Nursing Care and Interdisciplinary Geriatric Team
Geriatric Care and Health Care
A recent report from the Institute of Medicine of the National Academies (IOM) challenges all health care professionals to recognize the need for effective interdisciplinary team care (Institute of Medicine, 2001).
The sense of urgency
implied by the IOM report is related to the growing body of evidence that
effective interdisciplinary team care prevents medical errors and leads to
improved patient outcomes (Boult et al., 2001; Cohen, H., et al., 2002;
Sommers, Marton, Barbaccia, & Randolph, 2000).
Importance of Interdisciplinary Team Work
Geriatric interdisciplinary team care has been shown to be essential to manage the complex syndromes experienced by frail older adults (Cohen, H., et al., 2002; Regenstein, Meyer, & Bagby, 1998).
Providing comprehensive care to geriatric patients with multiple illnesses, disabilities, increased social problems, and fragmented care requires skills that no one individual possesses; therefore, older adults are best cared for by a team of health professionals (Baldwin, 1996; Pfeiffer, 1998; Regenstein et al., 1998).
Geriatric interdisciplinary team care improves older adults' functional status (Sommers et al., 2000), perceived well-being (Boult et al., 2001; Knaus, Draper, Wagner, & Zimmerman, 1986), mental status, and depression (Eng. Padulla, Eleazur, McCann, & Fox, 1997).
Geriatric interdisciplinary team care has also been
shown to be cost effective by reducing patient readmission rates and number of
physician office visits (Burns, R., Nichols, & Martindale-Adams, 2000).
Positive Outcomes
The most recent report demonstrating the positive outcomes of team care came from a large, randomized trial of 1,388 frail patients 65 years of age or older who were hospitalized at 11 Veterans Affairs medical centers (Cohen et al., 2002).
Participants were randomly assigned according to a two-by-two factorial design to receive either care in an acute inpatient geriatric unit or usual acute inpatient care, followed by either care at an outpatient geriatric clinic or usual outpatient care.
The interventions teams involved that provided geriatric assessment and management according to Veterans Affairs standards and published guidelines. The primary outcomes were survival and health related quality of life, measured with the use of the Medical Outcomes Study 36-Item Short Form General Health Survey (SF-36), 1 year after randomization.
Secondary outcomes were the ability to perform activities of daily living, physical performance, utilization of health services, and costs.
The results demonstrated significant improvements in scores for four of the eight SF-36 subscales, activities of daily living (p<.001), and physical performance of those patients cared for by a geriatric interdisciplinary health care team as inpatients (p< .001).
Neither the inpatient nor the outpatient intervention had a significant effect on mortality (21% at 1 year overall), nor were there any synergistic effects between the two interventions. At 1 year, patients cared for by an outpatient geriatric team had better scores on the SF-36 mental health subscale, even after adjustment for the score at discharge, than those assigned to usual outpatient care.
Total costs at 1 year were similar for the intervention and
usual-care groups. This study suggests the quality-of-life benefits of
geriatric interdisciplinary team care. Al- though geriatric interdisciplinary
team care did not have an impact on overall survival at 1 year, preserving
function and improving mental health are consistent with the goals of care for
frail older adults.
Research Outcomes of Effect of Teak Work
Another randomized clinical control trial demonstrating the positive effects of team care included 128 veterans, age 65 years and older, who were outpatients in a primary care Geriatric Evaluation and Management Unit (GEM) (Burns, R., et al., 2000). This study investigated the outcomes of patients who were randomized to outpatient GEM or usual care (UC).
Two-year follow-up analyzes were based on the 98 surviving individuals. Study outcome measurements included health status, function, quality of life, affect, cognition, and mortality. The results, after 2 years, demonstrated positive intervention effects for eight outcome measures, five of which attained significance at 1 year.
GEM subjects, compared with UC subjects, had significantly greater improvement in health perception (p<.001), smaller increases in numbers of clinic visits (p<.019), improved instrumental activities of daily living (IADL) (p<.006 ), improved social activity (p < .001), greater improvement in Center for Epidemiologic Studies Depression (CES-D) scores (p < .003), improved general well-being (p < .001), life satisfaction (p<.001), and Mini Mental State Exam (MMSE) scores (p<.025).
There were no significant treatment effects in activities of daily living (ADL) scores (p<.386), number of hospitalizations (p<.377), or mortality (p<.155). These findings suggest that a primary care approach that combines an initial geriatric interdisciplinary comprehensive assessment with long term, interdisciplinary outpatient management may significantly improve outcomes for targeted older adults.
In
addition, Burns and colleagues have demonstrated the sustainability of positive
interdisciplinary geriatric team outcomes over time.
The success of team care has also been demonstrated by investigating service utilization, including rehospitalizations, office visits, emergency department visits, and nursing home admissions (Sommers et al., 2000).
A controlled cohort study of 543 patients in 18 private office practices of primary care physicians was conducted to examine the impact of a team intervention involving a primary care physician, a nurse, and a social worker for community dwelling seniors with chronic illnesses.
The intervention group received care from their primary care physician working with a registered nurse and a social worker, while the control group received care as usual from their primary care physician.
The outcome measures included changes in number of hospital admissions, readmissions, office visits, emergency department visits, skilled nursing facility admissions, home care visits, and changes in patient self rated physical, emotional, and social functioning. From 1992 (baseline year) to 1993, the two groups did not differ in service use or in self-reported health status.
From 1993 to 1994, the hospitalization rate of the control group increased from 0.34% to 0.52%, while the rate in the intervention group stayed at baseline (p<03). In the intervention group, mean office visits to all physicians fell by 1.5 visits compared with a 0.5-visit increase for the control group (p<.003).
The patients in the intervention group reported an increase in social activities compared with the control group's decrease (p<.04). With fewer hospital admissions, average per-patient savings for 1994 were estimated at $90, inclusive of the intervention's cost but exclusive of savings from fewer office visits.
This geriatric interdisciplinary team model of primary care shows potential for reducing the utilization of health care services and maintaining health status for older adults with chronic illnesses.
Dependency of Interdisciplinary Team
The effectiveness of geriatric interdisciplinary team care is dependent on the process of team functioning (Drinka & Clark, 2000; Farrell, M., Schmitt, & Heinemann, 2001), Well-developed team skills are necessary for clinicians to represent their various disciplines when developing a geriatric interdisciplinary care plan (Farrell, M., et al.).
Geriatric interdisciplinary team care has been shown to improve patient outcomes through the development of team skills and a willingness to collaborate more effectively (Grant, Finoc Chio, & the California Primary Care Consortium Subcommittee on Interdisciplinary Collaborative Teams in Primary Care, 1995; Drinka & Clark ).
The process of team functioning is dependent on the team skills and
attitudes of the individual team members, their ability to identify ineffective
team behaviors, and their ability to develop an interdisciplinary plan of care
(Drinka & Clark; Heinemann, Schmitt, & Farrell , 1994).
Conflicts to Interdisciplinary Team
In addition to team skills, positive attitudes toward health care teams contribute to effective geriatric interdisciplinary team care (Leipzig et al., 2002; Farrell, M., et al.). Attitudes toward interdisciplinary geriatric team care of nurses, physicians, and social workers have been shown to have an impact on team success, as reflected in, for example, hospital readmission rates (Sommers et al., 2000).
Negative attitudes toward geriatric interdisciplinary team care that contribute to sources of team conflict include:
(a) differing disciplinary and personal perspectives.
(b) role competition and turf issues.
(c) differing inter professional perceptions of roles.
d) variations in professional socialization processes.
(e) physician dominance of teams and decision makin.
(f) the perception that physicians do not value collaboration with other
groups (Abramson & Mizrahi, 1996; Leipzig et al., 2002).
In 1995, the John A. Hartford Foundation of New York City funded the Geriatric Interdisciplinary Team Training (GITT) program, a large multisite national team training program designed to create models to train 2,500 health care professionals in interdisciplinary team care.
From 1997 to 2000, the eight GITT sites measured the effectiveness of this training intervention by conducting a pre-post training evaluation of the GITT participants. The GITT program was foremost a training model and therefore the core measures that were collected were focused on the trainees, the ultimate unit of analysis.
The purpose of the core
measures was to evaluate the effectiveness of the intervention, the team
training program.
Outcomes of GITT
The results from the GITT study demonstrated an overall effect of GITT training at posttest on measures of attitudinal change, change in test of geriatric care planning, and the test of team dynamics (Fulmer, Hyer, et al., 2004). Changes were greatest for attitudinal measures including team skills and modest for knowledge changes in geriatric care planning and testing of team dynamics.
At
the level of the individual variables, significant changes were observed
between the pre- and post-test mean scores for overall team skills scale and
for the overall attitudes scale and each of its subscales. The GITT program
serves as a model for implementing and evaluating interdisciplinary geriatric
team training programs.
Areas of Improvement
The need to improve the effectiveness of geriatric interdisciplinary team care has never been more urgent then in today's health care environment. Providing comprehensive care to older adults with multiple illnesses, disabilities, increased social problems, and fragmented care compounds the demographic imperative we face in our aging society.
Effective geriatric interdisciplinary team care
has been shown to improve patient outcomes by improving functional status
(Sommers et al., 2000), perceived well being (Boult et al., 2001; Knaus et al.,
1996), mental status and depression (Eng et al., 1997). In addition, effective
geriatric interdisciplinary team care has been shown to reduce medical errors:
(IOM, 2001).
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