Team Care in Geriatrics
High quality health care for older adults must take into account common age-related challenges such as the presence of multiple disorders, geriatric syndromes, impact of events over the individual’s life course, and age-related changes that can affect coping with illness. Such challenges are best served by an interprofessional team approach. According to the Interprofessional Education Collaborative Expert Panel (2011), interprofessional collaboration, or teamwork is viewed as the key to the safe, high quality, accessible, patient-centered care. Teamwork is required in any setting where health professionals interact on behalf of shared goals for care with patients or communities. Teamwork behaviors involve cooperating with other professionals in delivering patient-centered care; coordinating with other professionals so that gaps, redundancies, and errors are avoided; and collaborating with others through shared problem-solving and shared decision making (IPEC, 2011). The quotes that follow from Duke GEC faculty provide some insights into how various clinicians engage in teamwork behaviors to better manage care for older adults who are at risk for delirium or who are suffering from delirium.
Mitch Heflin, MD
As a geriatrician in a teaching hospital, I wear many hats. Geriatricians are physicians trained in internal medicine or family practice who choose to pursue a year of additional specialized training in the care of older adults. As a clinician, I provide care in our outpatient comprehensive assessment clinic where I see older adults and their caregivers along with a team of providers that includes a nurse, a social worker and often a pharmacist. These patients often have complex medical problems and personal care needs. I also work in the hospital seeing patients who have a variety of problems, including dementia and delirium, difficulty with balance and falls, and multiple medical problems and medications. As a teacher, I provide direct instruction to a variety of learners from a variety of professions. Geriatrics, perhaps more than any specialty, relies on teamwork and, as a result, we are trying to bring students together from different professions to learn how to more effectively communicate and work together and, as a result, take better care of older adults. To that end, I also work with teams of teachers to plan courses and other learning experiences that will improve our ability to educate students about this important field.
Ellie McConnell, PhD, RN, GCNS,BC
As a clinical nurse specialist, I alert the clinical team to risk factors for delirium, and focus on their management. Important ones for nurses include pain management, preserving sleep wake-cycles, compensating for sensory impairments, and promoting hydration. For patients who develop delirium, one of the most critical roles for a nurse is “thinking for two” – being alert to how much the patient is taking in (both fluid and food), and managing safety risks.
Lisa P. Shock, MHS, PA-C
As a Physician Assistant (PA) - I am a front line clinician, working with physicians and other interprofessional members of the health care team to recognize, treat and prevent delirium. PAs practice in every health care setting and in every medical specialty. It is critical that all team members work together to ensure early recognition of delirium. Recognition can often be challenging and as a diagnosis, delirium is often missed or diagnosed later in its course, directly affecting patient morbidity and mortality. Risk factor education and interprofessional communication across transitional care settings ( ie hospital to long term care to home) are two key elements that must be consistently fostered in order to effect and improve patient outcomes.
Families and friends of high risk elder patients often know first that something is not quite right with their loved one. It is critical that these family members advocate for their loved ones within the health care system. Alerting members of the team when behavior may be changing or when there is increased inattention or sleep disturbance is critical. Persistence is often required and necessary and will ultimately be welcomed as a delayed diagnosis of delirium can be harmful and have adverse outcomes for patients. Education regarding risk factor recognition and clear interprofessional communication are critical components of elder care for patients who are at high risk.
Heidi White, MD
As a consultant in the hospital, I encourage physician teams to get me involved early if they have a patient that is at high risk for delirium. This would be patients who are over the age of 85, have a diagnosis of dementia, or have multiple chronic medical conditions. I am much better at working with family members, nurses and other team members to avoid delirium. Once delirium takes hold, it is difficult to treat and can take a long time to resolve.
As a physician taking care of nursing home patients, I am always all the lookout for signs of delirium. For many of these frail cognitively impaired patients delirium may be the first sign of illness. We have to work quickly to figure out what is contributing to their delirium so we can avoid sending them to the hospital and have the best chance for a quick resolution of these symptoms that can have profound negative effects on their wellbeing.
Mamata Yanamadala, MD
As a geriatrics consultant in the hospital, I help the primary teams in managing their complicated elderly patients presenting with issues such as falls, medication complications, delirium and dementia. I instruct several learners while managing the patients. I try to emphasize to my learners that caring for elderly demands strong inter-professional team work and coordination with the patients’ caregivers as most elderly have multiple co-morbidities and communication barriers due to sensory and cognitive impairment.
Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.