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 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
 Preparing the Workforce
Five Skills

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
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 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

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 1970s

Referrals from state hospitals
Case review and assignment
Case consultations and reviews
Consultation & Education Initiatives
 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
 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

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 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
PACE
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
Veterans Administration
Mental Health In-
patient and Out-patient

Drug/Alcohol programs

Homeless programs

Vocational – work
readiness

Residential community
homes
 Mental Health
Assertive 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 Philosophy is not to use

responsibility for care” facilities – not to use
means that the team structured programs
provides the majority of the
services the consumer The team itself provides
needs the needed services

It is not a brokering Flexibility if there is a

model of case management needed service that would
augment the person’s
One person on the team service array – the team
can substitute for another might access that service
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.
 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 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
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
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
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
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
1.
12 C’s of Team Process
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)

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)
 Where is future with interdisciplinary
teamwork?
 Informatics – increased technology

 Computer based services

Contact

Inquiry

Service

 ???