next Steps: Workforce Preparation through Interprofessional Educational Models

Interprofessional educational models Engaging students across professional disciplines


Source: Core Competencies for Interprofessional Collaborative Practice . Report of an Expert Panel, May 2011, Sponsored by the Interprofessional Education Consortium, cover page picture.

What is Interprofessional Education?

When “students” from two or more professional learn about, from, and with each other to enable effective collaboration and to improve health outcomes

Framework for Action on Interprofessional Education & Collaborative Practice, World Health Organization, 2010


Educational Modelsto Prepare Competent Interprofessional

Practitioners

“The transformation envisioned would enable opportunities for health professions students to engage in interactive learning with those outside their profession as a routine part of their education”

Source: Core Competencies for Interprofessional Collaborative Practice . Report of an Expert Panel, May 2011, Sponsored by the Interprofessional Education Consortium, p3. http://www.aacn.nche.edu/education-resources/ipecreport.pdf

Educational Strategies in Fostering Interprofessional Collaborative Practice

Patient/family centered Community/population oriented Relationship focused Process oriented Linked to learning activities, educational strategies, and

behavioral assessments that are developmentally appropriate for the learner

Able to be integrated across the learning continuum Sensitive to the systems context/applicable across practice

settings Applicable across professions Stated in language common and meaningful across the

professions Outcome driven

Source: Core Competencies for Interprofessional collaborative Practice Report of an Expert Panel, May 2011, Sponsored by the Interprofessional Education Consortiumhttp://www.aacn.nche.edu/education-resources/ipecreport.pdf

Competencies in the Care of Older Adults at the Completion of the Entry-level Health Profession

Representing 10 Health Care Professions

Dentistry Medicine Nursing Nutrition Occupational Therapy Pharmacy Physical Therapy Physician Assistants Psychology Social Work

Partnership for Health in Aging (PHA)

Developed broad competencies in six domains to provide a baseline for geriatrics and gerontology training

To Access competencies: http://www.americangeriatrics.org/files/documents/health_care_pros/PHA_Multidisc_Competencies.pdf


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Competencies in the Care of Older Adults at the Completion of the Entry-level Health Profession

Domains:1. Health Promotion and Safety2. Evaluation and Assessment3. Care Planning and Coordination Across the

Care Spectrum4. Interdisciplinary and Team Care5. Caregiver Support6. Healthcare Systems and BenefitsSource: Partnership for Health in Aging Workgroup on Multidisciplinary Competencies in Geriatrics

http://www.americangeriatrics.org/files/documents/health_care_pros/PHA_Multidisc_Competencies.pdf

EndorsementsCompetencies in the Care of Older Adults at the Completion of the Entry-level Health Profession

Alliance for Aging Research

American Academy of Nursing – Expert Panel on Aging*

American Academy of Physician Assistants

American Assisted Living Nurses Association*

American Association of Colleges of Pharmacy

American Association for Geriatric Psychiatry

American Association for Long Term Care Nursing*

American Association of Nurse Assessment Coordinators*

American College of Clinical Pharmacy

American Dental Association

American Dietetic Association

American Geriatrics Society

American Occupational Therapy Association

American Pharmacists Association

American Physical Therapy Association

American Society on Aging

American Society of Consultant Pharmacists

Association of Directors of Geriatric Academic Programs

Association for Gerontology in Higher Education

Council on Social Work Education

Gerontological Advanced Practice Nurses Association*

Gerontological Society of America

The Hartford Institute for Geriatric Nursing*

National Association for Geriatric Education

National Association of Geriatric Education Centers

National Association of Directors of Nursing Administration in Long Term Care*

National Association of Professional Geriatric Care Managers

National Gerontological Nursing Association*

New York Academy of Medicine/Social Work Leadership Institute

PHI – Quality Care through Quality Jobs


Lessons Learned….

Social workers are experts on interprofessional collaboration so should be at the forefront

Review the Core Competencies for Interprofessional Collaborative Practice http://www.aacn.nche.edu/education-resources/ipecreport.pdf

Utilize the Partnership for Health and Aging (PHA) Core Competencies to establish dialogue with other professions in exploring interprofessional educational opportunities

Remember: Interprofessional Education as a model is a long term “process”

Seek funding


Getting Started….

Determine your goals for interprofessional education

Gain support from university leadership at all levels

Conduct syllabus audit to identify strengths and areas for change related to interprofessional content

Document and promote the interprofessional collaboration strengths of the social work profession


Getting started…

Curricular interventions: Integration into existing courses (including practicum

seminar) Cross-listing courses Co-teaching courses Certificate/minor/specialization

If your university has no health professions, consider reaching out to the community


Resources: Interprofessional Teams, Assessment & Instruction Tools

King, G., Shaw, L., Orchard, C., & Miller, S. (2010). The interprofessional socialization and valuing scale: A tool for evaluating the shift toward collaborative care approaches in health care settings. (35 ed., pp. 77-85). IOS Press.

Team Fitness Test (GITT) Geriatric Interprofessional Team Tools) available www.gittprogram.org/files/team_fitness_test.doc

Models of Care and Inter-Professional Care Related to Complex Care of Older Adults by Sharon Stahl Wexler pdf download available at : hartfordign.org/uploads/File/.../gnec_interdisciplinary_care.pdf

GITT video on You Tube available: available at http://www.youtube.com/watch?v=YrpPcgk99l8

Interprofessional Care and Training ( Pharmacy & Medicine) University of Pittsburgh available at http://www.youtube.com/watch?v=OTqJxneLRtQ



Online training module on Interprofessional Geriatric Assessment available from the Finger Lakes Geriatric Center (Includes Social Work)

http://www.nptrainingworks.com/flgec

The Center for Interprofessional Education and Research, Saint Louis University ipe.slu.edu

The National Coordinating Center for Interprofessional Education and Collaborative Practice, University of Minnesota

For information on this new project, contact: Barbara F. Brandt; [email protected]; 612/625-3972



American Association of Colleges of Pharmacy (AACP)*

http://www.aacp.org/resources/education/Pages/IPEC.aspx

*See Core Competencies for Interprofessional Education

Framework for Action on Interprofessional Education & Collaborative Practice

http://www.who.int/hrh/resources/framework_action/en/


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