Approaching the complex patient in a skilled nursing facility: Interprofessional team strategies

1. Approaching the complex patient in a skilled nursing facility: Interprofessional team strategies Hannah Johnson, PT, DPT, GCS January 21, 2019 Concordia University Wisconsin School of Health Professions Conference

2. Objectives • Synthesize professional perspectives on what defines a “complex” patient in terms of clinical stability, medical and psychiatric comorbidities, and psychosocial factors • Verbalize benefits and challenges of working in an interprofessional health care team • Note similarities and differences between complex patient management in a skilled nursing facility (SNF) setting and one’s own practice area

3. Content outline • Interprofessional teams defined and defended • General definitions • SNF-specific definitions • Roles of interprofessional team (IPT) members in a SNF setting • Benefits and challenges of IPTs • What defines a complex patient? • Literature review • Suggestions from experience • How can IPTs address the complex patient? • Benefits to leverage • Obstacles to avoid or address • Case examples

4. Interprofessional teams (IPTs): why use this approach? (Mitchell et al., 2012; Neumann et al., 2010; Clerencia-Sierra et al., 2015) • Do you work on a team? If so . . . • Where does it function? • Who is on it? • What does it do well? • What are its goals? • Accelerate innovation (Rogers’ curve) • Varied scope and duration • No single definition • Evidence-based care • Typically led by experienced MD • Diverse members treat within ICF • Multifaceted patient presentations • Patterns of multimorbidity with geriatric syndromes • Beyond number of conditions

5. Defining the IPT: general concepts (Mitchell et al., 2012; Camicia et al., 2013; Neumann et al., 2010) • Coordination, collaboration, and commonality • Values: honesty, transparency, discipline, creativity, idea-sharing, humility, trust, curiosity • Principles: shared performance goals, clear roles, trust, communication, measurable processes and outcomes • At least 2 health care providers • Include the patient • Need common aims, language, knowledge, skills, trust, respect, openness, expertise

6. Defining the IPT: SNF-specific (Camicia et al., 2013; Shippee et al., 2017; Warshaw and Bragg, 2014) • Care coordinator identity (RN or MD) depends on resources and patient needs • Diverse options: PA, marriage/family therapist, chaplain, hospice, county • Palliative care/hospice considerations • Direct care workers (DCWs) are CNAs or HHAs • Majority of care provision • ACA requires 75 hours training; IOM recommends 120 • Wage gap issues • Lower Medicare (T18) reimbursement • Even lower Medicaid (T19) reimbursement • Time-consuming clinical decision making

7. IPT member roles (Loeb et al., 2015; Camicia et al., 2013) • Medical director is an MD, usually coordinates care in collaboration with nursing (RN or NP) and social worker (SW) • Rehabilitation: • Physical therapy (PT) • Occupational therapy (OT) • Speech therapy (ST) • Clinical care and specialists: • Physician assistant (PA) • Pharmacist • Care transition person(s) • Diagnosticians (phlebotomist, mobile X-ray tech) • Monthly podiatry, audiology, ophthalmology • Other: • Activities director • Admissions/marketing

8. Benefits of IPTs (Camicia et al., 2013; Hartrick Doane et al., 2012; Tsakitzidis et al., 2016) • Care coordination • Required by ACOs • Reduces medical costs • Improves survival, emergency services usage, patient confidence in self-management, safe care transitions, satisfaction, and outcomes • Less service duplication (one measurement of care coordination) • End-of-life care • Resource efficiency • Innovation • Holistic care • Practical professional development

9. Challenges of IPTs (Mitchell et al., 2012; Huls et al., 2015; Hartrick Doane et al., 2012; Lencinoni, 2002) • External to team: • Reimbursement structures! • Lack of role models • Facility resistance to change • Lower resources in SNFs versus hospitals • Lack of suitable care models (palliative care mostly) • Tension between autonomy and interprofessional practice • Internal to team: • Communication - quality, amount • Five core dysfunctions: • Inattention to results • Avoidance of accountability • Lack of commitment • Fear of conflict • Absence of mutual trust

10. Patient complexity: how is it defined? (Nelson et al., 2016; Grant et al., 2011; Loeb et al., 2015; Zulman et al., 2014; Shippee et al., 2012; Wyatt et al., 2014) • Terms: • Clinical practice guidelines (CPGs) • Multiple chronic conditions (MCC) • Substance use disorder (SUD) • Randomized controlled trials (RCTs) • Evidence-based practice (EBP) • Electronic health record (EHR) • Algorithm • Problems: • CPGs rarely address comorbidities • Comorbidity management under-trained • RCTs exclude persons with MCC → clinical populations are not reflected • At this time, MCC research is mostly descriptive, not prescriptive

11. Patient complexity: How is it defined? (continued) • Common algorithms for complexity: • Charlson score: age, 16 diagnoses → death • Higashi method: 9 chronic conditions • Centers for Medicare and Medicaid Services (CMS) tool: costs, age, diagnoses → hospitalization • MDs’ views: • Younger age + mental illness + SUDs • Older age + more decision making + care coordination • Older age, uncontrolled diabetes, antipsychotic use, alcoholism • Socioeconomic (homelessness, poverty, low health literacy/insurance) • Behavioral (demanding, arguing) • Lack of controllability by the health care professional

12. Patient complexity: How is it defined? (continued) • Zulman et al. (2014): considerations • Comorbidities interact • Uncertain diagnoses • Medication choices • Weigh risks/benefits of each treatment • Behavioral/environmental influences • Develop EHR as data source for MCC care quality, reimbursement, performance assessment and reward for cognitive load • Shippee et al. (2012): cumulative complexity model customized to patient’s experience: • Patient workload • Patient capacity • Interaction of workload and capacity

13. IPTs and the complex patient: Benefits to leverage (Shippee et al., 2012; Tsakitzidis et al., 2016; Hartrick Doane et al., 2012; Zulman et al., 2013 and 2016; Ford et al., 2013; Giovannetti et al., 2015; Katzenbach and Smith, 1993) • Combined knowledge and skill • Communicate + coordinate = collaborate • Consistent staffing • Involve patient, family, MD, pharmacist • Long-term leader to facilitate good dynamics and model appropriate behaviors • Awareness of Rogers’ adoption/innovation curve • Innovators (2.5%) • Early adopters (13.5%) • Early majority (34%) • Late majority (34%) • Laggards (16%)

14. IPTs and the complex patient: Obstacles to avoid or address • Lack of CPG guidance especially for MCC • Difficulties in meeting time • Lack of standard complexity definition • Lack of outcome measures of team performance • Fragmented care transitions prevalent • Katzenbach and Smith (1993): • Inattention to strict application of team basics (mutual skills, accountability, commitment) • Focus on “teams” over performance • Lack of concrete, consistent leadership support • Inaccurate understanding of “teams” and shared vocabulary • Excessive individuality

15. IPTs and the complex patient: Case examples (Boyd and Fortin, 2010; Katon et al., 2010) • 79 year old hypothetical woman • Moderate osteoporosis • Osteoarthritis • Diabetes mellitus (type 2) • Hypertension • COPD • Following each CPG results in: • 12 medications with 19 doses/day • 14 contradictorynon-pharmacological treatments (diet, exercise, labs, appointments, and lifestyle modification) • Adverse interactions: drug-condition, drug-drug, food-drug • Considerations: no disease is central; patient must prioritize; lack of appropriate outcome measures; adherence impossible

16. IPTs and the complex patient: Case examples (continued) https://aims.uw.edu/teamcare • TEAMcare study (Katon et al., 2010) included persons with comorbid CAD, type 2 diabetes, and depression: • Complexity involves poor control of MCC, behavioral/mental health concerns, costs • Behavioral targets: exercise + medication adherence • Software for decision support • Team = half-time RN manager (35-50 patient caseload), PCP supervision, internist, psychiatrist, family physician • Intervention = initial face-to-face visit, phone check-ins 1-2 times monthly • Excluded SNF residents but a good start • Improved outcomes over usual care • Lower costs over a 12-month period

17. Take-home points • Interprofessional teams (IPTs) • Include the patient • Require close coordination and communication • Accelerate evidence-based care • Complex patients • Are difficult to define • Challenge individual providers and IPTs • Can be the norm in many SNFs • Avoid team dysfunctions of • Inattention to results • Avoidance of accountability • Lack of commitment • Fear of conflict • Absence of mutual trust

18. Questions and comments? Thank you for attending! Contact: hannah.johnson1@cuw.edu

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