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Preparing Health Professionals for

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1 Preparing Health Professionals for
Models of Interdisciplinary Practice in an Aging Society JoAnn Damron-Rodriguez, PhD, LCSW School of Public Affairs Department of Social Welfare University of California, Los Angeles Taipei, Taiwan May 17, 2010 Thank you for having me in your country. It is an honor to be with you today.

2 Worldwide Aging Percent of Population over age 65 Both Taiwan and USA in the 8.0 to 12.9 Category
First a few picturtes and words about Aging Societies. This is Geriatric Imperative is called the Age Quake, the Greying of the Globe Both Percent Aged 65 and Over: 2000 (An Aging World:2001, November 2001) Over half (59%). of the world’s elderly now live in developing nations (Africa, Asia, Latin America, Caribbean, Oceania) Industrialized nations of Europe, North America, and Japan: higher percentages of older people. Both the South Korea and the USA are experiencing this.

3 Average Life Expectancy in Asian Countries and the U.S.A.
1986 1991 2005 Indonesia 55 61 70 Philippines Taiwan 62 73 64 74 78 China 69 72 Japan 77 79 81 U.S. 75

4 OUR AGING WORLD: CHANGING THE SHAPE OF THE AMERICAN POPULATION
THE FUTURE OLDER POPULATION WIIL: BE MORE EDUCATED AND DIVERSE BE CHALLENGED TO MANAGE CHRONIC ILLNESS DEMAND SERVICE CHOICES HAVE FEWER FAMILY CAREGIVERS THE SHAPE OF THE WORLD WE LIVE IN IS CHANGING. IT WAS A TRIANGLE IN 1900 AND NOW IT IS A RETANGLE. THIS IS A PICTURE OF THE USA POPULATION AND IT IS A PICTURE OF THE DIFFERENCE BETWEEN THE MORE AND LESS DEVELOPED WORLD. WE NOW KNOW THAT THIS IS NOT TO BE SEEN AS ONLY A PROBLEM BUT ALSO AS A TRIUMPH OF MODERN SOCIETY. READ THE FUTURE OLDER POLULATION WILL: POINTS

5 OUTLINE Preparing Competent Health Professionals in the Field of Aging
Interdisciplinary and Cross-Cultural Competence Evidence-based Models of Interdisciplinary Healthcare TODAY I WILL DISCUSS WITH YOU THREE MAIN POINTS. FIRST, HOW WE CAN PREPARE A COMPETENT PROFESSIONAL LABOR FORCE TO MEET THE NEEDS OF THE GROWING OLDER ADULT POPULATION. SECOND, HOW WE MUST WORK ACROSS DISCIPLINES TO MEET THE NEEDS OF THE DIV ERSE OLDER POPULATION. THIRD, WHAT IS THE EVEIDENCE BASE FROM RESEARCH FOR NEW INTERDISCIPLINARY HEALTHCARE DELIVERY.

6 I. SOCIAL WORK RESPONSIBILITIES IN Today’s Delivery System for the
Growing Population of Older Persons and Their Families I. Patient Centered Care Family Care giving Support Community Care Cultural Competence LONG SLIDE TWO INTERPRETATIONS SOCIAL WORK makes a difference in the lives of older persons. In today’s healthcare delivery system here are some of the ways that there is research evidence to support social work’s role: I. Social workers direct the care toward the needs and choices of older people. Older person’s are at the center of the target for the care plan. II. Social workers support families who provide the majority of care to older persons. In the USA 85% of the care provided to older person’s are provided by family not professionals or paid help. Social workers enable family to care over time and not “burn out” or become ill themselves. III. Social workers develop care in the community and link the different types of community care together. There is a US Department of Justice Decision- The Olmstead Decision- that states it is against the civil rights of a person to put them in an institution if the person prefers care in his or her home. Social workers assist older people in obtaining this right. IV. Social workers are prepared to address the needs of the diverse older population. Diverse by virtue of differences in age, in ability, in socioeconomic status and well as ethnicity.

7 Professional Competence:
COMPETENCE IS THE STANDARD Council on Higher Education Accreditation (CHEA) CBE Now Required 76 Different Professions Define Competence Competence: The state or quality of being adequately or well qualified… a specific range of skill, knowledge or ability Professional Competence: The achievement and demonstration of core knowledge, values and skills in social work practice Geriatric Competence: Establishing geriatric competencies shape curricular, field training, and continuing education programs that effectively prepare practitioners to address the need of older adults and their families One of the new movements in education which is not essentially new is competency-based education. GERIATRIC COMPETENCE IS NOT ABOUT BEING COMPETENT OR NOT BUT RATHER LEVELS AND DEGREES OF COMPETENCE TO WORK WITH OLDER PEOPLE. READ DEFINITIONS.

8 Adoption of defined set of competencies as a framework for education
Elements of Competency-Based Education and Evaluation (CBE) for the Field of Aging Adoption of defined set of competencies as a framework for education Establishment of student learning goals based on the competencies Assessment of student skill level using the identified competencies Integration of classroom and field curricula THERE ARE FOUR PARTS OF A COMPETENCY BASED EDUCATION: READ THE FOUR PARTS

9 Geriatric Nursing and Social Work Competencies :Cross-Cultural
Hartford Foundation Geriatric Nursing and Social Work Competencies :Cross-Cultural Nursing Competency Social Work Competency Diversity: Attitudes and Values Clarification Recognize one’s own and others’ attitudes, values, and expectations about aging and their impact on care of older adults and their families. Respect diversity among older adult clients, families, and Professionals (e.g., class, race, ethnicity, gender, and sexual orientation). Appreciate the influence of attitudes, roles, language, culture, race, religion, gender, and lifestyle on how families and assistive personnel provide long-term care to older adults. Address the cultural, spiritual, and ethnic values and beliefs of older adults and families. Damron-Rodriguez,J.A. (2008).  State of the science: Developing nurse and social worker competence for professional practice with family caregivers. American Journal of Nursing & Journal of Social Work Education The first part of defining specific competencies has been accomplished in the USA through the John A. Hartford Foundation. Here we see nurse and social work competencies related to diversity.

10 Interdisciplinary Teamwork
Geriatric Nursing and Social Work Competencies : Family Caregiver Support Family Education Nursing Social Work Involve, educate, and, when appropriate, supervise family, friends, and assistive personnel in implementing best practices for older adults. Use educational strategies to provide older persons and their families with information for wellness and disease management. Interdisciplinary Teamwork Here are complimentary nurse and social work competencies related to supporting families. Understand the perspective and values of social work in working effectively with other disciplines in geriatric interdisciplinary practice. Recognize the benefits of interdisciplinary team participation in care of older adults.

11 Competencies to Learner Outcomes
Professional Competency Educational Program Learning Objectives Learning Activities to Support Objectives Assessing Competency-based Learner Outcomes A competency-based approach must be implemented throughout the social work curricula.

12 TYPES OF CROSS-DISCIPLINARY TEAMS
II. It is not only nurses and social workers but physicians, pharmacists and physical therapists and others that need to work together in a coordinated way to serve older people and their families. Multidisciplinary is when each discipline plays a distinct role. Interdisciplinary requires a greater degree of coordination and synthesis of their interventions for the benefit of the patient. Transdisciplinary is a new term and it connotes each member of the team contributing to the others role, shared responsibilities.

13 Cross-Cultural Practice
This is an example of the biopsycosocial framework in serving older persons and their families. The italics represent areas of knowledge needed to serve diverse elder. The dotted area shows evidence-based practice that requires knowledge in the biopsychosocial domains of aging.

14 Distribution by Race and Ethnicity
Slide 6 Distribution by Race and Ethnicity (Shows distribution by total population of the people over the age of 65) The older population will become more racially and ethnically diverse in the next 50 years. Non-Hispanic whites make up 84 percent of the population age 65 and older in 2000, this is expected to decline to 64 percent in 2050. (Older Americans 2000: Key Indicators of Well-Being, page 4)

15 Asian Americans refers to individuals who trace their heritage to the following countries:
Bangladesh Bhutan Cambodia China Hong Kong India Indonesia Japan Macau Laos Malaysia Maldives Mongolia Myanmar Nepal North Korea Pakistan Philippines Singapore South Korea Sri Lanka Taiwan Thailand Vietnam Within the Asian category, there is tremendous heterogeneity. The Asian countries are listed here and consist of more than 34 groups. Allthese groups are represented in the USA as well as the many Latino and African American groups. This presents the complexity and richness of diversity in the USA.

16 Minority Elders Barriers to LTC Need Utilization
PROGRAM APPROPRIATENESS Geriatric Assessment, Level of Care Continuum, Continuity, Coordination, ACCESSIBILITY Information and referral, Healthcare coverage, Location, Accommodate Disability, Intake, Hours, Translation ACCEPTABILITY Outreach, Cultural Diversity, Family Friendly POPULATION Acute, Chronic, Disease Prevalence, Symptom Presentation, SES, Health Insurance, Immigration Status, Neighborhood, Language, Functional Level Ethnicity, Support Systems, Acculturation, STRUCTURAL LONG This is a framework I have developed with UCLA colleagues to address the diverse needs of ethnic elders. Minority elders face both structural and cultural barriers to service. Though minority elders have greater need they use fewer community services. The diverse population have certain characteristics as shown here on the left. These in themselves do not create the barriers but rather the way in which the programs are designed to respond. There are three main characteristics of programs that are designed well to address barriers. They are: 1. Appropriate-the rights service at the right time. Not the emergency room when an older person needs a comprehensive geriatric assessment as an example. 2. The service is accessible. It is in the neighborhood, It does not ask for unnecessary paperwork. It has translation available. 3. It is acceptable to all minority elders who need the help. Culture is respected. CULTURAL

17 IOM: Redesign models of care broaden provider & patient roles to achieve greater system responsiveness III. Needs must be addressed comprehensively Services must be provided efficiently Older persons must be active participants in their own care Increased dissemination of more effective and efficient models is needed Expanded roles of health care providers The USA Institute of Medicine (IOM) in 2009 issued an important report. It is entitled: Re-tooling for an Aging America. It calls for community-based services linked with acute care to be Responsive in the following ways. READ the above points.

18 OLDER ADULTS AT RISK IN TRANSITION
Why at risk? Co-morbidity Disability Frailty At risk for? Incompatibility in treatments Polypharmacy/adverse drug events Social Isolation/similarly frail caregivers Rapid decompensation Re-hospitalizations, institutionalization, mortality Points at which older persons move from one service to another are called transitions. The transition is frequently not coordinated well. In transitions older persons are at risk of: READ the above.

19 Adults are Most Vulnerable. at the Transitions in Care
Adults are Most Vulnerable at the Transitions in Care The Advisory Board Company Needs/Circumstances of Clients & Family/Social Network In-Community Services Congregate Housing Services In-Home Services Institutional Services This is a diagram of the flow between transitions.

20 IOM Recommendation: Care Coordination
PACE Social HMO Medicare Coordinated Care Demonstration Arizona LTC System This diagram show that often older persons are in need of a lot of different services. In the USA these services are often not connected together. In this diagram it show that a person was “ping-ponged” back and forth and it took hours of time for a social worker to make all the linkages. On the right is a list of evidence-based programs that the IOM Report notes address this problem. These programs need wider adoption.

21 Site of Program in Community-Based Care
Home Services ·         Emergency response system ·         Home-delivered meals ·         Home health care ·         Home Health Aide ·         Homemaker/Companion ·         Telephone Reassurance Friendly Visitor ·         Hospice ·         Home repair Community Services ·         Adult day health care ·         Congregate meals ·         Exercise program ·         Information and referral ·         Legal ·         Money management ·         Outpatient mental health ·         Protective services ·         Public Guardian ·         Recreation ·         Respite care ·         Senior Center ·         Support groups ·         Transportation This points aging to the older person and the family being at the center of care planning. It also lists many of the community-based services in the USA. Residential Services ·         Assisted living ·         Continuing care retirement community ·         Nursing Home ·         Residential care (Board & Care) ·         Senior Citizen Apartments ·         Shared Housing

22 Functional Status IMPACT GRACE Spirituality Affective Medical
IOM Recommendation: Interdisciplinary Teams For Geriatric Assessment and Intervention IMPACT GRACE Functional Status Social Support Spirituality Affective Medical Cognitive Environment Economic This is a diagram of the assessment by an interdisciplinary team. In geriatrics the ability of the older persons to live with functioning is a goal of care. The two bullets are evidence-based programs that address interdisciplinary assessment and care management. This biopsychosocial model, in addition to the professional staff, must include the patient’s family. Family members are able to bring information and unknown material to the team. “Interacting Dimensions of Geriatric Assessment” Let us use Mrs. Sanchez as an example of a person from a culture that values family interactions (what culture doesn’t?). Knowing what you do about Mrs. Sanchez, what might her daughter tell a social worker assigned to the case about each of the “functional dimensions” of the geriatric assessment that Mrs. Sanchez would not tell?

23 . IMPACT=Improving Mood Program of Activated Collaborative Treatment ONE OF THE MODELS OF EVIDENCE BASED CARE. It addresses the important issue of depression in late life. These are the clinical symptoms of depression.

24 Read this slide.

25

26 psychiatrist -> adjust
IMPACT Intervention Team Flow Depression Care Specialist (PCP)=Nurse or Social Worker , Primary Care Doctor, Psychiatrist PCP Team Referral Initial visit with DCS Consult with PCP and team psychiatrist Step 1 treatment Consult with team psychiatrist -> adjust Treatment plan This treatment for depression involves the older person’s physician and a psychiatric nurse or social worker who follow-up's the Depression Care Specialist. There may also be a consultation with a psychiatrist. Frequently depression treatment is composed of only the prescription of medication which the older person may never take or take improperly. The Depression Care Specialist teaches about the symptoms of depression, develops patient action plans which include behavioral activation and scheduling pleasurable events as well as frequently measuring the level of depression.. Reevaluation Relapse prevention

27 Read the slide title.

28 Involvement of Family and Caregiver
IOM Recommendation: Involvement of Family and Caregiver AIM IDEAtel Family Health Options These are models to involve families and support their ability to care.

29 The Comprehensive Geriatric Assessment (CGA) is the hallmark of geriatrics. This is a schema of how social work and physicians can work together to assess and then link to community-based care. It involves the biopsycho social assessment which we mentioned earlier. It next assess the eligibility for payment of the community resources that the older persons needs. Next the older persons decisional capacity is assessed and thee identification of alternative decisional supports identified. Lastly referral and monitoring of community-based support services.

30 Primary Care in the Veterans Health Administration
Largest integrated health care system in the US Comprehensive electronic medical record >850 sites of Primary Care 152 Medical Centers >700 Community Based Outpatient Clinics (CBOC) 4.8 million primary care patients-each assigned to an individual primary care provider 53% in 12 million encounters/year in CBOCs A last evidence-based model that is currently being adopted by the Veterans Health Administration. READ THE MAIN BULLET POINTS BUT NOT THE SUB-POINTS.

31 Patient Centered Primary Care
Replaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship     The Primary Care Team Takes collective responsibility for patient care Responsible for providing all the patient’s health care needs Arranges for appropriate care with other specialties as needed  Enhanced Access Enhanced communication between Patients Providers Staff A last evidence-based model of interdisciplinary home is the “Patient Centered Medical Home” (PCMH) which is defined as g A last evidence-based model of interdisciplinary home is the “Patient Centered Medical Home” (PCMH) which is defined as "an approach to providing comprehensive primary care... that facilitates partnerships between individual patients, and their personal Providers, and when appropriate, the patient’s family"[1]. The provision of medical homes may allow better access to health care, increase satisfaction with care, and improve health.[2][3][4][5] Contents [hide] Team-based Care Patient-centered Care Continuous Improvement

32 Pillars of the Medical Home
Patient-Driven The primary care team is focused on the whole person Patient-preferences guide the care provided to the patient Team-Based Primary care is delivered by an interdisciplinary team led by a primary care provider using facilitative leadership skills Efficient Veterans receive the care they need at the time they need it from an interdisciplinary team functioning at the highest level of their competency Comprehensive Primary care serves as point of first contact for a broad range of medical, behavioral and psychosocial needs, fully integrated with other VA health services and community resources Continuous Every patient has an established and continuous relationship with a personal primary care provider Communication The communication between the Veteran patient and other team members is honest, respectful, reliable, and culturally sensitive Coordinated The PCMH team coordinates care for the patient across and between the health care system including the private sector THE MEDICAL HOME IS COMPRISED OF THE FOLLOWING: READ THE MAIN HEADINGS TO THE LEFT.

33 Patient-Centered Perspective
Personal Health Care Building Relationships Preferred means of communication Involving families and caregivers Continuity Clinical Management Provider/Team Information Shared Decision Making Preference centered health care choice made by the patient together with the provider Education Decision Support Tools Resources Patient Participation New patient orientation Personalized brochures Staff information Patient advisory board Focus groups Self Management Patients, not health care providers, are the primary managers of their health conditions Support Tools Home Telehealth, My HealtheVet, Other tools Provider skills Cultural competency Motivational interviewing You will see in this last evidence-based model many of the elements we have mentioned throughout the presentation: 1. patient or older person centered, 2. Patient activation as in the IMPACT model, 3. Involvement of family caregivers, 4. Interdisciplinary team care and 5. Competency based including cultural competence to attend to diversity. Social work can play a key role in these evidence-based model and they require a focus on skills as a member of a team. 33

34 34 34

35 THANK YOU FOR INVITING ME
感謝聆聽 JoAnn Damron-Rodriguez’s


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