UAB Geriatric Education Center

1. UAB Geriatric Education Center Geriatric Interdisciplinary Team Training and Settings of Care Kendra D. Sheppard, MD, MSPH, CMD University of Alabama at Birmingham July 25, 2013

2. 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.

3. 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 Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51

4. 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)

5. 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

6. GITT Curriculum • Didactic curriculum • Clinical Experience • Use of geriatric case studies • Teach trainees about the knowledge and skills of other disciplines

7. 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

9. GITT Curriculum Guide • Team and Team Work • Team Member Roles and Responsibilities • Team Communication and Conflict Resolution • Care Planning Process • Multiculturalism • Ethics and Teams http://www.americangeriatrics.org/education/gitt/gitt.shtml

10. 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

11. 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

12. 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” Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51; Wise et al, Making Health Teams Work, Ballinger Pub, 1974

13. 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

14. 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 GITT Curriculum: Teams and Teamwork

15. 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

16. 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 Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51

17. Clinical/Quality Outcomes from Primary Care Teams • Improved diabetes control • Improved hyperlipidemia control • Improved patient-perceived quality • Improved patient satisfaction • Improved provider satisfaction Stevenson et al, Fam Pract, 2001; Campbell et al, BMJ, 2001; Goni et al, Health Policy, 1999; Williams et al, Med Care, 1999

18. 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

19. Outcomes from ICU Teams • Better technical quality of care • Reduced length of ICU stay • Improved provider-family relationships Shortell et al, Med Care 1994;32(5):508-25

20. 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 Grumbach K, Bodenheimer T. JAMA 2004;291:1246-51

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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: Teams and Teamwork

28. 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

29. 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

30. Team Conflict • Natural and Unavoidable • Requires individual professionals to relinquish familiar hierarchies and freedoms GITT Curriculum: Team Communication and Conflict Resolution

31. 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

32. 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

33. 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: Team Communication and Conflict Resolution

34. 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

35. 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

36. 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 GITT Curriculum: Care Planning Process

37. 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 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

39. Settings of Care for Older Adults

40. 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

41. 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 http://www.eldercare.gov/Eldercare/Public/resources/fact_sheets/assisted_living.asp

42. 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

43. 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 adults www.eldercare.gov Link: www.eldercare.gov/Eldercare/Public/resources/fact_sheets/assisted_living.asp

44. 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

45. 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

46. 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

47. 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

48. Green House Model of Long-Term Care Photographs of Cedars Health Center's Green House Homes, Tupelo, MS, used with permission

49. Green House Model of Long-Term Care Photographs of Cedars Health Center's Green House Homes, Tupelo, MS, used with permission. Link: www.ncbcapitalimpact.org/thegreenhouse

50. Rates of nursing home residence per 1000 persons aged 65 years and over Ness et al, Journal of Gerontology: A Biol Sci Med Sci 2004;59A:1213-17.