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Geriatrics, Inter-professional Practice and Inter-organizational Collaboration (GiiC): Primary Care Lessons. David Ryan, PhD, Regional Geriatric Program of Toronto, University of Toronto

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Geriatrics, Inter-professional Practice and Inter-organizational Collaboration (GiiC): Primary Care Lessons

David Ryan, PhD, Regional Geriatric Program of Toronto, University of Toronto

Cheryl Cott Ph.D. William Dalziel MD, Dr. Iris Gutmanis PhD, David Jewell MSW, Mary Lou Kelley PhD, Barbara Liu MD & John Puxty MD


What is frailty? Inter-organizational Collaboration (GiiC): Primary Care Lessons

Complex bio-psychosocial and functional difficulties co-occur.

Risk of adverse health events is high

Independence and self-worth are

easily compromised

Risk of institutionalization is high

A fast growing demographic

Frailty brings increased need for health care services and demands high levels of teamwork and inter-sectoral collaboration.


“Go to where the puck is going to be” Inter-organizational Collaboration (GiiC): Primary Care Lessons

Wayne Gretsky’s Dad


Articles on Teamwork in the Journal of Orthopsychiatry by Decade,since the Journal began in 1930

25

20

15

# of Articles

23

10

16

5

8

6

5

5

4

0

30s

40s

50s

60s

70s

80s

90s

From moral treatment to mental hospitals

The medical model and the orthopsychiatric trinity

The trinity won the right to treat

Sociotherapy and broadening of the mental health team

Community mental health and sociotherapy’s democracy

Hospitals emptied and community mental health funding dwindled

DRG’s, managed care and mental health fragmentation

Integrated care and inter-team collaboration

Decades



Funding supported 90 interprofessional research & development projects

Regulatory Colleges formed an interprofessional care working group

Investment in Academic Interprofessional Education & Training eg:

interprofessional coaching

interprofessional mentoring

interprofessional preceptorship

stand alone and embedded interprofessional curricula

Investment in interprofessional development in the practice environment eg:

Interprofessional care of the diabetic foot

Accountability Framework for Regulated and Unregulated Health Care Providers in Long Term Care

Interprofessional prevention of delirium in the Emergency Department

Geriatrics, Interprofessional Practice & Inter-organizational Collaboration (GiiC) Initiatives


What we wanted . . . development projects

Health professionals still aren’t being sufficiently trained in geriatrics

Help us to build the health human resources needed for an aging population

Going to where the puck is . . .

“Just putting people to together to work doesnt necessarily produce effective teamwork let us help build your 200 new family health teams”

“Teamwork is the traditional method of service delivery in geriatrics. Let us use geriatrics as a clinical focus through which we can train family health teams”

“We are in the integration era but no-one is trained let us add our inter-organizational collaboration skills into the mix”

“Then let us help the entire circle of care work from a common toolkit”

. . . Suddenly the puck was on our stick


GiiC: Family Health Teams/Community Health Centers development projects

GiiCPlus: Community Care Access Centers, Public Health and Community Support Agencies

GiiC Plus: Patients Families and Health Care Teams

GiiC Hospitals: Seniorfriendlyhospitals.ca


Clinical Focus development projects

Never

Only if symptoms

Routinely every 6 months

Routinely every year

Use of Standardized Tools

Continence Screening

12%

68%

0%

25%

9%

Drive Safe Protocol

12%

73%

5%

26%

12%

Polypharmacy Reviews

5%

35%

19%

41%

18%

Cognitive Screening

3%

85%

0%

13%

92%

Geriatric Practice in FHTs

Delirium Screening

24%

73%

0%

2%

32%

11%

ADL/IADL

Assessment

74%

3%

18%

41%

Depression Screening

0%

74%

78%

2%

20%

Falls Risk Assessment

13%

64%

0%

23%

29%

Abuse Screening

20%

2%

15%

25%

63%


When is a family health team not a high performance team? development projects

When it is an organization – some family health teams have 250 people

When it is a network - some family health teams have docs in their offices and a new building in the middle of town for allied health folks

When it doesn’t take on the qualities of team – one manager had a “closed door policy”

When its roles are fixed, leadership hierarchical and everyone does their own thing.


When is a family health team not a high performance team? development projects

When it excludes unregulated employees from making credible contributions


When is a family health team not a high performance team? development projects

When the “shadow workforce” is not incorporated in team proceedings

  • The distinction between “formal” and “informal” care giving does not reflect the reality of the work of many family caregivers who are often:

  • Geriatric Case Managers

  • Mobile medical records

  • Service gap fillers

  • Continuous care providers

  • Acute change of condition monitors

  • Paramedic service providers

  • Quality Control experts

  • Inter-organizational boundary crossing

  • Continuing medical education students

  • (From Brookman & Harrington: 2007)


‘Edumetrics” and the Knowledge-To-Practice Process development projects

In the continuing health professional education world a new model has emerged in the pursuit of practice change outcomes

Knowledge translation, knowledge transfer, implementation science and the knowledge-to-practice process emerged as guiding constructs

Central to all, is the idea that practice change is more likely to the extent that researchers engage ‘subjects’ more actively in the development of research questions and the dissemination of findings.


GiiC researchers wanted development projects to understand the performance of family health teams, standardize a Dimensions of Teamwork Survey (DTEAM) for use by Family Health teams and compare DTEAM surveys with social network analyses, and improve interprofessional practice.

Fifty-five participating Family Health Teams wanted information on the quality of their teamwork and how they stood with regard to other similar teams.


Dimension of development projects

Teamwork

Level of Inter-professional Teamwork

Below Average

Levels of Teamwork

(One standard deviation below the group mean )

Teams at Average Levels

of Teamwork

(Within +/- one standard deviation of the group mean )

High Performance Teamwork

(One standard deviation above the group mean )

Patient and Inter-team focus

5 (9%)

40 (73%)

10 (18%)

Team members strengths and skills

7 (13%)

40 (73%)

10 (18%)

Communication and Conflict Management

9 (16%)

39 (71%)

7 (13%)

Roles and Interdependence

9 (16%)

35 (64%)

11 (20%)

Clarity of Team Goals

11 (20%)

35 (64%)

9 (16%)

Decision-making and leadership

9 (16%)

36 (68%)

10 (18%)

Organizational Support

12 (22%)

38 (69%)

5 (9%)

Total teamwork

9 (16%)

37(68%)

9(16%)

The distribution of high performance teamwork in a sample of 55 family health teams using the Dimensions of Teamwork Survey


When environments require complex interdependency the quality of collaborative alliances may predict outcomes better than the internal processes of individual teams (Pfeiffer, 86)


And then we started working on the “community care” side of the health system where the world is different and so are teams


On Emergence in Community Based Shared Care of the health system where the world is different and so are teams

Initial conditions

Health professionals don’t own the space

Co-caregivers may not know each other

Care providers are inter-organizational

Regulated and unregulated providers

Unpaid “shadow workforce” prevails

Interactions are non-linear

Self-organizing

Local ecology and regional diversity

Strength of ties is variable

No single agent knows everything

Practice Jazz

Lots of surprises

No standardization

Improvisational

Sense-making

Local Adaptations

Co-evolving

Patient Focused Community Based Teamwork


Questions for the Interprofessional Academies of the health system where the world is different and so are teams

Are we responding to emerging conditions?

Does it matter how the word ‘team’ is used?

Are we developing the essential skill sets?

What is the relationship between teams and the shadow workforce?

How are regulated and unregulated health professionals working together

Is ‘knowledge-to-practice process’ in the curriculum?

Is ‘team’ the right concept for community based health care collaboration?

Are we heading to where the puck is going now?

Economic Recession

Integration

Quality Management

Safety


That’s all for now of the health system where the world is different and so are teams

Goodnight Irene

http://giic.rgps.on.ca

[email protected]


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