The care of older adults in PALTC settings is complicated and requires us to address the co-occurring physical, behavioral, social, and functional challenges of our patients. Twenty years ago, the Institute of Medicine recommended that team-based care was needed to minimize the fragmentation of health care delivery and to improve the quality of patient care (Crossing the Quality Chiasm: A New Health System for the 21st Century, 2001). Additionally, since the 1990s, federal regulations for nursing homes require an interdisciplinary approach in the development and implementation of the care planning process. Despite these recommendations and mandates, there is still room to grow and improve when it comes to team-based care in PALTC. It is easy to say that we provide team-based care, but what do we really mean? I asked members of the editorial advisory board of Caring for the Ages and a past president of AMDA – The Society for Post-Acute and Long-Term Care Medicine to share some of their best experiences with team-based care so that we could reflect on what it truly means to be interdisciplinary.
Multidisciplinary versus Interdisciplinary Teams
Some of us use the terms multidisciplinary and interdisciplinary interchangeably; however, they are quite different. A multidisciplinary team consists of members from different disciplines who draw from their individual disciplinary knowledge in a separate, but parallel fashion to meet patient needs. Multidisciplinary teams may have the advantage of efficiency but tend to lack communication and problem solving and may result in redundancies of patient assessment and care. Alternatively, an interdisciplinary team includes members of different disciplines and the patient and family working in a collaborative fashion toward a common goal. The patient’s needs are at the forefront. Interdisciplinary teams support shared leadership and decision making. To be highly effective, interdisciplinary teams require trust, communication, collaboration, consensus building and mutual respect of different disciplines. There is evidence that interdisciplinary teams are more effective than multidisciplinary teams and produce better patient outcomes (JAMDA, 2013; 14, 471-478).
Interdisciplinary teams require a lot of hard work, and there are several barriers to overcome for the team to be highly effective. For many of us, the time spent in team meetings is not reimbursable and carving out time in the schedules of multiple team members remains a persistent obstacle (The Consultant Pharmacist, 2014; 29, 149-153). The COVID-19 pandemic has resulted in greater use of technology to improve communication among team members and should continue to be utilized when traditional face-to-face team meetings may not be feasible.
Additionally, there are interpersonal and professional barriers to team-based care. Some of us have not had adequate opportunities to learn with and from different members of the health care team (JAGS, 2014; 62, 961-965). The lack of interdisciplinary experiences in our education helps to reinforce discipline-specific siloes. We make assumptions about other disciplines based on lack of exposure, incomplete information or previous unsatisfactory working relationships. Interdisciplinary team education in geriatrics has gained some increased popularity in recent years; however, schools and programs still focus on time-limited interdisciplinary days rather than integration of interdisciplinary care into curricula and clinical experiences.
Communication and Shared Decision-Making
Team processes such as communication, shared decision-making, consensus-building, and the ability to resolve conflict are critical in improving team cohesiveness (Medical Care, 2004; 42, 472-481). Travis Neal, PA-C, a member of Caring’s editorial advisory board, described an interdisciplinary team that focused on psychotropic medication use and included nurses, social services professionals, pharmacists, physicians, and advanced practice providers. Strategies such as open communication and shared decision-making helped to support the interdisciplinary work of this team. According to Mr. Neal, “what makes this meeting so good is the tone, which is an open forum to challenge each other and seek each other’s opinions. They all felt like they had a voice at the meeting…. One of the key features of creating real collaboration is trying to remain flexible. Recognizing that I have my clinical preferences and biases, I try to be flexible enough to change my mind in front of everyone or openly admit when something I recommended prior is not working.”
Paige Hector, LMSW, associate editor for Caring for the Ages, described her patterns of open communication with a daily stand-up meeting that focused on clinical operations. “We had robust discussions on a wide variety of topics including pre-admission screening, medical changes of condition, psychosocial needs, discharge planning goals and barriers, and general coordination of clinical and operational tasks. While residents and families did not attend this meeting, members of the interdisciplinary team connected with them to provide information, follow-up with issues and report back to the team.”
Staying Focused on the Patient
Interdisciplinary teams function well when all members strive to maintain a patient-centered perspective. Keeping the focus on the patient allows team members to discuss and decide who might be the best team member to implement needed interventions (The Consultant Pharmacist, 2014; 29, 149-153). Phyllis Famularo, DCN, RD, dietician and member of Caring’s editorial advisory board, shared that the best interdisciplinary teams that she had worked with “always had the resident’s best interests at heart” and utilized expertise and knowledge of different team members to help solve challenging problems that could not be solved by one discipline. Ms. Famularo described partnering with a recreational therapist to help address nutrition concerns. The recreational therapist knew “the resident’s behaviors and food preferences from multiple activity events.”
Cari Levy, MD, PhD, CMD, Society past president, describes the collaborative nature of interdisciplinary team in fulfilling a patient and family wishes at the end of life. “The nurse practitioner saw the patient and learned that his family members all lived out of state where he spent most of his life. His daughter very much wanted to care for him during this precious time. Commercial air was not an option given his functional status and medical conditions. The social worker obtained a charter flight and our interdisciplinary team developed a medication plan to maintain his comfort during the flight and he arrived in the morning to be with his family.”
In the world of PALTC, where the complexities of delivering high quality interdisciplinary care are many, I try to remain humble about my individual contributions. I remind myself of Mother Teresa’s wise words, “None of us, including me, ever do great things. But we can all do small things, with great love, and together we can do something wonderful.”
Dr. Galik is editor in chief of Caring for the Ages. The views the editor express are her own and not necessarily those of the Society or any other entity. Dr. Galik is a nurse practitioner in LTC- and community-based settings through a clinical practice with Sheppard Pratt Health System. She is a professor at the University of Maryland School of Nursing, where she teaches in the Adult-Gerontology Primary Care Nurse Practitioner Program and conducts research to improve care practices for older adults with dementia and their caregivers in long-term care.