Interprofessional team care

2


Interprofessional team care





Objectives


Upon completion of this chapter, the reader will be able to:


• Describe three traits of effective geriatric care teams.


• Describe two barriers to team care.


• Describe four components of an effective geriatric care team.


• Describe the role of the patient and the family in the team.


Health care teams play a crucial role in geriatric care. Geriatrics is characterized by its complexity and attention to biopsychosocial needs of the patient. It is virtually impossible for the primary care provider (PCP) to provide comprehensive assessment and management of complicated elders without working in a team of professionals. Many older people have several chronic conditions, geriatric syndromes, polypharmacy, perhaps some cognitive problems, functional deficits, and social needs. The best care requires the skills of an interprofessional team. It is important that all members of the geriatric health care team have adequate knowledge and skills and appropriate attitudes regarding team care.


The major organizations involved in physician training have established recommendations regarding team training and core competencies in interprofessional collaborative practice. The Accreditation Council of Graduate Medical Education, in its discussion of the competency “interpersonal and communication skills” requires residents to “demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients … and professional associates.”1 Residents should be trained to “work effectively with others as a member or leader of a health care team.” Training in teamwork is also recommended under the “systems-based practice” competency. The Association of American Medical Colleges has also recognized the importance of team-related training.2 The core competencies in collaborative practice have been agreed upon by the major organizations in health professional training.3 (See Box 2-1.)



BOX 2-1   CORE COMPETENCIES FOR INTERPROFESSIONAL COLLABORATIVE PRACTICE





CASE 1   Rachel Paul (Part 1)


Mrs. Rachel Paul is a 78-year-old who was living independently in an apartment. Earlier this morning, she tripped while going to the bathroom, and landed on her hip. She felt an immediate pain and was unable to get up to walk. She dragged herself to the bedside table, where she was able to reach the phone and call her daughter. You now see her in the emergency room and the emergency physician informs you she has a fractured neck of the left femur.



Although much of the discussion of health care teams focuses on the roles of the health professionals, patient-centered care requires that the patient needs always be given priority. In addition, because most care is provided to older persons by their families it is crucial that the patient’s caregiver and family be included in the team process. This approach can be difficult for health care professionals. Asking patients for their input, encouraging them to ask questions, and remembering to provide the patient and family with all the information needed to make informed decisions takes time and sensitivity. However, it is through patient involvement that we can achieve the desired outcomes and at the same time reduce errors and iatrogenic disease. image



Effective health care teams have certain traits—roles and responsibilities are clear and understood by all, and members are flexible and knowledgeable of the other members’ skills. The team has a strong sense of collegiality, trust, and mutual respect. An especially important characteristic of an effective team is the ability to collaborate. Collaboration requires not just respect of other team members, but a mutual dependence. Perhaps the most important trait is the ability to communicate effectively. This ability is not limited to being able to exchange information; team members also must be able to both support and confront one another, especially in situations involving patient safety. Ultimately, the goal of the health care team is to optimize patient-centered outcomes while reducing the risk for error.




Barriers to effective team function


Both external and internal factors can result in barriers to the use of teams in health care. Teams, by their nature, increase complexity. Many teams are formed with members who have received no training in team-based care. To be effective teams must develop communications systems, protocols, and have time to interact. The common, hierarchical model of medicine is antithetical to effective team care. Finding the exact number of team members to provide efficient care is difficult. There may be a U-shaped nature to team member numbers; too few does not allow for improved efficiency, and too many becomes too complicated to manage. One study found that in primary care 6 team members was the ideal number, and teams with greater than 12 members were less effective.4 Finally, the fee-for-service reimbursement system does not place value on team care. Many of the activities of key team members, such as social workers, are not reimbursable in standard Medicare billing.



The most important trait of an effective health care team is the ability to communicate effectively.




Teams in different geriatric care settings


Team care occurs in a variety of health care settings. In its simplest form a physician works with an assistant and sometimes a clerical support person. However, when the demands of care are diverse and require professionals with different skill sets, a formal team structure is necessary. In the well-developed patient-centered medical home primary care practice, every office staff member works together as an integrated team, partnering with the patient, family, and community health workers. Teams are also seen in geriatric assessment clinics, long-term care settings, rehabilitation, hospice care, transplantation units, and surgical settings.


The disciplines participating in a geriatric health care team will vary by setting and the needs of the patients. Regardless of which members are on the team, it is important that all team members are trained not only in their discipline, but also in teamwork. In the care of a frail and complicated older person, the minimum team is comprised of a PCP, a nurse, and a social worker. Table 2-1 lists the skills of a variety of health care disciplines. A more detailed description of the PCP, social work, and nurse roles follows, though it is clear that many others, including pharmacists, rehabilitation therapists, chaplains, music therapists, and others are involved in the patient’s care.



TABLE 2-1


Geriatrics Team—Selected Discipline Participants



















































Audiology Evaluates, diagnoses, and treats hearing loss and balance disorders. Recommends and provides hearing aids.
Chaplain Provides spiritual and emotional support to patients and family.
Dietitian (Registered) Evaluates the nutritional status of patients; sets nutritional goals; educates patient and family.
Geriatrician Physician with special training in the care of older adults.
Registered Nurse Provides direct and indirect patient care; helps to maintain function; coordinates care; provides patient education.
Nurse Practitioner/Advanced Care/Geriatric Medicine Nurse with advanced training in clinical practice, geriatric medicine, health education, and counseling.
Occupational Therapist Assists patients with developing independence with ADLs and IADLs, especially upper extremity function; home safety evaluations; adaptive equipment recommendations; extremity splinting.
Pharmacist Monitors optimal medication therapy; information resource.
Physical Therapist Assists patient with mobility, balance, strength training, and pain relief; adaptive equipment recommendations.
Physician (Primary Care) Diagnosis and treatment; prevention, prescribing, manage chronic illness.
Physician Assistant Practices medicine with supervision of physician.
Psychiatrist Physician who treats patients with mental, emotional, and behavioral disorders.
Psychologist Assessment, treatment, and management of mental disorders.
Social Worker (Medical) Assessment and management of patient and family psychosocial functioning; locating services; counseling.
Speech/Language Evaluate and diagnose speech, language, cognitive.
Pathologist Communication and swallowing disorders.

ADLs, Activities of daily living; IADLs, instrumental activities of daily living.



CASE 1   Rachel Paul (Part 2)


Mrs. Paul undergoes left hip replacement with no complications and has minimal pain with walking. But she is unsteady and somewhat fearful when ambulating. The physician reviews her past medical history and finds that she has been taking hydrochlorothiazide for hypertension, ibuprofen for osteoarthritis, and diphenhydramine for sleep. Recognizing that the nonsteroidal antiinflammatory drug could be contributing to Mrs. Paul’s hypertension, he discusses with the patient using acetaminophen. He discontinues the diphenhydramine and discusses sleep hygiene with the patient. The physician orders evaluations by occupational and physical therapists.





Roles of core team members




Primary care provider (physician, nurse practitioner, physician assistant)


The primary care provider on the geriatric team usually has the responsibility of assessing and managing the patient’s medical problems. In addition, when the team does not have a pharmacist the PCP, along with the nurse, is also responsible for careful monitoring for medication effects. There are some important differences between a primary provider’s standard role in a primary care practice versus a primary provider’s role as part of a geriatric care team. In traditional primary care the PCP interviews and examines the patient, considers medical recommendations, and then enters into a discussion in which the patient’s goals and wishes are clarified, education is provided, and the patient and provider decide on a course of treatment. This is the essence of shared decision making in primary care. In a team environment, the PCP has the additional responsibility to not only inform other team members of the patient’s conditions, but also to learn from other team members the patient’s needs that were identified in their assessments. Furthermore, because the areas of need are much broader than the standard medical approach, the team and patient (and often family or other caregivers) must determine priorities and decide which problems to address first. This is a more complicated, but also more comprehensive, approach to patient management.


In older adults with multiple medical problems decisions will need to be made about the balance of benefits and risks of simultaneous treatment of multiple conditions. Based on the patient’s goals, targets for treatment will be decided. For example, although many guidelines recommend a target of <7.0% for glycosylated hemoglobin (HbA1c) in diabetic patients, such a target may not be appropriate for many older patients.5 Similarly, decisions on the appropriate approach to symptom management and preventive screening tests will be required. The PCP also reviews the patient’s medication regimen, assesses the use of over-the-counter medications, and decides on appropriate medications to continue or to stop. The process continues with oversight and adjustments based on the patient’s responses.



In a team environment, the PCP has the responsibility to inform other team members of the patient’s conditions, and also to learn from other team members the patient’s needs that were identified in their assessments.



A key area of involvement for the PCP is advance care planning. Often this process is initiated by the social worker through a discussion of the patient’s goals and wishes. A number of initiatives and techniques are available to facilitate the discussions, such as using the “Go Wish” cards.6 These are a set of 36 playing cards with statements about common things people value at the end of life. The patient is asked to sort the cards into his or her top-10 prioritized wishes and then use that as a springboard for discussing advance care planning. Although this part of the advance care planning may be led by the social worker, the physician or nurse practitioner is crucial to discussing the medical implications of the patient’s wishes and for completing a set of orders if desired. The Physician Orders for Life Sustaining Treatment form is one mechanism for doing that.7 It is now used in more than 13 states.


The PCP also serves in the important role as a patient advocate within the medical care system. Given the diversity of older persons, each patient will make health care decisions not only on the medical facts, but on their own goals and wishes. Spouses, family members, and even other members of the geriatric care team may have opinions about the proper course of treatment. Sometimes these opinions are in the direction of less intensive care, sometimes more. It is the PCP’s role to help patients choose among treatment options, and to help patients understand the risks and benefits of the choices as well as what is likely to happen if no treatment is provided. This is the essence of informed consent. When working with a surrogate (or proxy) decision maker the PCP must be certain that the decisions of the surrogate reflect those choices that would have been made by the patient.


A word of caution is warranted regarding the role of the physician in geriatric care teams. Physicians are socialized through their professional training to be leaders. Many assume the physician will be the team leader. This is often not the case in geriatric care teams. Leadership not only varies by the type of team, but also may vary by the situation. For instance, in Program of All-Inclusive Care of the Elderly sites, the social worker is often the team leader. As nursing homes move toward more homelike settings, nurses are often team leaders. In well-functioning teams with good communication skills, team leadership may shift based on the primary issue being addressed, such as when decisions are being made about transfer of care to a different site. Physicians on geriatric care teams must be facile at changing roles and in providing the support needed by the team to achieve the best patient outcomes.



CASE 1   Rachel Paul (Part 3)


Mrs. Paul is now in rehabilitation for her repaired hip fracture. The physical therapist notices that the patient becomes extremely anxious when she attempts to start gait training. The patient expresses, under her breath, “I don’t know that I’ll ever be able to go home again . . .” The therapist reports this to the social worker on the team, who decides to conduct a depression screen.





Social work


Social workers provide both tangible and intangible contributions to the geriatric health care team. Historically, social workers became active in health care settings, especially hospitals, as informants to doctors and nurses regarding the social and psychological impacts of disease upon patients and their families. This remains a critical role of social workers in the geriatric health care teams of today. Furthermore, shorter hospitalizations have resulted in patients requiring more health-related social work services in the community.8 Indeed, the social worker can become a translator between the patient and the rest of the geriatric care team. Social workers often meet with the patient and/or his or her family and provide critical information for meeting the needs of the whole person (Box 2-2).



BOX 2-2   SOCIAL WORK ON GERIATRIC TEAMS


Medical social work is a form of practice that:




In well-functioning teams with good communication skills, team leadership may shift based on the care topic being addressed.




Advocacy

Essentially, social workers serve as advocates for the patient. This advocacy serves to support the patient’s right to self-determination regarding medical decisions. As an advocate, the social worker focuses on the patient, with the patient’s needs, wishes, well-being, and interests taking precedence over all else.9 The social worker consults privately with patients and represents patients who cannot represent themselves (e.g., homeless, cognitively impaired). Therefore, one part of the social work role is to engage parties who might feel ignored.


At times, the prevailing medical model of patient care clashes with the social work profession’s model of patient autonomy and self-determination.10 Team members may become angry with the patient and expect the social worker to force the patient to get “the help she needs.” In these instances, the social worker must skillfully model respect for the patient’s autonomy as well as educate the patient on the importance of considering all treatment options.


In some cases, the patient’s right to refuse treatment is overridden by concerns regarding patient safety or the safety of others. When there is the possibility of irrefutable, irreversible harm involved and the social worker has made every effort to gain consent, the social worker will work with the team to obtain appropriate treatment for the patient. Constantly, the social worker balances the advocacy role with responsibility to the health care delivery system.


In other cases, the social worker serves as a cultural broker or advocate. In today’s diverse world it is essential that the health care team understand how an individual’s culture shapes his worldview and how he interprets medical care. Cultural dynamics can require adjustment of medical approaches and the social worker can interview the patient and learn as much as possible about his or her background and cultural and individual traits and beliefs. Social workers also seek help from other members of the patient’s family and frequently research the patient’s culture and cultural perceptions of aging and medical care. Finally, the social worker brings this information to the team to assist in diagnosis and treatment planning and interprets the culture to the rest of the team.


For example, social workers can provide information regarding the culturally specific systems that affect the patient as well as provide the patient with the names and purposes of tests. In addition, the social worker translates a greater understanding of the health care system and medical terms. Yet, it is also essential that the social worker, as well as the rest of the health care team, avoid losing sight of a patient’s individuality by stereotyping the patient on the basis of culture.11 When appropriately nuanced, this inclusion of the patient’s beliefs and rituals affects everyone and leads to the increased comfort of the patient and to greater trust of the medical providers. However, in no case does the social worker interpret the test results or diagnose medical conditions. Rather, the social worker is a translator and communicator.



Assessment

In addition to bringing psychosocial issues to the geriatric medical team, social workers perform both formal and informal psychosocial assessments. Assessment is considered the basis of social work practice,12 specifically characterizing gerontologic social work.13 Individualized assessments are essential in developing patient-specific interventions and treatments.14 Comprehensive assessments, within the purview of social work, encompass physical, functional, financial, social, emotional, spiritual, and psychological resources, supports, and unmet needs.


Ideally, a social worker develops a social history for each patient that provides critical information regarding the patient’s past as well as current social, psychological, spiritual, and financial issues. Embedded in this history is the person-in-the-environment perspective,15 suggesting that understanding the patient’s environment influences understanding and enhances care. In addition, social work endorses a strengths-based perspective,16

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Jun 8, 2016 | Posted by in GERIATRICS | Comments Off on Interprofessional team care

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