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Interdisciplinary Care and Care Coordination

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Geriatric Medicine

Abstract

Team-based care is essential when caring for older adults, no matter whether the setting is inpatient or outpatient. Geriatricians and other physicians play an influential role in team-based care at both a team and organizational level and work closely with nurse practitioners, physician assistants, registered nurses, social workers, and others. They must be familiar with, become skilled in, and integrate the IPEC competencies in their various practice settings. Team role modeling can facilitate the development of and lead to inclusive, interprofessional teams that deliver efficient, effective, and person-centered care. A clear understanding of and respect for the roles of other health professions and the ability to integrate the various professions into the team has a positive influence on the team and organizational culture. Shared ethics and values, high-quality communication, and purposeful teamwork must also be part of the geriatrician’s knowledge and skills in the primary care practice environment. This establishes a strong foundation for successful care coordination, which can improve patient outcomes.

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References

  1. Rowe JW. The US eldercare workforce is falling further behind. Nat Aging. 2021;1:327–9. https://doi.org/10.1038/s43587-021-00057-z.

    Article  PubMed  Google Scholar 

  2. American Geriatrics Society. Geriatric Workforce by the Numbers. 2019. https://www.americangeriatrics.org/geriatrics-profession/about-geriatrics/geriatrics-workforce-numbers

  3. Akintayo-Usman NO. Fragmentation of care: a major challenge for older people living with multimorbidity. Geriatr Gerontol Aging. 2021;15:1–4.

    Article  Google Scholar 

  4. Donaldson MS, Corrigan JM, Kohn LT, (Eds.). To err is human: building a safer health system. Washington, DC: The National Academies Press; 2000. https://doi.org/10.17226/9728

    Google Scholar 

  5. Richardson WC, Berwick DM, Bisgard JC, Bristow LR, Buck CR, Cassel CK. Crossing the quality chasm: a new health system for the twenty-first century. Washington, DC: The National Academies Press; 2001.

    Google Scholar 

  6. Knebel E, Greiner AC, editors. Health professions education: a bridge to quality. Washington, DC: National Academies Press; 2003.

    Google Scholar 

  7. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative; 2011. https://www.ipecollaborative.org/ipec-core-competencies

    Google Scholar 

  8. Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative; 2016. https://www.ipecollaborative.org/ipec-core-competencies

    Google Scholar 

  9. Reeves S, Lewin S, Espin S, Zwarenstein M. Interprofessional teamwork for health and social care, vol. 8. John Wiley & Sons; 2010. https://doi.org/10.1002/9781444325027.

    Book  Google Scholar 

  10. Fink-Samnick E. Leveraging interprofessional team-based care toward case management excellence. Part 1, history, fundamentals, evidence. Professional Case Manage. 2019;24(3):130–41. https://doi.org/10.1097/NCM.0000000000000360.

    Article  Google Scholar 

  11. Choi BC, Pak AW. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education, and policy: 1. Definitions, objectives, and evidence of effectiveness. Clin Invest Med. 2006;29(6):351–64.

    PubMed  Google Scholar 

  12. Reiss-Brennan B, Brunisholz KD, Dredge C, Briot P, Grazier K, Wilcox A, et al. Association of integrated team-based care with health care quality, utilization, and cost. J Am Med Assoc. 2016;316(8):826–34. https://doi.org/10.1001/jama.2016.11232.

    Article  Google Scholar 

  13. Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med. 2014;12(2):166–71. https://doi.org/10.1370/afm.1616.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Edmondson AC. Teaming: How organizations learn, innovate, and compete in the knowledge economy. John Wiley & Sons; 2012. Hoboken, New Jersey.

    Google Scholar 

  15. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff. 2013;32(11):1881–6. https://doi.org/10.1377/hlthaff.2013.0234. PMID: 24191075

    Article  Google Scholar 

  16. Levengood TW, Peng Y, Xiong KZ, Song Z, Elder R, Ali MK, et al. Team-based care to improve diabetes management: a community guide meta-analysis. Am J Prev Med. 2019;57(1):e17–26. https://doi.org/10.1016/j.amepre.2019.02.005.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Meyers DJ, Chien AT, Nguyen KH, Li Z, Singer SJ, Rosenthal MB. Association of team-based primary care with health care utilization and costs among chronically ill patients. JAMA Intern Med. 2019;179(1):54–61. https://doi.org/10.1001/jamainternmed.2018.5118.

    Article  PubMed  Google Scholar 

  18. Song H, Ryan M, Tendulkar S, Fisher J, Martin J, Peters AS, Frolkis JP, Rosenthal MB, Chien AT, Singer SJ. Team dynamics, clinical work satisfaction, and patient care coordination between primary care providers: a mixed methods study. Health Care Manag Rev. 2017;42(1):28–41. https://doi.org/10.1097/HMR.0000000000000091.

    Article  Google Scholar 

  19. Mitchell P, Wynia M, Golden R, McNellis B, Okun S, Webb CE, Rohrback V Von Kohorn I. Core principles & values of effective team-based health care. NAM Perspectives Discussion Paper, National Academy of Medicine, Washington, DC; 2012.

    Google Scholar 

  20. Sangaleti C, Schveitzer MC, Peduzzi M, Zoboli ELCP, Soares CB. Experiences and shared meaning of teamwork and interprofessional collaboration among health care professionals in primary health care settings: a systematic review. JBI Database System Rev Implement Rep. 2017;15(11):2723–88. https://doi.org/10.11124/JBISRIR-2016-003016.

    Article  PubMed  Google Scholar 

  21. Rice K, Zwarenstein M, Gotlib Conn L, Kenaszchuk C, Russell A, Reeves S. An intervention to improve interprofessional collaboration and communications: a comparative qualitative study. J Interprofession Care. 2010;24(4):350–61. https://doi.org/10.3109/13561820903550713.

    Article  Google Scholar 

  22. Pitkälä KH, Martin FC, Maggi S, Jyväkorpi SK, Strandberg TE. Status of geriatrics in 22 countries. J Nutr Health Aging. 2018 May;22(5):627–31.

    Article  PubMed  Google Scholar 

  23. Stefanacci R, Buffa A. Full-risk population health programs for older adults like PACE benefit from COVID-19. Population Health Manage. 2021;24(3):307–9.

    Article  Google Scholar 

  24. Wong RY. Strategies to promote broad-based implementation of Acute Care for Elders (ACE) units. Geriatrics. 2018;3(3):58.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Nikooie R, Neufeld KJ, Oh ES, Wilson LM, Zhang A, Robinson KA, Needham DM. Antipsychotics for treating delirium in hospitalized adults: a systematic review. Ann Intern Med. 2019;171(7):485–95.

    Article  PubMed  Google Scholar 

  26. Butler DE, Frank KI, Counsell SR. The GRACE model. In: Malone M, Capezuti E, Palmer R, editors. Geriatrics models of care. Cham: Springer; 2015. https://doi.org/10.1007/978-3-319-16068-9_10.

    Chapter  Google Scholar 

  27. Hirschman KB, Shaid E, McCauley K, Pauly MV, Naylor MD. Continuity of care: the transitional care model. Online J Issues Nurs. 2015;20(3)

    Google Scholar 

  28. American Geriatrics Society Health Care Systems and Clinical Practice Committees. Ambulatory geriatric clinical care and services—AGS Position Statement. J Am Geriatr Soc. 2000;48:845–6.

    Google Scholar 

  29. Nordström P, Thorngren KG, Hommel A, Ziden L, Anttila S. Effects of geriatric team rehabilitation after hip fracture: meta-analysis of randomized controlled trials. J Am Med Dir Assoc. 2018;19(10):840–5. https://doi.org/10.1016/j.jamda.2018.05.008. Epub 2018 Jun 27. PMID: 29958818

    Article  PubMed  Google Scholar 

  30. Morton G, Masters J, Cowburn PJ. Multidisciplinary team approach to heart failure management. Heart. 2018;104(16):1376–82. https://doi.org/10.1136/heartjnl-2016-310,598. Epub 2017 Nov 23. PMID: 29170356

    Article  PubMed  Google Scholar 

  31. American Association of Nurse Practitioners. Practice information by state. 2022. https://www.aanp.org/practice/practice-information-by-state

  32. AMA. Physician assistant scope of practice https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/arc-public/state-law-physician-assistant-scope-practice.pdf

  33. AAPA. State Laws and Regulations. https://www.aapa.org/advocacy-central/state-advocacy/state-laws-and-regulations/

  34. Bakerjian D, Boltz M, Bowers B, Gray-Miceli D, Harrington C, Kolanowski A, Mueller CA. Expert nurse response to workforce recommendations made by the coronavirus commission for safety and quality in nursing homes. Nurs Outlook. 2021;69(5):735–43.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Donelan K, Chang Y, Berrett-Abebe J, Spetz J, Auerbach DI, Norman L, Buerhaus PI. Care management for older adults: the roles of nurses, social workers, and physicians. Health Aff (Millwood). 2019;38(6):941–9. https://doi.org/10.1377/hlthaff.2019.00030. PMID: 31158015

    Article  PubMed  Google Scholar 

  36. Chapman SA, Marks A, Dower CJD. Positioning medical assistants for a greater role in the era of health reform. Acad Med. 2015;90(10):1347–52. https://doi.org/10.1097/ACM.0000000000000775.

    Article  PubMed  Google Scholar 

  37. Li X, Dorstyn D, Mpofu E, O’Neill L, Li Q, Zhang C, Ingman S. Nursing assistants and resident satisfaction in long-term care: a systematic review. Geriatr Nurs. 2021;42(6):1323–31. https://doi.org/10.1016/j.gerinurse.2021.08.006. Epub 2021 Sep 22. PMID: 34560527

    Article  PubMed  Google Scholar 

  38. Nazir A, Unroe K, Tegeler M, Khan B, Azar J, Boustani M. Systematic review of interdisciplinary interventions in nursing homes. J Am Med Dir Assoc. 2013;14(7):471–8. https://doi.org/10.1016/j.jamda.2013.02.005. Epub 2013 Apr 6. PMID: 23566932

    Article  PubMed  Google Scholar 

  39. Agency for Healthcare Research and Quality. Care Coordination. https://www.ahrq.gov/ncepcr/care/coordination.html

  40. Wasserman MR. Care management: from channeling to grace. In: Powers J, editor. Healthcare changes and the affordable care act. Cham: Springer; 2015. https://doi.org/10.1007/978-3-319-09510-3_8.

    Chapter  Google Scholar 

  41. Foronda C, MacWilliams B, McArthur E. Interprofessional communication in healthcare: an integrative review. Nurse Educ Pract. 2016;19:36–40. https://doi.org/10.1016/j.nepr.2016.04.005.

    Article  PubMed  Google Scholar 

  42. Heinrichs WM, Bauman E, Dev P. SBAR ‘flattens the hierarchy’ among caregivers. Stud Health Technol Inform. 2012;173:175–82.

    PubMed  Google Scholar 

  43. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998;9(2):117–25. https://doi.org/10.1353/hpu.2010.0233.

    Article  CAS  PubMed  Google Scholar 

  44. Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? The Permanente Journal. 2011;15(2):71–8.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Valaitis R, Cleghorn L, Dolovich L, Agarwal G, Gaber J, Mangin D, Oliver D, Parascandalo F, Ploeg J, Risdon C. Examining interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory. BMC Fam Pract. 2020;21(1):1–14. https://doi.org/10.1186/s12875-020-01131-y.

    Article  Google Scholar 

  46. Law KL, Rowe JM. Team-based care: views from community health center staff. Soc Work Health Care. 2018;57(4):284–99. https://doi.org/10.1080/00981389.2018.1438330.

    Article  PubMed  Google Scholar 

  47. Stevens E, Hulme A, Salmon PM. The impact of power on health care team performance and patient safety: a review of the literature. Ergonomics. 2021; https://doi.org/10.1080/00140139.2021.1906454.

  48. Poghosyan L, Norful AA, Martsolf GR. Primary care nurse practitioner practice characteristics: barriers and opportunities for interprofessional teamwork. J Ambulator Care Manage. 2017;40(1):77–86. https://doi.org/10.1097/JAC.0000000000000156.

    Article  Google Scholar 

  49. Khalili H, Orchard C. The effects of an IPS-based IPE program on interprofessional socialization and dual identity development. J Interprofession Care. 2020; https://doi.org/10.1080/13561820.2019.1709427.

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Bakerjian, D., Wasserman, M.R. (2024). Interdisciplinary Care and Care Coordination. In: Wasserman, M.R., Bakerjian, D., Linnebur, S., Brangman, S., Cesari, M., Rosen, S. (eds) Geriatric Medicine. Springer, Cham. https://doi.org/10.1007/978-3-030-74720-6_99

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  • DOI: https://doi.org/10.1007/978-3-030-74720-6_99

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