Team Form & Functions: From Multi-Disciplinary to Interprofessional Collaborative Geriatric Teams- Assessment & Educational Models Marla Berg-Weger Professor, School of Social Work Executive Director, Geriatric Education Center Saint Louis University bergwm@slu.edu 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 dffaria@brockport.edu 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

Objectives Define types of teams Multidisciplinary Interdisciplinary Interprofessional Transprofessional Understand the roles of interprofessional team members Describe the value of interprofessional geriatric assessment Introduce model of using interprofessional education in clinical settings and courses to prepare the next generation of interprofessional team members 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. NYS Office of Mental Health, Assertive Community Treatment http://bi.omh.ny.gov/act/index www.socialworkleadership.org

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

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.

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

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 Taken by ambulance to the hospital 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

Mrs. C. - Discharge Planning Fearful of falling, hard time using walker Discharged to a skilled nursing facility for rehabilitation

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

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

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

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

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 )

What challenges do older adults experience as they age? Disability (loss of function) Comorbidity (chronic medical conditions) Frailty (vulnerability) Multiple Losses (compounding effect)

Why is assessment important? Goal: decrease disability and dependence Identify “pre-clinical” disability Majority older adults live independently 50% Lifetime Risk of nursing home placement

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

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 Debra * ACUU Conference 2010

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 Neuropsychologists Nurses Pharmacists

Addressing Complexities Through an Interprofessional Approach Medicine Association 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. Nursing John A. Hartford Foundation Institute for Geriatric Nursing,2002 Social Work Geriatric 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 IADLs http://www.pcssprimarycare.org/nsw/competencies/competencies.php# Interface of Geriatric Competencies Functional Assessment 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

Interface of Competencies http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf Interface of Competencies Medication Management Medicine Association 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. Pharmacist Medication Management Therapy in Pharmacy Practice, (2008). http://www.pharmacist.com/sites/default/files/files/core_elements_of_an_mtm_practice.pdf Nursing Geriatric 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.

Components of Geriatric Assessment Cognitive Social Economic Family Dynamics Medical Functional Psychological

Dimensions of Geriatric Assessment: Medical Assessment Geriatric Syndromes: Vision & Hearing Incontinence Falls/Mobility Memory/Mood Nutrition Pain Past Medical and Surgical Histories Family History Physical Exam Review Medications: Polypharmacy “Bad Drugs” Tom * ACUU Conference 2010

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

Functional Assessment: Activities of Daily Living (ADL) Geriatric Assessment Functional Assessment: Activities of Daily Living (ADL) Dressing Eating Bathing/Hygiene (personal care) Toileting (+/- continence) Mobility Ambulating Transferring ACUU Conference 2010

Instrumental Activities of Daily Living (IADLs) Shopping Housekeeping (cleaning, laundry) Finances Cooking Using telephone Medications Transportation (driving, buses, etc.)

Psycho-Social * Social History Geriatric Assessment 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 Debra * ACUU Conference 2010

Assessment Cognitive Function Dementia Mild Cognitive Impairment Normal Aging Alzheimer’s Disease

DEMENTIA Cognition Behavior Function

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

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

Establishing Goals with Older Adults Geriatric Assessment 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”) Tom * ACUU Conference 2010

Function Time Family & Caregiver Stress Nursing Home Functional Decline: Illness Good Health Functional Impairment Hospitalizations Family & Caregiver Stress Function Rehab Threshold Nursing Home Disability Time

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 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. www.socialworkleadership.org

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 www.socialworkleadership.org

Educational Models to 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 Consortium http://www.aacn.nche.edu/education-resources/ipecreport.pdf

Partnership for Health in Aging (PHA) 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/docu ments/health_care_pros/PHA_Multidisc_Co mpetencies.pdf www.socialworkleadership.org

Health Promotion and Safety Evaluation and Assessment Competencies in the Care of Older Adults at the Completion of the Entry-level Health Profession Domains: Health Promotion and Safety Evaluation and Assessment Care Planning and Coordination Across the Care Spectrum Interdisciplinary and Team Care Caregiver Support Healthcare Systems and Benefits Source: Partnership for Health in Aging Workgroup on Multidisciplinary Competencies in Geriatrics http://www.americangeriatrics.org/files/documents/health_care_pros/PHA_Multidisc_Competencies.pdf

Endorsements Competencies 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 www.socialworkleadership.org

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 www.socialworkleadership.org

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 www.socialworkleadership.org

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 www.socialworkleadership.org

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 www.socialworkleadership.org

Resources: Interprofessional Teams, Assessment & Instruction Tools 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; brandt@umn.edu; 612/625-3972 www.socialworkleadership.org

Resources: Interprofessional Teams, Assessment & Instruction Tools 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/ www.socialworkleadership.org