Interdisciplinary Geriatric Teams: response to a colleague

 
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Interdisciplinary Geriatric Teams: response to a colleague

Interdisciplinary Geriatric Teams: response to a colleague
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Care of the elderly population cannot be fully complete without the input of all the interdisciplinary professional teams. The American Geriatrics Society (AGS, 2011), noted that geriatric care promotes preventive care that is centered on care coordination and management to maintain functional independence.  I currently do my practicum in one of the VA Community Living Centers (CLC), and I noted that the Program of All-Inclusive Care for the Elderly (PACE) Model is being utilized by the facility. The PACE Model was developed to “promote effective and efficient treatment of patients with multiple chronic conditions outside of the hospital setting” (Casiano, 2015). The AGS, (2011) also noted that, this model empowers the individual to live independently in the community with a high quality of life. The interdisciplinary geriatric care team comprises of the unit physician, advanced nurse practitioner (ANP), registered nurse, physical, occupational, speech, and recreational therapists, neuropsychologist, psychiatrist, nutritionist, and podiatrist. All these professionals work together to provide high quality care for the veterans, keeping them out of the hospital, and making them independent in their activities of daily living.

Interdisciplinary Geriatric Teams: response to a colleague

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Interdisciplinary Geriatric Teams: response to a colleague

With regards to other sites of care such as the hospital, the nursing homes and the rehabilitation centers, different models of care are used. For instance, in the hospital, the Geriatric Resource Nurse (GRN) is used based on the “belief that the primary nurses know the most about the daily patterns and needs of the older adults in their units” (Flaherty & Resnick, 2011). Although the nurses work hand in hand with the physicians and the nurse practitioners, they carry the workload of the patients and serve as resource for geriatric practices. I also noted that, the primary care clinics use the Guided Care Model where a registered nurse assists three to four physicians in providing care for the patients.

Interdisciplinary Geriatric Teams: response to a colleague Differences on ANP roles based on sites

At CLC levels, the NP practices in collaboration with the unit physician, but in the absence of the unit attending, the NP practices independently. In some primary care clinics, NPs are independent practitioners, but in some clinics, though they are independent, there is a physician overseeing their activities. During my Primary care practicum a few months ago, one of the physicians was telling me that when he practiced outside the VA in the primary care clinic, his team of caregivers included NP, RN, LPN, and a tech. He stated that, the NP had her own patients that she was seeing, but he had to oversee her practices per the policy of the facility. He added that “but that NP was great, in my absence she took care of all my patients including hers”.

Interdisciplinary Geriatric Teams: response to a colleague Model of care for Case Study #2

Mr. William certainly has multiple chronic diseases which requires an interdisciplinary team to manage his care.  The PACE Model, which was developed to promote effective and efficient treatment for patients with comorbidities like Mr. William will be effective in managing his care as well as empowering him to  live independently in the foster home. Mr. William will need the care of a physical and occupational therapists for muscle strengthening and ADLs. His history of benign prostatic hypertrophy (BPH) can also cause him to use the bathroom frequently, and given his unsteady gait, he is at risk for falls. Therefore, he will also benefit from a urologist. Buttaro, Trybulski, Polgar Bailey, & Sandberg-Cook (2013) noted BPH is common among elderly men and symptoms include urinary frequency, urgency, and nocturia. The other team that should be involved in Mr. William’s care is the ophthalmologist to evaluate and treat his sight.
References
American Geriatrics Society. (2011). The principles of geriatric care. Retrieved from
http://www.americangeriatrics.org
Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2013). Primary care: A
            collaborative practice (4 ed.). St Louis, MO: Mosby.
Casiano, A. (2015). PACE: A model of care for individuals with multiple chronic conditions
Retrieved from
http://www.managedhealthcareconnect.com/article/pace-model-care-individuals-multiple-chronic-conditions
Flaherty, E. & Resnick, B. (2011). Geriatric nursing review syllabus: A core curriculum in
advanced practice geriatric nursing (3^rd ed.). New York, NY: American Geriatrics Society.
Required:
•   Offer and support an alternative perspective based on your own experience and additional literature search.
OR
•   Validate an idea with your own experience and additional literature search.

Introduction

Older patients often develop multiple conditions requiring attention and specific approaches to care. To treat such persons, health care providers cannot engage a single specialist as he/she may not have a full range of skill to address all arising problems. Thus, multiple people need to participate in patient care together, forming an interdisciplinary team of specialists as a result. Currently, there are many geriatric teams operating in different environments: hospitals, homes, and rehabilitation facilities. It should be noted that the majority of teams include nurses, whose role is often significant to the patient’s outcomes. In a model of care titled GRACE (Geriatric Resources for Assessment and Care for Elders), advanced practice nurses are responsible for care management and in-home assessment activities.

Models for Interdisciplinary Geriatric Teams

Many approaches to geriatric patient care are discussed in scholarly research. For instance, one can outline such models as BOOST (Better Outcomes for Older adults through Safe Transitions) and INTERACT (Interventions to Reduce Acute Care Transfers) (Hansen et al., 2013; Ouslander, Bonner, Herndon, & Shutes, 2014). The first format includes social workers, nurses, and therapists overseen by an advanced practice nurse and focused on the patient’s safe transition from a hospital to home-based care. The second model is mostly used in nursing homes – this program incorporates physicians, nurses, and administrators, creating an effective framework for addressing acute changes in one’s health.
Another approach, which is currently being implemented at my practicum site, is GRACE. The leading specialists engaged in this model are nurse practitioners and social workers (Ritchie et al., 2016). They lead care management practices performed by a team of mental health specialists, community workers, pharmacists, and medical directors. GRACE focuses on individualized plans for patients with several conditions such as hearing loss, depression, difficulty walking, and others. In comparison to such models as INTERACT, GRACE does not view acute changes as the only requirement for action – the environment of the patient is also considered as a factor that needs management (Kubat, 2016).

The Role of the Advanced Practice Nurse

While advanced practice nurses have a similar set at all places of work, their roles may differ according to the specific site. For instance, in home-based care, nurse practitioners act as managers and evaluators of other specialists’ work. According to the GRACE model, their collaboration with social workers is aimed at reviewing all factors affecting patients’ health and improving them through working with other medical professionals (Ritchie et al., 2016). In the INTERACT model, nurses in nursing homes evaluate acute conditions of patients to decide whether treatment is necessary (Ouslander et al., 2014). In a hospital, nurses may be responsible for discharge planning and lowering the length of one’s stay (Hansen et al., 2013).

Analysis

In the first case study, Mrs. Martinez does not have many activities available to her during her free time. According to the GRACE model, it is not necessary to transfer Mrs. Martinez to a nursing home. Instead, a social worker and an advanced practice nurse should assess her living conditions and work together with the rest of the team to improve her environment (Kubat, 2016). Moreover, they should regularly check on Mrs. Martinez and design a specific plan that would both relieve her daughter form daily care and help Mrs. Martinez find an interesting way to spend time. Leisure time activities can drastically improve one’s mental and physical health (Ritchie et al., 2016). Therefore, they are directly connected to the model of care and should be addressed by the care team.

Conclusion

Models of interdisciplinary care teams address different problems of older people in various conditions. Some approaches work in nursing homes, where acute changes are easy to monitor and treat. Other programs are focused on helping patients to leave the hospital and adjust to home-based care. GRACE is a model that assesses patients’ surroundings and creates personal plans for health management. In all models, nurses play a significant role, leading teams, evaluating their direction and actions, and choosing the path for future care.

References

Hansen, L. O., Greenwald, J. L., Budnitz, T., Howell, E., Halasyamani, L., Maynard, G.,… Williams, M. V. (2013). Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. Journal of Hospital Medicine, 8(8), 421-427.

Kubat, B. (2016). The amazing GRACE care team model. Caring for the Ages, 17(5), 6-7.
Ouslander, J. G., Bonner, A., Herndon, L., & Shutes, J. (2014). The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: An overview for medical directors and primary care clinicians in long term care. Journal of the American Medical Directors Association, 15(3), 162-170.
Ritchie, C., Andersen, R., Eng, J., Garrigues, S. K., Intinarelli, G., Kao, H.,… Barnes, D. E. (2016). Implementation of an interdisciplinary, team-based complex care support health care model at an academic medical center: Impact on health care utilization and quality of life. PloS One, 11(2), e0148096.
Name:  Discussion Rubric

		Excellent 90–100	Good 80–89	Fair 70–79	Poor 0–69
Main Posting: Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.		40 (40%) – 44 (44%) Thoroughly responds to the Discussion question(s). Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. No less than 75% of post has exceptional depth and breadth. Supported by at least three current credible sources.	35 (35%) – 39 (39%) Responds to most of the Discussion question(s). Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. 50% of the post has exceptional depth and breadth. Supported by at least three credible references.	31 (31%) – 34 (34%) Responds to some of the Discussion question(s). One to two criteria are not addressed or are superficially addressed. Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module. Cited with fewer than two credible references.	0 (0%) – 30 (30%) Does not respond to the Discussion question(s). Lacks depth or superficially addresses criteria. Lacks reflection and critical analysis and synthesis. Does not represent knowledge gained from the course readings for the module. Contains only one or no credible references.
Main Posting: Writing		6 (6%) – 6 (6%) Written clearly and concisely. Contains no grammatical or spelling errors. Adheres to current APA manual writing rules and style.	5 (5%) – 5 (5%) Written concisely. May contain one to two grammatical or spelling errors. Adheres to current APA manual writing rules and style.	4 (4%) – 4 (4%) Written somewhat concisely. May contain more than two spelling or grammatical errors. Contains some APA formatting errors.	0 (0%) – 3 (3%) Not written clearly or concisely. Contains more than two spelling or grammatical errors. Does not adhere to current APA manual writing rules and style.
Main Posting: Timely and full participation		9 (9%) – 10 (10%) Meets requirements for timely, full, and active participation. Posts main Discussion by due date.	8 (8%) – 8 (8%) Meets requirements for full participation. Posts main Discussion by due date.	7 (7%) – 7 (7%) Posts main Discussion by due date.	0 (0%) – 6 (6%) Does not meet requirements for full participation. Does not post main Discussion by due date.
First Response: Post to colleague’s main post that is reflective and justified with credible sources.		9 (9%) – 9 (9%) Response exhibits critical thinking and application to practice settings. Responds to questions posed by faculty. The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.	8 (8%) – 8 (8%) Response has some depth and may exhibit critical thinking or application to practice setting.	7 (7%) – 7 (7%) Response is on topic and may have some depth.	0 (0%) – 6 (6%) Response may not be on topic and lacks depth.
First Response: Writing		6 (6%) – 6 (6%) is professional and respectful to colleagues. Response to faculty questions are fully answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	5 (5%) – 5 (5%) is mostly professional and respectful to colleagues. Response to faculty questions are mostly answered, if posed. Provides opinions and ideas that are supported by few credible sources. Response is written in standard, edited English.	4 (4%) – 4 (4%) Response posed in the Discussion may lack effective professional communication. Response to faculty questions are somewhat answered, if posed. Few or no credible sources are cited.	0 (0%) – 3 (3%) Responses posted in the Discussion lack effective communication. Response to faculty questions are missing. No credible sources are cited.
First Response: Timely and full participation		5 (5%) – 5 (5%) Meets requirements for timely, full, and active participation. Posts by due date.	4 (4%) – 4 (4%) Meets requirements for full participation. Posts by due date.	3 (3%) – 3 (3%) Posts by due date.	0 (0%) – 2 (2%) Does not meet requirements for full participation. Does not post by due date.
Second Response: Post to colleague’s main post that is reflective and justified with credible sources.		9 (9%) – 9 (9%) Response exhibits critical thinking and application to practice settings. Responds to questions posed by faculty. The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.	8 (8%) – 8 (8%) Response has some depth and may exhibit critical thinking or application to practice setting.	7 (7%) – 7 (7%) Response is on topic and may have some depth.	0 (0%) – 6 (6%) Response may not be on topic and lacks depth.
Second Response: Writing		6 (6%) – 6 (6%) is professional and respectful to colleagues. Response to faculty questions are fully answered, if posed. Provides clear, concise opinions and ideas that are supported by two or more credible sources. Response is effectively written in standard, edited English.	5 (5%) – 5 (5%) is mostly professional and respectful to colleagues. Response to faculty questions are mostly answered, if posed. Provides opinions and ideas that are supported by few credible sources. Response is written in standard, edited English.	4 (4%) – 4 (4%) Response posed in the Discussion may lack effective professional communication. Response to faculty questions are somewhat answered, if posed. Few or no credible sources are cited.	0 (0%) – 3 (3%) Responses posted in the Discussion lack effective communication. Response to faculty questions are missing. No credible sources are cited.
Second Response: Timely and full participation		5 (5%) – 5 (5%) Meets requirements for timely, full, and active participation. Posts by due date.	4 (4%) – 4 (4%) Meets requirements for full participation. Posts by due date.	3 (3%) – 3 (3%) Posts by due date.	0 (0%) – 2 (2%) Does not meet requirements for full participation. Does not post by due date.
Total Points: 100

Name:  Discussion Rubric