Post on 15-Jan-2016
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UAB Geriatric Education Center
Geriatric Interdisciplinary Team Training and Settings of Care
Kendra D. Sheppard, MD, MSPH, CMDUniversity of Alabama at Birmingham
July 25, 2013
Session Learning Objectives
Discuss the function of interdisciplinary teams and share evaluation tools related to team function.
Participate in a geriatric interdisciplinary team meeting to develop an optimal plan of care.
Provide examples from an established interdisciplinary team curriculum for integration into their respective curricula.
Describe distinguishing features of various settings of care for older adults.
Participate in a group exercise highlighting the differences in settings of care.
Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51
Is there a call for teams?
Crossing the Quality Chasm: A New Health System for the 21st Century– Health care teams play a central role
Chronic Care Model utilizes teams Physicians and dentists alone no
longer able to cope with the complexity of practice
Cost containment imperative– Increased use of non-physician/dental
providers Demand for quality requires providers
with skills physicians and dentists don’t posses
Attitudes
Medicine trainees value teams less than trainees from other disciplines
Physicians’ attitudes about sharing their role on the teams appear to be an important barrier to embracing geriatric teams (Leipzig et all, 2002)
Disciplinary focus of clinical education is a major barrier to implementing geriatric team training (Reuben et al, 2004)
How GITT Was Born
John A. Hartford Foundation Funded Program 1997– 8 programs to develop Geriatric
Interdisciplinary Team Training (GITT) Programs
Why?– Successful chronic care management
requires coordination across settings and disciplines
– Value of teams demonstrated– Inter-professional collaboration requires a
distinct skill set– Training programs to teach these skills are
rare
GITT Curriculum
Didactic curriculum Clinical Experience Use of geriatric case studies
– Teach trainees about the knowledge and skills of other disciplines
GITT Learning Objectives
To improve trainees’ attitudes toward geriatrics and teams
To assess trainees’ self perceptions regarding their team skills
To increase trainees’ interest in teams and geriatrics
To improve trainees’ knowledge of interdisciplinary geriatric planning
To improve trainees’ knowledge of team dynamics
Table 2 GITT Trainee Objectives, Source of Data, and Measures
Objective Source Measure
To improve trainees’ attitudes toward geriatrics and teams
To assess trainees’ self perceptions regarding their team skills
To increase trainees’ interest
in teams and geriatrics
To improve trainees’
knowledge of interdisciplinary geriatric planning
To improve trainees’ knowledge of team dynamics
Questionnaire
Questionnaire
Questions about future interest in geriatrics and teams
Case study test of interdisciplinary geriatric care planning
Videotape test of simulated team meeting
Attitudes toward health care teams (total scale score) and subscales: Attitudes Toward Team Value, Attitudes Toward Team Efficiency, and Attitudes To-ward Physician’s Shared Role (Heinemann, Schmitt, & Farrell, 1999)
Team Skills Scale (Fulmer & Hyer, 1998; Hyer, Heinemann, & Fulmer, 2002)
Trainee’s plan for future practice in teams and geriatrics
Questions asking trainee to identify the dominant issue from a case history, the three basic problems, the factors that complicate the plan of care, the strengths of the patient, and who should be involved in developing the plan of care and what contributions that person should make
Trainee asked to rate the portrayed team’s effectiveness,
list ineffective team behaviors, list effective team behaviors, list methods to cope with ineffective team behavior, and rate and justify the overall potential of the team to develop an effective care plan
Note. GITT = Geriatric Interdisciplinary Team Training.
http://www.americangeriatrics.org/education/gitt/gitt.shtml
GITT Curriculum Guide
Team and Team Work Team Member Roles and
Responsibilities Team Communication and Conflict
Resolution Care Planning Process Multiculturalism Ethics and Teams
GITT Impact
Trainees had positive attitudinal change, no change on the geriatric care planning measure, and a change in some of the question on the test of team dynamics
GITT Impact
Significant changes in:– ATHCT Scale– TSS
Most substantial change here, indicating GITT training has an impact on trainees’ perceived ability to perform key team skills such as creating an interdisciplinary care plan, carrying out your discipline’s role on a team, and communicating succinctly
Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51; Wise et al, Making Health Teams Work, Ballinger Pub, 1974
What makes a group of individuals a team?
“A team is a group with specific task(s) that require the interdependent collaborative efforts of its members”
What characteristics do winning teams
have? Clear leadership Definite aim Common enemy Trust each other Communication Heterogeneity of members Established rules Plan to deal with
barriers/change
Mutual respect Flexibility/
adaptability Self-selected Understanding of
roles Optimal team size Able to cooperate Measure
performance Self/team reflection
GITT Curriculum: Teams and Teamwork
Types of Teams
Unidisciplinary: – Group of people all from the same
discipline working together Multidisciplinary:
– Group of people from different disciplines who develop a treatment plan independently
Interdisciplinary: – Group of people from different disciplines
assess and plan care in a collaborative manner
Introducing Teams into a Health Care Setting
Assess the current working group’s:– Goals and measurable outcomes
Clinical Business Work environment
– Clinical and administrative systems– Division of labor– Staff Training– Communication processes
Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51
Process Outcomes from Primary Care
Teams Staff trained in team function Effective/Efficient Systems and
Processes– Triage process that does not require
clinician– Utilize diagnostic software– Utilize IT/Electronic health records– Lab/radiology review process– Making referrals– Renewing prescriptions
Routine evaluation of team functioning
Stevenson et al, Fam Pract, 2001; Campbell et al, BMJ, 2001; Goni et al, Health Policy, 1999; Williams et al, Med Care, 1999
Clinical/Quality Outcomes from
Primary Care Teams Improved diabetes control Improved hyperlipidemia control Improved patient-perceived
quality Improved patient satisfaction Improved provider satisfaction
Outcomes from Acute Care Setting Teams
Improve functional performance Reduced delirium Reduce mortality Reduce nursing home admissions Reduce use of restraints Reduce use of inappropriate
medications Reduce health care costs Improved patient and provider
satisfaction
Shortell et al, Med Care 1994;32(5):508-25
Outcomes from ICU Teams
Better technical quality of care
Reduced length of ICU stay
Improved provider-family relationships
Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51
Challenges for Teams
Add organizational complexity to a care setting
Increased team size = increased communication requirements– How big is too big?– Patients may prefer interacting with one
provider Difficult team members
– Dominators, blockers, evaders, recognition seekers
Varied nature of clinical problems/patients– Easier if just a Heart Failure clinic
Economic disincentives
GITT Curriculum: Teams and Teamwork
Interdisciplinary Team Development Phases
Forming: creation stage for the group
Storming: tasks and roles are worked out
Norming: norms and patterns are worked out
Confronting: conflictual stage Performing: team working
together for the care of the patient
GITT Curriculum: Teams and Teamwork
Aspects Affecting Team Development
Personal/Professional: – Commitment to team concept– Willingness to engage in teamwork – Commitment to learn the values and
knowledge bases of other professionals
– Interdisciplinary protocols for patient care developed and used by team
GITT Curriculum: Teams and Teamwork
Aspects Affecting Team Development
Intra-Team:– Environment and technology used to
maximize communication– All members view themselves and
are recognized by others as leaders– Team goals and members’ roles are
negotiated and reviewed periodically by the team
– Conflict viewed as healthy
GITT Curriculum: Teams and Teamwork
Aspects Affecting Team Development
Organizational:– Organization’s philosophy consistent
with team’s philosophy on patient care
– Ongoing resource support from local organization
– External organization(s) recognize and are willing to work on common problems
GITT Curriculum: Teams and Teamwork
Aspects Affecting Team Development
Team Maintenance:– Team regularly evaluates and
improves itself (outcomes and processes)
– Members teach team leadership skills and empowers new members
– Team members welcome a questioning environment
– Feedback is open and direct
GITT Curriculum: Teams and Teamwork
Characteristics of Effective Teams
Purpose, goals, and objectives of the team are known and agreed upon
Staff are trained in team functioning Roles and responsibilities are clear
– “Non-traditional” roles for staff Communication is open, sharing, and
honest Leadership shifts depending on the
circumstances Team minimize struggles for power
and focus on how best to get the job done
GITT Curriculum: Teams and Teamwork
Effective Team Meetings Require
Structure Agenda: what is to be
accomplished Time management Establishment of roles at
meeting:– Facilitator– Timekeeper– Recorder
Summary of agreements
GITT Curriculum: Team Communication and Conflict Resolution
Effective Team Communication
Well-designed system for communication– Between team members– With the external system within which the
team operates
Cultural competency is required for team members to effectively communicate with each other, patients, and families
GITT Curriculum: Team Communication and Conflict Resolution
Barriers to Effective Teamwork
Lack of a clearly stated, shared and measurable purpose
Lack of training in interdisciplinary collaboration
Role and leadership ambiguity Team too large or too small Team not composed of appropriate
professionals Lack of appropriate mechanisms for
timely exchange of information
GITT Curriculum: Team Communication and Conflict Resolution
Team Conflict
Natural and Unavoidable
Requires individual professionals to relinquish familiar hierarchies and freedoms
GITT Curriculum: Team Communication and Conflict Resolution
Types of Conflicts Experienced by Teams
Intra-personal: member having conflicting feelings about a personal course of action with a patient or colleague
Inter-personal: recurring differences between team members
Intra-group: subgroups within a team are in conflict
Inter-group: organizational pressures produce conflicts between programs or teams
GITT Curriculum: Team Communication and Conflict Resolution
Common Approaches for Conflict Resolution
Clarify the nature of the problem as seen by both parties– What is the real problem?
Deal with one problem at a time– Start with easier issues
Listen with understanding/interest and not evaluation
Separate the person from the problem– Attack data, facts, assumptions,
conclusions, but not individuals
GITT Curriculum: Team Communication and Conflict Resolution
Common Approaches for Conflict Resolution
Identify areas of agreement– Focus on common interests
Brainstorm about possible solutions
Invent new solutions where both parties gain
GITT Curriculum: Care Planning Process
Interdisciplinary Care Planning
Developing a care plan requires assessing patients needs– Medical, functional, emotional, spiritual,
cognitive, environmental, economic, etc– Identify impact of problem on patients health
and quality of life
Achieve consensus on desired patient outcome(s)– Cure at all cost?– Focus on comfort and less aggressive
interventions?– Varied goals can keep a team in conflict
GITT Curriculum: Care Planning Process
Interdisciplinary Care Planning
Patient/caregiver goals must be central to care planning
Identify community/family resources available or needed
Identify activities to be done and which team member is responsible– What priority should be assigned to
each problem
GITT Curriculum: Care Planning Process
Interdisciplinary Care Planning
Must have a system for documenting the care plan and delineating individual responsibilities
Identify outcomes/triggers to notify team when plan is not working
System of communication (formal and informal) and continuing next steps between meetings
1. Heinemann et al, Eval Health Prof 1999;22:123-42; 2. Long, D.M., & Wilson, N.L. (Eds.). (2001). Houston GITT curriculum. Houston, TX: Baylor; 3. Bendaly, L. New York: The McGraw-Hill Companies, 1996
Evaluation Tools for Teams and Members
Attitudes Toward Health Care Teams Scale1 – Attitudes Toward Team Value– Attitudes Toward Team Efficiency– Attitudes Toward Physicians Shared
Role Team Observation Tool2 Team Fitness Test3
Settings of Care for Older Adults
Independent Living
Location– Home– Apartment– Senior Apartment Buildings
Health care services can be delivered by Home Health
Senior Apartment Facilities may provide coordinated activities and meals, but generally do not provide nursing or physician services
http://www.eldercare.gov/Eldercare/Public/resources/fact_sheets/assisted_living.asp
Assisted Living Facilities (ALFs)
No uniform definition of what “assisted living” entails
Established as an alternative to nursing home placement
~ 33,000 ALFs in US house ~ 1 million older adults
www.eldercare.gov
Assisted Living Facilities (ALFs)
Vary in size, staffing, and cost
Services provided typically include:– Room and board– Housekeeping and laundry– Assistance with basic activities of daily living
Other services provided may include:– Medication reminders– Physical and occupational therapy on site– Some nursing services– Recreation areas and group activities
www.eldercare.gov
Assisted Living Facilities (ALFs)
Eligibility criteria for ALFs vary state to state
Medicare does not pay for Assisted Living– Costs may be $800 to over
$4000/month, depending on the city/state
Average cost in US is $1800/month– Often not affordable for low- or
moderate-income senior adultsLink: www.eldercare.gov/Eldercare/Public/resources/fact_sheets/assisted_living.asp
Specialty Care ALFs (SCALFs)
Specially designed to care for residents with cognitive impairment
3 categories of SCALFs– Family SCALF – authorized to care
for 2-3 adults– Group SCALF – authorized to care for
4-16 adults– Congregate SCALF – authorized to
care for 17 or more adults
Skilled Nursing Facilities (SNFs)
Provide a level of care between hospitalization and a lower level of care such as home or an ALF
May be associated with a hospital, nursing home, or be a freestanding facility
Skilled Nursing Facilities Patients eligible if they require daily skilled
nursing or rehabilitative services– IV medications, enteral tube feedings,
wound care/dressing changes, PT or OT
Medicare Part A covers up to 100 days of SNF services following a hospitalization 3 days– 100% coverage for first 20 days– 80% coverage for last 80 days
Most Medicare supplements and Medicaid cover this co-payment
Nursing Home Over 17,000 nursing homes in
US housing ~ 2 million adults Minimum Data Set (MDS)
completed within 14 days of admission
Required frequency of physician assessments vary between facilities
A licensed nurse assess each resident daily
Medicare does not cover long-term care
Medicaid covers long-term care once patient has “spent down” life savings
Photographs of Cedars Health Center's Green House Homes, Tupelo, MS, used with permission
Green House Model of Long-Term Care
Photographs of Cedars Health Center's Green House Homes, Tupelo, MS, used with permission.
Green House Model of Long-Term Care
Link: www.ncbcapitalimpact.org/thegreenhouse
Ness et al, Journal of Gerontology: A Biol Sci Med Sci 2004;59A:1213-17.
Rates of nursing home residence per 1000 persons aged 65 years
and over
0
50
100
150
200
250
1977 1985 1995 1997 1999
65-74years
75-84years
85 yearsand older
Where are older adults living?
Coordinated Care Models
Primary Care - Module I– Guided Care Model– GRACE– PACE Programs
Acute Care - Module I– Acute Care for Elders (ACE) Units– Care Transitions Intervention
Advanced Illness and/or Multimorbidity - Module II– Specialty ACE Units– Palliative Care and Palliative Care Units– Hospice
The Price is Right