Interdisciplinary Team Practices
Interdisciplinary Team Practices
Abstract and Keywords
This chapter discusses interdisciplinary team practice and its importance in providing comprehensive services to older adults. This approach is valuable for its ability to attend to the wide range of needs of the older adult, utilizing the expertise of physical and mental health professionals. Both strengths and weaknesses of this approach are identified and illustrated through the use of a case presentation of how a multidisciplinary approach is superior to any specific profession's approach in identifying both problems and solutions.
Social work with older persons frequently includes interdisciplinary teamwork. An interdisciplinary team can be described variously as “a functioning unit, composed of individuals with varied and specialized training, who coordinate their activities to provide services to a client or group of clients” (Ducanis & Golin, 1979, p. 3), as “a group with a specific task or tasks, the accomplishment of which requires the interdependent and collaborative efforts of its members” (Beckhard, 1972, p. 287), and, more fully defined, as
a group of persons who are trained in the use of different tools and concepts, among whom there is an organized division of labor around a common problem with each member using his own tools, with continuous intercommunication and reexamination of postulates in terms of the limitations provided by the work of the other members and often with group responsibility for the final product. (Luszki, 1958, as cited in Given & Simmons, 1977, p. 166)
Rationale for Interdisciplinary Team Practice
The importance of an interdisciplinary team approach in the health care of older persons has been recognized and espoused in the literature for the past 30 years. As early as 1915, health educators, physicians, and social workers were working together in teams at Massachusetts General Hospital, but it was not until the 1950s when Drs. Cherasky and Silver advocated a team approach to the delivery of primary care service that attention began to be given to the interdisciplinary team modality. By the 1960s, interdisciplinary educational experiences were being developed for students in the health professions, and the federal government “advocated the use of health teams in its newly created Neighborhood Health Center Program” (Bernard et al., 1997, p. 155). The following decade witnessed funding of training for interdisciplinary teamwork in geriatrics by the Department of Veterans Affairs and the Bureau of Health Professions (Geriatric Education Centers) at the federal level and by the Robert Wood Johnson and W. K. Kellog Foundation in the private foundation arena. From the early 1970s through the 1980s there were numerous presentations at professional conferences and journal articles focused on interdisciplinary team care, nearly all of which were either descriptive, highlighting inter-disciplinary (p.766) team development and activities, or prescriptive, encouraging the health care professions, including social work, to adopt such practices.
By the early 1980s, funding for interdisciplinary teams and training in interdisciplinary teamwork waned. Following this lull, interest in the team approach in the care of the older person once again came to the fore and was highlighted by the National Institutes of Health 1987 Consensus Development Conference, which issued the following statement:
This process, comprehensive geriatric assessment, is defined as a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person’s problems…. Comprehensive geriatric assessment involves clinicians from the many health care professions who are necessarily involved in good geriatric care. (Solomon et al., 1988, p. 342)
The concept that underlies interdisciplinary team health care is that the patient generally presents with a multitude of interlocking needs and issues and that no one discipline is equipped with the knowledge and skills to assess and develop appropriate care plans to meet these needs. Geriatric patients are frequently beset by many health, social, and environmental needs. The same is true of other populations, such as chronically ill children and the disabled. Complicating the care of these populations is not only that the patients/clients have several needs and issues but that these several needs may overlie each other or interact in such a manner that correct assessment is compromised and attention to any one need, in isolation, is ineffective.
In many situations involving older persons, a plethora of physical, psychological, social, environmental, and financial issues need to be addressed and holistic care provided. It is this holistic care that can be provided only by an interdisciplinary team. The following case studies provide examples of the need for a team approach to health care for the elderly.
Maria Harrod is an 83-year-old widow who lives alone and is discovered by her daughter lying on the floor in her apartment in a weak-ened state. Hospitalization follows, and Maria is diagnosed as suffering from malnutrition. After being stabilized and restored to health, she is discharged with the admonition to eat five small but nutritious meals each day. Maria’s daughter works but manages to visit every evening and prepare a meal for her mother before returning home to care for her family. Six weeks later, Maria is again hospitalized. While in the hospital, she is visited by a social worker, who identifies Maria as depressed. Her previously undiagnosed depression and social isolation caused the initial incident and also resulted in noncompliance of the five-meals-a-day routine that the physician had recommended, contributing to ongoing malnutrition.
George and Peggy Wylie
Mr. and Mrs. Wylie are in their early 70s and recently celebrated their 50th wedding anniversary. They enjoy an active retirement which includes volunteering for several organizations, such as delivering meals to homebound neighbors once a week for the local Meals on Wheels program. Recently, the director of the Meals program, a social worker, received a complaint from one of the recipients, who declared that Mr. Wylie was unaccountably rude to her. The director, knowing George as a kind, friendly person, believed that the incident had been misinterpreted but decided to drop in on the Wylies on her way home from work. She found them drinking martinis before dinner and stayed for a brief chat. George seemed more outgoing than usual, but there seemed no cause for concern. The director wondered whether he might have a drinking problem but decided that she should watch for further signs of this before advising him to seek counseling. Two days later, both the Wylies turned up in the emergency room at their local hospital. Peggy had a deep gash on her leg and George was concussed. Apparently, Peggy discovered her husband about to leave the house wearing only shorts and a T-shirt, even though the temperature was below freezing. When she tried to stop him and told him to put on other clothing, he became violent and threw a pair of scissors at her. Peggy then pushed him and he fell to the floor, hitting his head and passing out. In (p.767) the emergency room, Peggy receives stitches for the leg injury. Meanwhile, assessment of her husband’s concussion results in the finding that he has suffered a stroke, which is probably the cause of his uncharacteristic behavior.
Without the initial input of a social worker or psychiatrist, in the case of Maria, and the input of a physician or nurse, in the case of George Wylie, the complete pictures remained hidden. The correct diagnoses are relatively simple; even so, without the attention and teamwork of several disciplines, timely and effective care remained out of reach. For Maria, earlier involvement of a social worker or psychiatrist would have resulted in an initial assessment of depression, and for George, it was perhaps fortunate that his behavior caused him to be seen by a physician and nursing staff.
By the late 1980s, recognition of the value of interdisciplinary team care resulted in interdisciplinary team education becoming a mandatory requirement for the newly funded Geriatric Education Centers (GECs). Funded by the Bureau of Health Professions of the U.S. Health Resources and Services Administration, the GEC’s goal is to increase the geriatric expertise of those who educate and train health care professionals. The inclusion of training in collaborative, interdisciplinary care remains a key element in the offerings of these centers. More recently, the John A. Hartford Foundation began funding the Geriatric Interdisciplinary Team Training (GITT) Program and its initiatives for promotion of geriatric education in the disciplines of medicine, nursing, and social work, further promoting interdisciplinary team care of older persons (Robbins & Rieder, 2002). The Institute of Medicine has issued a call for a “New Health System for the 21st Century,” in which teams are identified as playing a central role in primary care (Grum-bach & Bodenheimer, 2004).
Interdisciplinary Team Makeup
The core interdisciplinary team in geriatric care generally includes a physician, a nurse, and a social worker sharing their expertise in the assessment and treatment of older persons. Beyond these three core disciplines, it is recognized that many other professions may need to be included, depending on the individual circumstances. Clinic and hospital interdisciplinary teams may include representatives from other disciplines on an ongoing basis or seek to include them as needed. Nursing facilities routinely include the disciplines of nutrition, psychiatry, and physical and occupational therapy and call on others as needed.
Advantages of Interdisciplinary Team Care
The understanding that geriatric interdisciplinary team care is beneficial to the older patient and the efforts of the Veterans Affairs Medical Centers, GECs, and the recent Hartford initiatives in training health care professionals in interdisciplinary team skills has created a growing interest in and practice of interdisciplinary team care. A number of research studies in the 1980s (Rubenstein et al., 1984; Rubenstein, Stuck, Siu, & Wieland, 1991; Williams, Williams, Zimmer, Hall, & Podgorski, 1987) reported on the beneficial impact of comprehensive geriatric assessment (i.e., team assessment) of hospitalized older patients. The more recent emphasis on evidence-based outcomes is underscoring the benefits of the interdisciplinary practice modality both for the older person in terms of improved care and quality of life and for health insurance companies in terms of cost savings. Grum-bach and Bodenheimer (2004, p. 1246) conclude, “Medical settings in which physicians and nonphysician professionals work together as teams can demonstrate improved patient outcomes.”
The holistic approach of the interdisciplinary geriatric health care team is more valuable than the sum of its parts. Representatives of a variety of health care professions working together promote the wellness of older persons, decrease acute care incidents, and are cost-effective.
Barriers to Team Care
In spite of the increasing support for interdisciplinary team care, the development of such teams is not without difficulties. Gathering together representatives of several disciplines to discuss older patients or ensuring that the various professionals communicate with each other in regard to assessment and treatment is insufficient in itself. The development of an effectively functioning interdisciplinary team, as opposed to a multidisciplinary group, itself requires interdisciplinary effort and the willingness of its members to overcome the following barriers.
In developing a functioning team, as with any group developed for a purpose, one needs to overcome the differences in age, ethnicity and culture, gender, socioeconomic status, language, and personality of the members. But, beyond these factors, there are a number of differences related to the various disciplines that frequently create barriers to the formation of a smoothly functioning interdisciplinary team.
Communication Versus Jargon
Each discipline has its own professional language or jargon, enabling its members to communicate in a form of shorthand. The resulting alphabet soup and specific terminologies can be a source of confusion and give rise to charges of elitism by outsiders. Even more troubling, though frequently unrecognized, is the use of similar phrases or terms by members of different disciplines that hold different meanings for each discipline. For example, a patient’s “support system” means one thing to a social worker and something altogether different to a nurse or physician. Lack of communication results, with accompanying damage to team functioning.
Culture and Philosophy
Philosophies and cultural milieus differ among the disciplines. For example, social workers are educated to value self-determination of the individual client/patient, whereas physicians are educated to cure and overcome illness. Social workers see the best interests of their clients as based on the clients’ psychological and social needs; physicians view the best interests of their patients as lying in full restoration of health. This divergence in perspectives can create irreconcilable caring strategies when a patient or family is hesitant about or refusing treatment. Within the interdisciplinary team setting, these different perspectives can promote distrust between the disciplines.
Time Constraints and Schedules
Differing schedules and organization of practices result in concrete difficulties in finding time to meet or otherwise communicate between the disciplines. For instance, the availability of physicians on call or working in a community practice is often at odds with the schedules of nurses and social workers employed full time by a medical center or nursing facility. Other health care professionals, such as nutritionists, dentists, and therapists, may be available only on a parttime basis. Student education within the disciplines also tends to be structured differently: as semesters versus 4-week rotations, integrated class and field practice versus class followed by practice internships. All these differing schedules and time constraints become a programmatic barrier in fostering interdisciplinary teams.
Levels of Training
Health care disciplines vary in the level of knowledge and educational requirements for entry into the professions. Physicians are required to spend many years in gaining their medical credentials and expertise within their selected specialty. Nursing education can range from the minimal training of a nurse’s aide to a licensed certificate or master’s degree level. Similarly, social workers may hold master degrees but are also employed with undergraduate degrees, as are physical therapists. A functioning interdisciplinary team must overcome these differences in educational backgrounds and levels and the potential they afford to create superiority/inferiority complexes and consequent lack of respect for each other’s contribution to the team.
Health care professions are set apart from each other by the nature of their specific area of knowledge and expertise. It is this special knowledge and expertise that rightly give each profession its authority and credibility but also give rise to the universally recognized turf battles. Members of each profession naturally work to protect and enhance their own area of specialty. Participation in an interdisciplinary team both enhances the feeling that the boundaries of one’s own discipline are being breached by another discipline and also provides a forum to react directly, in person, in asserting one’s own turf. Overcoming this barrier is perhaps the hardest and yet most important task in the development of a functioning interdisciplinary team.
To be truly effective, all members of an interdisciplinary team have to be very clear about the specific knowledge and skill areas that they contribute to the team but also be willing to allow members of the other disciplines to talk their language and venture into their realm of knowledge. The term transdisciplinary (p.769) team is increasingly used, especially in the field of palliative care, to identify a higher order of interdisciplinary team in which the members have earned each other’s trust and learned each other’s specialty so that they seamlessly carry out each other’s discipline-specific tasks. However, an interesting dynamic is often experienced in interdisciplinary teams in their process of metamorphosing into transdisciplinary teams. Members of a discipline become open to other team members embracing their special knowledge, but when a member of a discipline reaches a point at which his or her use of adopted knowledge begins to equal that of members of that other discipline, the discipline-specific role is threatened, and there is a pulling back and reassertion of turf. In this sense, the task of overcoming the turf barrier may never completely be accomplished.
Administrative support for interdisciplinary teamwork within a health care organization is crucial. Without such support, it is very unlikely that the various disciplines will buy in to the concept. Team participants require the support of the administration in order to justify the time that is spent in interdisciplinary teamwork at the expense of other tasks. In addition, putative teams wither away when support from the top is lacking, as a new team generally includes one or more less than enthusiastic participants. Without the acknowledged backing of the organization’s leadership, there is no incentive for reluctant participants to remain involved, and the team will fail to thrive.
When state or federal regulations mandate interdisciplinary team assessments, as they may do in nursing facilities and Veterans Affairs medical centers, participation in an interdisciplinary team is one of the ongoing tasks of a salaried employee. For the vast majority of social and health care providers, however, whose earnings derive from fee for services or involve contractual arrangements between organizations and government or insurance companies, there is no third-party payment coverage for time spent in interdisciplinary teamwork. This lack of funding may be judged shortsighted in light of the cost effectiveness of interdisciplinary team care, for it is clearly a barrier to the development and ongoing maintenance of teamwork.
Danger of Success
There is one final barrier to the making of the ideal interdisciplinary team, and this is peculiar in that it emerges only when a team is experiencing success. Generally this setback is found in stable teams that have been in existence for a lengthy period. The team members know each other well, respect each other’s knowledge, and are comfortable with the team’s decisions. The team may even be transdisciplinary in nature. The danger lies in the emergence of a “group-think” mentality: The members know how each of them is thinking about a specific patient/client, there is little or no disagreement, and decisions regarding assessment and treatment plans are reached quickly. Therein lies the danger. The team members are no longer challenging each other, and although the group determinations may prove accurate, they are equally likely to be flawed. Either insufficient thought is given to the case under discussion and vital signs and symptoms are ignored, or the team moves unquestioningly to the acceptance of a multiplicity of overlapping variables and sees complications where simplicity is the reality. To outward appearances, the interdisciplinary team is functioning smoothly, but its outcomes may well be detrimental to the patient’s/ client’s well-being.
Characteristics of a Well-Functioning Team
Drinka and Clark (2000) note that interdisciplinary health care teams are “not just assemblages of individuals from different professions. They are complex and paradoxical entities that often seem to defy understanding.” Most interdisciplinary geriatric care teams are neither a disaster nor the ideal. Interdisciplinary teams, like organizations, are evolving, changing systems and remain fluid.
A functioning interdisciplinary team is one in which its members:
• Recognize the knowledge and skills of each of the members.
• Trust and respect each other.
• Fulfill certain roles, such as leader, facilitator, recorder, or process evaluator. Leadership can be democratic, authoritarian, vested in one individual or shared.
• Convene on a regular basis. Interdisciplinary teams need not necessarily meet in person but can interact by phone or e-mail. The important criterion is a regular time schedule maintained for sharing assessments and developing/evaluating care plans.
• Are able to think “outside the box.”
• Tolerate, and even welcome, conflict as an aid to problem solving.
Social Workers as Team Members
Because of their relationship skills and professional training, social workers are ideally suited for interdisciplinary teamwork. Social workers’ knowledge and specific training in biopsychosocial assessment, work with families, short-term treatment modalities, and identification and referral to community services are especially helpful to the work of the interdisciplinary team. Apart from these areas of expertise, social work training in working with individuals and groups and emphasis on relationship skills means that social workers tend to be good listeners, group facilitators, managers of interpersonal conflict, and focused on collaboration. As such, social workers are valuable not only as interdisciplinary team members but for the leadership they offer in the development and maintenance of fully functioning interdisciplinary teams.
The Role of Social Work in the Interdisciplinary Team
The geriatric health care interdisciplinary team has always counted social work as a core participating discipline, along with nursing and medicine, but it is only in the past few years that the specific role and contribution of the social worker to interdisciplinary team practice has been articulated. A national interest group, emerging from the Hartford Foundation’s GITT program, spent several months in the late 1990s discussing and identifying social work’s specific role and contributions to the geriatric health care team.1 Mellor and Lindeman concluded that the role of the social worker as a member of an interdisciplinary team includes but is not limited to the following:
• Diagnosis/Assessment. The social work assessment takes into consideration how well the patient (and the family or caregiver) is functioning in six areas:
Physical: a brief medical history, functional abilities, appearance, and observed behavior.
Psychological: affect, mood, outlook, attitude, personality characteristics, cognitive functioning, self-image.
Social: vocation, social roles, support networks, education, and financial status.
Cultural: values, general rules of behavior, definition of the “sick role,” beliefs about the root causes of illness and prescribed treatments, communication patterns that encompass varied language and speech patterns as well as bilingual issues.
Environmental: living conditions and home surroundings, with focus on safety and maintaining functional independence.
Spiritual: beliefs about people’s roles and responsibilities, rules for living, belief system, diet, and acceptable medical treatments.
• Care Management. Also referred to as case management, this social work role includes problem identification (e.g., lack of financial resources, need for help with activities of daily living or mental health intervention) as well as linkages to and coordination of community resources to facilitate the highest practical level of functioning for the patient and family. It requires a knowledge of community resources and entitlements and skills in matching the patient/family with resources, linking resources, and serving as an interpreter and advocate for the patient/family.
• Individual Counseling. Psychosocial counseling includes treatment of mental health problems such as depression and anxiety through various techniques, including family therapy, relaxation, and stress management training for the patient and/or caregiver. This is intended to assist patients and families to adjust to major life stressors and transitions such as illness, disability, institutionalization, and loss as well as to empower the client. A patient’s ability to adapt to an illness has a profound impact on his or her quality of life as well as (p.771) the patient’s willingness/ability to comply with the prescribed treatment and is paramount to recovery, physical and emotional healing, timely discharge from the hospital, risk management, and effective decision making. The social worker brings skills in listening, problem resolution, and negotiation with attention to community and environmental factors.
• Group Work. Group psychotherapy and supportive psychoeducational groups are designed to help patients and families/caregivers cope with a specific illness (e.g., depression, Alzheimer’s disease, cancer, diabetes). The social worker brings skills in group development and facilitation.
• Liaison. The social worker can also serve as a liaison between the patient/family and the professional community, forming a vital link. This is particularly pertinent when the family lives out of the area and its input must be obtained via longdistance communication.
• Advocacy. Social workers’ training, including a working knowledge of ethics, confidentiality, advance directives, cultural/ethnic factors, and patient/family rights, serves to help teams face the challenge of balancing patient needs with the system demands. Often, the most important service provided to patients and families by a geriatric/ gerontological social worker is simply to assist in negotiating an overwhelmingly bureaucratic system, such as Medicaid, Social Security, disability, funeral arrangements, or dealing with insurance and hospital paperwork by acting on their behalf and/or teaching them to help themselves.
• Community Resource Expertise. Knowledge of community resources and how to access them is an invaluable piece of the social work profession. This involves high-level skill in negotiation and bargaining for appropriate resource allocation. A working knowledge of financial systems, including federal, state, and county programs, is part of this expertise. Serving as a resource referral coordinator requires negotiation and collaboration to assist patients and families in setting priorities, determining care goals, and balancing issues. (Mellor & Lindeman, 1998, pp. 5–7)
These areas are not necessarily exclusive to the discipline of social work, but they are knowledge and skill areas in which the social worker receives specific training and for which social work has particular expertise and responsibilities.
Interdisciplinary health care teams are not yet universal, but the growing body of information from evidence-based studies underscores the value of this model of practice. Well-functioning interdisciplinary teams are understood to promote quality of life for the patient and family and to be cost-effective in terms of health dollars, through reduced hospital stays and more timely, holistic treatment interventions. Furthermore, baby boomers, the next cohort of older persons, identify access to interdisciplinary team care as a feature of the health care system they envisage for their future. Hence, social workers in the field of aging are increasingly likely to participate in interdisciplinary teamwork. Social work has a valuable and crucial role to fill in this growing practice model.
1. Members of the Social Work Interest Group of the GITT program were Carole Ashendorf, Barbara Bacon, Judith Howe, Kathryn Hyer, Joann Ivry, David Lindeman, Marilyn Luptak, Marty Mandel, Russ Martineau, Joanna Mellor, James Reinardy, Barrie Robinson, Ann Schneider, Nancy Wadsworth, and Lisa West.
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