UAB Geriatric Education Center

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


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


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


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


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



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



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



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


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


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


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


Team Conflict

Natural and Unavoidable

Requires individual professionals to relinquish familiar hierarchies and freedoms


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


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


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



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



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


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


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

UAB Geriatric Education Center

Documents

Transcript of UAB Geriatric Education Center