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).