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Unit 8: Models of Care and Interdisciplinary Care Related to Complex Careof Older Adults : 

Unit 8: Models of Care and Interdisciplinary Care Related to Complex Careof Older Adults Authors: Sharon Stahl Wexler, Ph.D., candidate APRNGenie Siegler, MD The Geriatric Nursing Education Consortium (GNEC) is a national initiative of the American Association of Colleges of Nursing (AACN) to enhance geriatric content in senior level undergraduate nursing courses. The project is generously funded by the John A. Hartford Foundation

Interdisciplinary Teams : 

Interdisciplinary Teams Teams are often used to manage the care for older adults due to their complex healthcare needs Added value of teams relates to the assessment and management of older adults with complex illness who concurrently experience multiple geriatric syndromes such as delirium, falls, urinary incontinence and polypharmacy

Interdisciplinary Teams : 

Interdisciplinary Teams Interdisciplinary teams are defined as individuals from at least two different disciplines who coordinate their expertise to deliver care to patients Additionally interdisciplinary teams work together as an identified unit or system Where they function as a unit, team members communicate with one another regularly about the care of the patient (group of patients) as well as take on other participatory roles In effective teams, members pool their expertise so that patients receive better care By working together, the work can be done more effectively and efficiently

Interdisciplinary Teams : 

Interdisciplinary Teams The term “interdisciplinary” implies interaction or collaboration on some level while multidisciplinary implies many disciplines involved in the care of the patient, but not necessarily interacting with one another Interprofessional is somewhat limited in scope Team may consist of health care personnel other than healthcare professionals nursing assistants community support personnel Consensus is lacking as to which disciplines are considered professional as well as which category of personnel fall into the category of professionals

Interdisciplinary Teams : 

Interdisciplinary Teams Not all patients and patient care situations require teams An effective team can quickly assess a situation, decide what professionals need to be involved and work closely together to reach an effective solution, many times, assigning a team to a project is not the best choice or utilization of healthcare resources Some tasks are completed more efficiently if assigned to one person who has the knowledge, time, and experience to do the task independently

Interdisciplinary Teams : 

Interdisciplinary Teams Teams do not just happen; they evolve, a work in progress, so to speak. Putting people together in a room and calling them a “team” does not necessarily constitute a healthcare team or result in effective teamwork Administrators and other health care leaders may believe in the concept of team, but fail to offer substantial support to the team in terms of recognition of their work or release time As an evolving unit, teams pass through specific predictable phases as they form and begin their work Teams can move back and forth between the different phases, as can the members

Interdisciplinary Teams : 

Interdisciplinary Teams Five different phases of team formation Forming - identifies team goals, roles, and team members personal professional attributes Norming - phase where the team develops it goals and sense of purpose Confronting - is the phase where conflict that might have initially been suppressed surface. Performing - Performing is when the team is effective, efficient and creative. Leaving - Leaving is the last phase, when the team disbands, or individuals leave the team Unfortunately, in many settings, Phase 1 does not occur. Rather, individuals are placed together in a team and expected to begin work immediately. This is the team at its best.

Aspects of Team Effectiveness : 

Aspects of Team Effectiveness Effective communication is essential for both team members and the team leader Joint Commission of Accreditation of Healthcare organizations (JCAHO) cites effective communication as the most important aspect in reducing medical errors Learning how to give feedback and share opinions is essential to a successful team process Thinking out of the box Seeking clarification Active listening Important team communication techniques

Interdisciplinary Teams : 

Interdisciplinary Teams Although the empiric evidence-based research about specific contribution of a team to particular clinical situations faced by older adults is growing, care of the older adult with complex needs is predicated upon interdisciplinary collaboration Studies as to team effectiveness are difficult to conduct due to the many variables, including patient complexity, inconsistent terminology used to describe teams and the confounding data when the team in part of a larger intervention Teams are beneficial in the care of older adults with complex and multiple co-morbidities, and older patients with geriatric syndromes, and in reducing health care costs

Interdisciplinary Teams : 

Interdisciplinary Teams Approach convening of the team as you would any other beginning with the issues at hand and then determining who should be on the team Developing a problem list is often helpful First, identify the basic issues to be addressed Woman who is physically and socially isolated Who may be depressed Next, identify the key players or constituents of the team Considering how the team members will work together

Interdisciplinary Teams : 

Interdisciplinary Teams The third question entails the logistics of running a team Where and how often meetings should be held Other roles in a team, such as timekeeper and recorder Whom the team leader reports to How team recommendations can be implemented and evaluated When a team should disband

Slide 12: 

Geriatric Care Models:Acute Care for the Elderly (ACE)

Slide 13: 

Geriatric Care Models:Acute Care for the Elderly (ACE)

Slide 14: 

Geriatric Care Models:Geriatric Resource Nurse (GRN)

Slide 15: 

Geriatric Care Models:Syndrome Specific Model

Slide 16: 

Geriatric Care Models:Comprehensive Discharge Planning

Slide 17: 

Geriatric Care Models:Geriatric Consultation Teams

Slide 18: 

Geriatric Care Models: Geriatric Evaluation and Management Units (GEM)

Slide 19: 

Geriatric Care Models:PACE Model

Slide 20: 

Geriatric Care Models:Nursing Home Model