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ICMEInterprofessional Case Management Experience
The Joe and Thelma Hedgepath CaseLearners, go to this site and
make sure you are registered for ICME and have taken the
pretest.
https://medapp.louisville.edu/iCCOA/iccoa.cgi
This project is supported by the Health Resources and Services
Administration (HRSA) of the U.S. Department of Health and Human
Services (HHS) under grant
number 1 U1QHP28732-01-00, Geriatric Workforce Enhancement
Program.
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ACollaborationofMany
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TeamIntroductions
InyourteamsintroduceyourselfbyNAME&DISCIPLINEandanswerthefollowingquestions:
•Whatdoyouwanteveryonetoknowaboutyourdiscipline?•Whatstereotypedoyouhatethemostaboutyourdiscipline?
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InterprofessionalCaseManagementExperience
ICME
Inthissessionyouwilllearnaboutintegratedpatient-centeredgeriatriccommunitycare,conductagoalsofcare/familymeetingand“practice”workingwithaninterprofessionalteamtoplanthecareofacouplecopingwith
seriousillnessandmultiplesocialissues.
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ActivitiesforToday• Youwill:– Participate
inteamdiscussionsandactivitiesrepresentingyourdisciplineasateammemberinvolvedinthecareofthecouple,Mr.andMrs.Hedgepath.
– Observe
videotapedinteractionsbetweenmembersofMr.andMrs.Hedgepath'shealthcareteam
– Critiqueanddiscusstheseinteractions.– Participate
inafamilymeeting.
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“Ground Rules”
•Turn electronic devices OFF—this is a time for personal
interaction
•Participate in all discussions
•Respect one another—allow others to speak, do not interrupt
•Keep confidentiality related to team discussions
•Ask for clarification if you do not understand
•Have FUN!!
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WorldHealthOrganizationDefinitionsofHealth
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Health=“astateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity”
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Socialdeterminantsofhealth=theconditionsinwhichpeopleareborn,grow,live,work,andage
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WhatDeterminesHealth/Well-Being?
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SocialandEconomicFactors
• Caregiving• Supportsystem• Independence• Housing• Income•
Insurancecoverage• Previouslosses• Copingstyle•
Overallqualityoflife
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HealthBehaviors• Diet• Medicationadherence
• Substanceabuse• Exercise• Sleephabits•
Smoking&smokinghistory
• Homesafety
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HealthOutcomeDeterminants
Booske,BC, Athens,JK, Kindig,DA, Park,H, & Remington,PL.
(2010). Different perspectives for assigning weights to
determinants of health. University of Wisconsin Population Health
Institute.
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HowShouldSocialDeterminantsofHealthInformCareoftheOlderAdult?
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Ifweaddressonlythephysiologicalchangesandtreatmentofthedisease,wearemissing88%ofthefactorsimpactingpatientoutcomes
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Holisticpatient/family-centeredcareisessentialifwearetoobtaindesirableoutcomes
• Ittakesateam!
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MembersoftheCommunityTeam• PatientandCaregiver,FamilyMembers•
ClinicalCareTeam- PhysicianorNursePractitioner,RN,Clinical
SocialWorker• CommunityHealthNavigator• CommunityOrganizer•
CareManagers• PeerMentor• DentalHealthProfessionals• Attorneys•
Pharmacists•
Otherprofessionalsdependingonthepatient’splanofcare
(homehealth,PT,OT,specialistMDs,etc.)
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AnExampleoftheModel
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MultidisciplinaryTeam• Strong,focusedleadership
• Individualaccountability
• Individualizedworkproducts
• Efficientmeetings• Success=influenceonothers
Adapted from: the Discipline of Teams by Katzenbach and Smith,
1993.
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InterprofessionalTeam
• Sharedleadership• Individualandmutualaccountability
• Open-endeddiscussions,activeproblem-solving
• Success=collectivework-products
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Introducing:JoeandThelmaHedgepath
Learners read case summary
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WhatsocialdeterminantsofhealthwillimpactMr.andMrs.Hedgepath’s
care?
Baseduponthewrittensummary,eachteamwillexploredifferentissuesofMr.andMrs.Hedgepath'scase.•
IdentifyMr.andMrs.Hedgepath's mainissues
asdeterminantsinthearealistedonyourteam’schartpaper.
• Listtheseonchartpaper.•
Selectareportertoshareyourideaswiththe
fullgroup.
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Whoshouldbeontheintegratedcommunity
careteamforMr.andMrs.Hedgepath?
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Mr.andMrs.Hedgepath'sCareintheCommunity-Video
• In-HomeAssessmentbyCommunityTeam
• FlourishCaseConceptualizationMeeting
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BREAK10minutes
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What’sNext?
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TeamAssignment• Youwillroleplayafamilymeeting.•
Yourfacilitatorwillassignyouaroleonthisteam.•
Youwillbegivenadescriptionofthatroleandwhatthatteamorfamilymemberwillcontributetothemeeting.
• Basedonyourrole,youwillinteractaccordingtoyourrole.
• Yourmeetingwilllast15minutes(unlessyoufinishsooner.
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Mr.andMrs.Hedgepath'sCareintheCommunity-Video
• BriefFamilyTherapyMeetingwithHospiceClinicalSocialWorker
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Youwillnowdebriefandevaluatehowwellthisteamdidinassessing,planningandimplementingcareforthiscouple.
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Howwelldidtheteamhonorthepatientandfamilymembers’valuesandperspectives?
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ThankyouTEAMFACILITATORS:•Thankthelearnersfortheirparticipation.LEARNERS:Beforeleavingcompletethesurvey&consent•IfyouarenotaULuser:https://medapp.louisville.edu/iCCOA/iccoa.cgi•IfyouareaULuser:http://medapp.louisville.edu:9000