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Interdisciplinary Collaboration on the Behalf of Older Adults
Michael L. Malone, MD
June 14, 2017
National Association of Social Workers
Learning Objectives:
• Describe the key principles of interdisciplinary
models of care for older adults.
• Describe examples of interdisciplinary collaborative
models.
• Outline simple strategies to make your team more
effective.
Interdisciplinary Collaboration Case Scenario:
• An 83 year old white man was admitted to a community hospital for generalized weakness. He has been started on treatment for C. diff related diarrhea. The Acute Care for Elders interdisciplinary team is discussing the patient’s needs on hospital day 3.
• His weight has increased-from 92 g on admission to 100 kg.
• Past medical history: He has a chronic urinary catheter and lateral spondylosis requiring some assist to transfer at baseline.
• Social history: He comes from home with his wife. At baseline, he needs assist with dressing and bathing. He wants to return home.
• Physical therapy: He needs more assistance with his transfers from bed to chair and his wife may not be able to manage.
• Which of the following would provide the best interdisciplinary plan for his transition?
Which of the following would provide the best interdisciplinary plan for his transition?
A. Have patient and his wife select sub-acute nursing facility from a list of local sites.
B. Explore his eligibility for an in-patient acute care rehabilitation program.
C. Optimize his medical condition and his functional status (physical and occupational therapy) so that his overall needs are better defined.
Key Principles of Geriatrics Interdisciplinary Models of Care:
• Enable seniors to remain at home.
• Prevent functional disability.
• Preserve patient quality of life.
• Respect patient values, preferences,
and goals.
• Consider patient safety.
• Address needs of caregivers.
• Appreciate psychosocial needs.
With permission from Robert M. Palmer MD.
November, 2010.
Examples of Interdisciplinary Collaboration:
• Hospital- Based Models of Care:
– Acute Care for Elders (ACE).
– The NICHE program.
• Out Patient Models of Care:
– Program of All- Inclusive Care for Elderly (PACE).
– Geriatric Evaluation and Management (GEM).
– Guided Care.
– Geriatrics Resources for Assessment and Care of Elders (GRACE).
• Home Care Models:
– Hospital at Home.
– Home- Based Primary Care (HBPC).
– Independence at Home.
Model of Care: In- patient setting
Goal:
Key components:
Findings in support of the intervention:
Acute Care for Elders Lessen the chance of functional decline for hospitalized older adults.
• Inter-disciplinary team assessment and care.
• Prepared environment.
• Early planning to go home.
• Medical care review (using ACE Tracker report).
Randomized controlled trial (RTC) has shown improvement in ADL performance from 2 weeks prior to admission (p=.05) and admission compared to discharge (p=.009). RTC has shown nonsignificant reduction in total hospital costs per case ($6,608 vs. $7,240, p=.93). RCT significantly reduced mortality at 3 (12% vs 27%, p=.004) and 6 months (16% vs. 29%, p=.02) post- discharge.
NICHE Prepare nursing staff in care of older adults. Train a cohort of Geriatric Resource Nurses to become experts for other nursing staff.
• Nursing skills and competencies.
• Promotes geriatric quality of care.
• Patient safety across the care continuum.
• Benchmarking service.
Improved clinical quality at multiple sites: Improved patient satisfaction. Decreased falls. Decreased use of high-risk medications. Improved use of senior friendly protocols. Improved cultural competency. Improved care for older patients who developed delirium during hospital care.
©2017 National Association of Social Workers. All Rights Reserved. 8
Geriatrics Models of Care- Bringing “Best Practice” to an Aging America. Malone, Capezuti, Palmer eds. Springer International . Switzerland, 2015
Model of Care: Community
Goal:
Key components:
Findings in support of the intervention:
Program of all Inclusive Care for the Elderly (PACE)
Comprehensive primary care for adults aged >= 55 years to safely continue living in the community.
• Day Health center. • Medical care. • Nursing services. • Therapy . • Meals. • Personal care. • Social worker.
Lower rates of hospital use. Lower rates of nursing home use. Higher use of adult day care services. Better reported health status. Lower rates of emergency department use.
Geriatric Evaluation and Management (GEM)
Improve health outcomes of at-risk seniors. Develop plan of care and specific interventions .
• Comprehensive geriatric assessment.
• Co-management with PCP.
Randomized trial showed significant reductions in functional decline with inpatient GEM and improvements in mental health with outpatient GEM, with no increase in costs.
Guided Care Provides primary care coordinated by a RN for high- risk older adults.
• Case management • Transitional Care • Self- management. • Caregiver Support
Matched-pair, randomized control trial showed higher quality of chronic care. Higher physicians satisfaction managing chronic care.
GRACE program Improve quality of care for low- income seniors.
• NP + SW+ PCP= team. • Medical and psychosocial
evaluation. • Medication review. • Functional assessment . • Advance directives.
Randomized control trial showed reduced acute care utilization among a high-risk group.
©2017 National Association of Social Workers. All Rights Reserved. 9
Geriatrics Models of Care- Bringing “Best Practice” to an Aging America. Malone, Capezuti, Palmer eds. Springer International . Switzerland, 2015
Model of Care: Home setting
Goal:
Key components:
Findings in support of the intervention:
Hospital at Home In -home care for older patients who are medically suitable with: Pneumonia; CHF Exacerbation; COPD; Cellulitis .
• Eligibility criteria . • Direct nursing care. • Medical equipment. • Medicines.
Non-randomized, controlled study showed shorter length of stay. Higher patient and caregiver satisfaction. Lower delirium incidence . Lower cost of care.
Home Based Primary Care (HBPC)
Primary care and care coordination at home.
• Geriatrician, NP, SW working together.
• Periodic follow up.
Studies demonstrate improved quality of life without added cost.
Independence at home
Primary care and care coordination at home for frail older adults
• Assessment 24-72 hours of hospital discharge.
• NP • Home health
agency.
Case-controlled study showed cost reduction.
©2017 National Association of Social Workers. All Rights Reserved. 10
Geriatrics Models of Care- Bringing “Best Practice” to an Aging America. Malone, Capezuti, Palmer eds. Springer International . Switzerland, 2015
Healthy Mild
Chronic Illness
Multiple Chronic
Conditions
Frail
Usual (Acute) Care Model
Chronic Disease Care Model
Geriatric Care
Models
Dying
Palliative/
Hospice
Model
Adapted from James Pacala, M.D. University of Minnesota. Used with permission.
Debilitated
Coordination of care across settings.
Primary care
Match the Care to the Individual’s Needs:
Strategies for
Success:
Key Components to the Implementation of
Interdisciplinary Models:
