The Interdisciplinary Team: Building Better Care …...Building Better Care Together, Scott N. LaRaus, PT, DPT, CWS and Christine Carroll, RN 1. Chava R, Karki N, Ketlogetswe K, Ayala

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The Interdisciplinary Team:Building Better Care

TogetherScott N. LaRaus, PT, DPT, CWS

Christine Carroll, RN


• Financial– Scott LaRaus

• None

– Christine Caroll• None

• Nonfinancial– Scott LaRaus

• None

– Christine Caroll• None

Disclosures


• Discuss the benefits of an interdisciplinary team• Discuss the opportunities of the team approach to improve

outcomes• Define roles within an interdisciplinary team and the

contributions each discipline makes to the quality of patient care

• Discuss the function of an interdisciplinary team and its driving members within various clinical and community settings

• Identify barriers and challenges in interdisciplinary collaboration, and illustrate measures to overcome these barriers

Learning Goals


Chapter 1

Team Benefits


• Two or more people required to complete a task or project – Benefits

• Complementary skill sets

• Operating with a high degree of interdependence

• Shared responsibility for self-management• Accountability for the collective performance

• Working toward a common goal and shared rewards

• Performance greater than the sum of the performance of its individual members

What Is a Team?


• Unidisciplinary– Same specialty

• Multidisciplinary – Different specialties address a clinical problem but stay within their own

boundaries– Hierarchy, but share communication pattern

• Interdisciplinary– Each discipline knows each other’s role well– Assessment of the problems and tasks from several viewpoints– Collaborate to develop a cohesive action plan, often blurring boundaries

• Transdisciplinary– One collective group with no boundaries; roles and responsibilities shared – Elements difficult to implement, but some aspects are possible

Health Care Team Types


• Focus is always on patient needs and expectations

• Team-based health care is the provision of health services to individuals, families, and the community by at least two health care providers who, with patients and their caregivers, accomplish goals within and across settings to achieve coordinated high-quality care

• Shared responsibility and accountability for attaining desired results

Team-Based Approach


• Each member of the health care team is an expert in their own field

• They bring their own perspectives to the care of the patient

Team-Based Approach (cont.)






• Decreased length of stay• Decreased hospital costs• Decreased home visits• More efficient use of clinical time• Consolidation of services• Improved patient satisfaction• Improved functional outcome measures• Improved staff and member satisfaction• Expedited discharge planning• Reduced delays in start of services• Reduction in errors• Improved job performance• Reduction of costs• Increased job satisfaction• Greater retention of experienced personnel

What Can a Team Achieve?


• Reducing costs– Productivity– Sustainability– Cost-effectiveness– Comparative effectiveness

• Patient experience– Patient satisfaction– Outcomes– Quality– Safety

• Population health– Risk management– Preventive care– Socioeconomic impact

Berwick DM et al Health Affairs (Millwood) 2008; 27: 759–769.

Triple Aim of Health Care


• Studied traditional physician rounds vs. multidisciplinary rounds of an Acute Care of the Elderly (ACE) unit of a 555-bed community hospital. The study looked at communication and efficiency of participating staff via surveys.

• Found that there was increase in work satisfaction, decrease in job turnover, and increased feeling of breaking down of hospital hierarchies with multidisciplinary rounds

Gausvik et al. (2015)


• Performed a retrospective cohort study on ICU patients (over a two-year period) reviewing a multidisciplinary care model vs. a physician staffing model in relation to intensive care unit (ICU) mortality

• Found that multidisciplinary teams were associated with reduction of ICU mortality

Kim et al. (2010)


• Performed a pilot study that reviewed performances of patient-centered measures on patient quality of care

• Found that multidisciplinary rounds improved patient-centered outcome measures as well as perception of physician and nursing communication

Lau & Dhamoon (2017)


• Unofficial rounds

• Official rounds

Round Types


Individual conversations with members of the team such as case managers, social services, nursing, and physicians

Unofficial Rounding


Done to– Get information not in the chart

– Discuss special tests that are scheduled

– Discuss lab results– Coordinate medications

– Help prioritize by own treatment/examination list to assist with discharge

Unofficial Rounding (cont.)


Unofficial Rounding (cont.)

Pros– Effective

– Any communication is good communication

– Can be done in a variety settings

Cons– Not a true

multidisciplinary team

– Time-consuming

– Done almost in a silo of one or two professionals at a time, so not the whole team


Actual meetings with multiple disciplines, including but not limited to MD, RN, case management, social services, rehabilitation, respiratory, and nutritional services first, then all together to discuss the case with family/ caregivers

– Done in a meeting room

– Done outside of patient room

– Done inside a patient room

Official Rounds


Official Rounds (cont.)

Pros– Each member is communicating

and hearing all aspects of care– Each member is equal– Clear vision of patient care and

goals– Better coordination of services– Effective– Can be done in a variety of

settings– Better outcomes– Demonstrates a team culture– Improved patient/caregiver

satisfaction– Improved individual member

rewards and opportunities

Cons– Time-consuming


10 Principles of Good Interdisciplinary Teamwork1

1. Leader2. Team direction3. Interdisciplinary team culture and respect4. Clear process to uphold vision5. Providing clear process and patient-focused services with

documented outcomes6. Communication7. Sufficient staffing8. Facilitating recruitment9. Promoting independence but10. Staffing development1. Nancarrow et al., 2013


Development and support of multidisciplinary rounding will improve not only the patient experience and patient outcomes but also the staff experience by promoting staff development and fostering staff retention

Chapter 1 Summary


Chapter 2

Roles Within the Team


Chapter 2: Roles Within the Team

“Where there is no counsel, the people fall; but in the multitude of counselors there is safety.”

– Ancient Middle Eastern proverb


• Case management• Nursing• Nurse practitioner/physician assistant• Occupational therapy• Pharmacy• Physical therapy• Physician• Registered dietitian nutritionist• Respiratory therapist• Specialty medicine• Speech-language pathologist

Roles Within the Team


• Case manager (aka care coordinator or care manager) – Often RN but can also have background in social work,

rehabilitation counseling, and mental/behavioral health– Advocates for the patient and the patient’s support system– Works across and with other disciplines, listening to the

different voices of the team. Coordinates care while assessing the patient’s needs and connecting the patient with available services.

• Nursing: RNs/LPNs at bedside providing direct care– Advocates for patient’s physical needs and concerns– Implements plan of care– Educator/communicator with patient and family

Roles Within the Team (cont.)


• NPs and PAs: advanced health care professionals working alongside physicians– Able to diagnose and prescribe– From different schooling traditions but fill similar roles– Proving to be vital in addressing our physician shortage while

managing health care costs– Often land in a specialty

• Pharmacist– Assists in pharmacotherapy decision-making– Participation improves outcomes in treating infection,

anticoagulation therapy, analgesia, and sedation– Educational source for staff and patient– Essential in critical care setting



• Occupational therapy– Deals with the issues that affect function and quality of life by

assessing and treating patient’s functional abilities in ADLs• Physical therapy

– Services help restore function, improve mobility, increase strength, relieve pain, and prevent/limit permanent physical disabilities

– Leaders in prevention initiatives– Exclusion from discharge planning increases odds of readmission

nearly fourfold • PT and OT may seem similar, but their treatments and focus are

distinct. These lines are blurred in an acute care setting, but in the outpatient and subacute setting, differences are more apparent.



• Physician– Typically team leader– Assesses patient, collects history, diagnoses– Directs care– Integrates care elements– Counsels patient on plan of care

• Registered dietitian nutritionist– Assesses nutritional needs, determines resources– Sets goals and provides nutritional counseling– Implements and manages nutrition delivery systems



• Respiratory therapist– Assesses for, diagnoses, and treats alterations in pulmonary

function– Administers oxygen therapy, breathing treatments, mechanical

ventilation, CPR, and pulmonary drainage procedures and maintains artificial airways

• Specialist– Often consulted by attending/PCP– A physician who has completed advanced education and

clinical training in a defined branch of medicine– May take the lead contingent on patient’s chief complaint



• Speech-language pathologist– Labors to prevent, assess, diagnose, and treat speech, language,

social/cognitive communication, and swallowing disorders in adult and pediatric patients

• Honorable mention– Unlicensed assistive personnel: medical assistants, CNAs

• Provide patient care as delegated by the RN• Though not an official part of the team, they play a valuable role as

highlighted by a 2019 California study conducted in safety-net clinics• The same study also points out that an organizational structure that

empowers all staff by fostering an atmosphere of collaborative decision-making, interdependence, and shared responsibility can help us meet our goals of providing excellent patient care and improving outcomes



• The object of the team’s focus and effort

• Shared decision-making– Provide not just information, but conversation

– Commit to setting goals that honor the patient’s values

• Patient satisfaction

• Communication is key

Where Does the Patient Fit In?


• Hospital/acute care– Physician directed– Rounding typically occurs, which allows for immediate face-to-

face communication– Documentation is easily accessible to all members

• Home-based medical care– Nurse directed. Nurse is often the eyes and ears for physician.– Other disciplines that enter the home become advocates for

the patient as well– Efficient communication is key

• Team meetings, use of EMR, and secure messaging– Family plays a role

Interdisciplinary Care in Different Settings


• Long-term/rehab/subacute– Physician/nurse and sometimes PT/OT directed– Interdisciplinary care planning required by JCAHO– Resources on site such as PT/OT, case management,

RDN

• Outpatient (e.g., office/clinic, detox/rehab, school, occupational)– Varies, but generally more informal. No official team but

many conversations.– Communication can be more challenging as EMR is not

integrated

Interdisciplinary Care in Different Settings (cont.)


• Roles within the team– Multiple disciplines and perspectives positively impact

patient care and patient outcomes

• Remember to bring the patient and caregiver into the conversation

• Interdisciplinary care requires different key players and strategies, depending on the setting

Chapter 2 Summary


Chapter 3

Challenges Within the Team


Challenges Within the Team

• Bridging gaps

• Negotiating overlaps

• Creating spaces


A literature review by Schot, Tummers, and Noordegraaf(2019) finds there are three categories that factor into the successful collaboration of health care professionals

– Bridging gaps

– Negotiating overlaps

– Creating spaces

Challenges Within the Team (cont.)


Bridging gaps– Professional perspectives

• Overcoming differences in opinion on the best treatment approach• Seeking to understand knowledge bases and professional norms

outside of one’s own– Social

• Bridging personality and relational differences• Interactions beyond professional sphere

– Communicational divides• Effective transfer of knowledge

– For example: adapting medical terminology for the listener

– Task divisions• Professionals stepping outside their roles to perform tasks that aid

other members of the team



• Negotiating overlaps– Roles, responsibilities, and tasks may overlap in the delivery of

interdisciplinary care, which may create conflict– Communicate roles, manage expectations, and be flexible

• Creating spaces– Externally: generating a medium and rapport for interaction

with management, administration, outside institutions– Organizational space: creating new and utilizing current

structures in place that allow for collaboration



• Team structure– Composition and size

– Support and investment from the organization

– Definitive leadership– Stability of members

• Team process– Regular, well-attended meetings

– Clear shared objectives and well-defined roles

– Evaluation to assess performance and laud individuals

Other Factors to Consider


• Create space for communication

• Define roles and navigate overlaps

• See and fill the gaps

• Manage expectations

• Evaluate and adapt

• Provide quality care

Chapter 3 Summary


Discussion

Scenario #1


Discussion

Scenario #2


Questions?

References The Interdisciplinary Team: Building Better Care Together, Scott N. LaRaus, PT, DPT, CWS and Christine Carroll, RN

1. Chava R, Karki N, Ketlogetswe K, Ayala T. Multidisciplinary rounds in prevention of 30-day readmissions and decreasing length of stay in heart failure patients: A community hospital based retrospective study. Medicine Baltimore). 2019;98(27):e16233. doi:10.1097/MD.0000000000016233

2. Fathi, R., Sheehan, O. C., Garrigues, S. K., Saliba, D., Leff, B., and Ritchie, C. S. (2016). Development of an Interdisciplinary Team Communication Framework and Quality Metrics for Home-Based Medical Care Practices. Journal of the American Medical Directors Association, 17(8). doi: 10.1016/j.jamda.2016.03.018

3. Gausvik, C., Lautar, A., Miller, L., Pallerla, H., & Schlaudecker, J. (2015). Structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan and teamwork as well as job satisfaction. Journal of Multidisciplinary Healthcare, 8, 33–37. https://doi.org/10.2147/jmdh.s72623

4. Hargraves, I., Leblanc, A., Shah, N. D., and Montori, V. M. (2016, April 1). Shared Decision Making: The Need For Patient-Clinician Conversation, Not Just Information. Retrieved from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.1354

5. Harris, R. C., and Popejoy, L. L. (2019). Case Management: An Evolving Role. Western Journal of Nursing Research, 41(1), 3–5. https://doi.org/10.1177/0193945918797601

6. Kadivar, Z., English, A., and Marx, B. D. (2016). Understanding the Relationship Between Physical Therapist Participation in Interdisciplinary Rounds and Hospital Readmission Rates: Preliminary Study. Physical Therapy, 96(11), 1705–1713. doi: 10.2522/ptj.20150243

7. Kim, M. M., Barnato, A. E., Angus, D. C., Fleisher, L. A., & Kahn, J. M. (2010). The effect of multidisciplinary care teams on intensive care unit mortality. Archives of Internal Medicine, 170(4), 369–376. https://doi.org/10.1001/archinternmed.2009.521

8. Lau, C. & Dhamoon, A. S. (2017). The Impact of a multidisciplinary care coordination protocol on patient-centered outcomes at an academic medical center. Journal of Clinical Pathways, 3(4), 37–46.

9. Lyson, H. C., Ackerman, S., Lyles, C., Schillinger, D., Williams, P., Gourley, G., … Sarkar, U. (2019). Redesigning primary care in the safety net: A qualitative analysis of team-based care implementation. Healthcare, 7(1), 22–29. doi: 10.1016/j.hjdsi.2018.09.004

10. Nancarrow, S. A., Booth, A., Ariss, S., Smith, T., Enderby, P., & Roots, A. (2013). Ten principles of good interdisciplinary team work. Human Resources for Health, 11(1). https://doi.org/10.1186/1478-4491-11-19

11. Schot, E., Tummers, L., and Noordegraaf, M. (2019). Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration. Journal of Interprofessional Care, 1–11. doi: 10.1080/13561820.2019.1636007

12. Xyrichis, A., and Lowton, K. (2007, March 26). What fosters or prevents interprofessional teamworking in primary and community care? A literature review. Retrieved May 07, 2020, from https://www.sciencedirect.com/science/article/abs/pii/S0020748907000375

The Interdisciplinary Team: Building Better Care …...Building Better Care Together, Scott N. LaRaus, PT, DPT, CWS and Christine Carroll, RN 1. Chava R, Karki N, Ketlogetswe K, Ayala

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