Team Building An Interdisciplinary Approach Moderator Ruth Ann

Team Building: An Interdisciplinary Approach Moderator: Ruth Ann Tsukuda, Ed. D Panel: June Leland, MD; Barbara St. Hilaire, LCSW; Marla S. Mc. Laughlin, Ph. D ©AAHCM

Presenters Ruth Ann Tsukuda, Ed. D, MPH, RN Associate Director / Education VISN 20 Mental Illness, Research, Education, Clinical Center (MIRECC) VA Portland Health Care System June Leland, MD, MBA Medical Director Home Based Primary Care, Medical Foster Care and Home Based Transitional Care James A. Haley VA Health Care System Associate Professor, University of South Florida College of Medicine Barbara St. Hilaire, LCSW Program Director, Home Based Primary Care Asheville VA Medical Center Marla Shawaryn Mc. Laughlin Licensed Psychologist – Home Based Primary Care Philadelphia VA Medical Center ©AAHCM

Disclosures The presenters have no disclosures. ©AAHCM

Ruth Ann Tsukuda, Ed. D Why are we still talking about teams? ©AAHCM

Purpose The purpose of our panel is to discuss the challenges and opportunities facing providers who work in settings incorporating an interdisciplinary team approach. ©AAHCM

Why are we still talking about teams? • Geriatric care in the VA was one of the initial drivers promoting coordinated, comprehensive longitudinal care using an interdisciplinary team. • Delivery of complex health and medical care requires expertise from multiple disciplines. • Common goals and a well conceived care plan are essential to the provision of high quality care. • It is necessary to provide care to the "whole person" and to understand the context for care. • Shared decision-making among the team and the patient is essential for successful intervention. • Effective team work is an evolutionary process involving on-going feedback and refinement. ©AAHCM

Effective team work leads to: • Improved quality and continuity of care • Decreased hospitalizations • Preservation of function • Better use of medications • Staff satisfaction • Enhanced use of resources and financial benefits ©AAHCM

Essentials of Effective Teams • Common and Clear goals for patient and team • Clinical Competency-mature, confident, professional Core expertise • Common and shared knowledge • Case conferences and Combined case notes • Collaboration and Cooperation--understanding roles and relationships ©AAHCM

Essentials of Effective Teams (cont. ) • Communication--speaking, listening and documenting • Conflict management and resolution • Creativity and flexibility • Comprehensiveness--complete information • Individual Commitment and motivation for teamwork • Understanding the Context of care ©AAHCM

Blocks and Barriers Blockers: • Time, staff, money, resources Barriers: • Cultural norms - tradition of hierarchy • Lack of incentives • Inexperience • Competition • Team composition • Comfort with traditional ways of doing things • Organizational expectations ©AAHCM

Barbara St. Hilaire, LCSW Responsibility of the Program Director in Interdisciplinary Team ©AAHCM

Responsibility of the Program Director in Interdisciplinary Team Discussions Organizational aspects Expectations of staff Realities Role of the leader ©AAHCM

Organizational Considerations for Team Discussions • Be systematic so staff know the schedule for patient discussions • Ensure adequate time in schedule for thorough discussions • Provide a consistent structure for team meetings • Appropriate space: Sitting around a table? Projector to show care plan? • Teams benefit by participating in discussions about “Team Development. ” ©AAHCM

Establish Expectations of Staff • Come prepared: Know patients to be discussed • Thumbnail overview from each discipline to provide a context • Discuss actual goals and issues along with ideas for how to move forward • No rehashing of old/useless information • Respect each other: Safety for everyone to participate fully ©AAHCM

Realities of Team Discussions • Most members want to talk; find a way to make their contributions meaningful • Ebb & flow to all teams and meetings. Yours will never be permanently perfect • Be flexible. Robust (and longer) discussions may be needed for patients at times; at other times, discussions might be short. Do not set a “timer. ” ©AAHCM

Role of the Leader • Ensure consistency of approach, philosophy, and ethics across teams, care-sites • Encourage participation by all: pull out the quiet voices • Ensure interdisciplinary perspective; case should not be “owned” by one discipline ©AAHCM

The Case: Mr. Carson is a 62 year old Vietnam Era Veteran recently diagnosed with ALS. He married his second wife soon after his first wife’s suicide, but has been divorced for the past 3 years. He lives in a mobile home with his 27 year old daughter from his second marriage and her 18 month old son. She attends junior college in the evening and leaves the grandson with Mr. Carson. Several blocks away, he has a 30 year old son from his first marriage who was recently released from prison for a violent crime. He and the patient argue loudly and occasionally threaten each other. Mr. Carson completed high school and worked a variety of jobs before his disability, and values his independence above all else. A “self- made man, ” he considers himself spiritual but does not identify with any religion in particular. ©AAHCM

The Case: (cont. ) Mr. Carson's ALS has been rapidly progressing, affecting his balance, ability to walk, and his ability to feed and dress himself. He has an explosive personality, and is vocally angry about this diagnosis and claims that the diagnosis is wrong. He has recently been awarded 100% SC status for ALS. Most of the money has been spent on his daughter to purchase a new car and on his son, who is paying legal bills and having difficulty finding work. Mr. Carson enjoys the visits of the ARNP. He has been angry with the OT and refuses to use any recommended adaptive equipment. He is unwilling to engage further with the RD regarding his thoughts on a feeding tube, or with the RT regarding respiratory support. He has declined further visits from the SW or psychologist, stating he thinks they are "quacks. " ©AAHCM

The Case: (cont. ) During a team meeting several members report feeling threatened by the patient as well as his son who often visits unannounced. The ARNP reports that she never has any difficulties with the patient or the son and the rest of the team doesn’t understand what he is going through. She shares with the team that her mother had ALS, and as she did with her mother, she is assisting Mr. Carson to overcome his illness with prayer. ©AAHCM

June Leland MD, MBA Physician/Medical Director Role ©AAHCM

Medical Advances/Guidelines • http: //www. uspreventiveservicestaskforce. org • http: //www. choosingwisely. org • http: //www. americangeriatrics. org • http: //www. aahcm. org • http: //aahpm. org • http: //www. amda. com

Patient Level Realities Patient goals provide the context • Medical domain often takes a back seat to other domains • See patient as a person rather than a list of “medical problems” to be fixed. Multimorbidity Prognosis http: //eprognosis. ucsf. edu Cure vs. care

Facilitate/Interpret • MDs • Supervisors • Community providers and facilities • Interactions with consultants • Regulations

Promote Interdisciplinary Care • Integrate trainees • Five minutes of fame-discipline offers education • “Do no harm” and lateral violence • Burnout prevention • Ethical issues • Boundary issues

Medical Director • Address the location of the fulcrum on the balance between curative/palliative-where is it now? • “Do no harm” to the team (lateral violence) • Encourage and support team education (“ 5 minutes of fame”, journal club) • Assist with integrating trainees into the program • Team building-retreats, picnics, outings ©AAHCM

Medical Director (cont. ) • Focus attention on obtainable goals rather than “problems” • Monitor team member burnout and address prevention as a team (e. g. bereavement time to validate our losses) • Monitor boundary issues • Assist with prognostication to establish realistic goals in light of patient/family health care values ©AAHCM

Marla Shawaryn Mc. Laughlin, Ph. D How the Psychologist Can Help the Team ©AAHCM

How the Psychologist Can Help Interprofessional Team Members • To keep sight of the “whole person” • To rise above the judgment • To provide some helpful context for better understanding and tolerating the veteran and/or caregiver’s perspective • To listen to their struggles and validate what they are feeling ◦ Veteran and the caregiver ◦ Don’t take it personally ©AAHCM

How the Psychologist Can Help Interprofessional Team Members • (cont. ) To tap into their own strengths and strategies ◦ Help them provide good quality care without it taking too great a toll on them ◦ Be available and approachable to team members � One on one � As a group ◦ Offer behavioral health rounds � Gives space for expressing frustration, concerns, insights, and helps cohesiveness of team not feeling alone in their feelings � Develop a shared plan on how to best approach patient � Provide clarity, behavior options that consider complexity of situation including medical, behavioral, and family dynamics • To better understand what certain situations may be triggering in them ©AAHCM

How the Psychologist Can Help Interprofessional Team Members (cont. ) • To better understand what certain situations may be triggering in them • Give insights into patient/family issues • Role play or form “scripts” for challenging situations • Psychologist shares the burden of medically complex patients o Identifying that mental health issues can assist team in getting to core of the medical issues ©AAHCM

Summary Team approach is: • Patient centered • Efficient--right person providing the right care • Effective--evidence based, realistic, creative, flexible • Supportive and empowering ©AAHCM