Geriatric Interdisciplinary Teams

An approach to care of the elderly patient in which team members from different disciplines collectively set goals and share resources and responsibilities.

Not all elderly patients need a geriatric interdisciplinary team. However, for patients who have complex medical, psychologic, and social needs, teams are more effective in assessing patient needs and creating an effective care plan than are professionals working alone. Frail elderly patients benefit from interdisciplinary teams, as do caregivers, whose strengths and needs can be incorporated into the care plan.

To create, monitor, or revise the care plan, interdisciplinary teams must communicate openly, freely, and regularly. Core team members must collaborate with trust and respect for the contributions of others and coordinate (ie, delegate, share accountability, jointly implement) the care plan. Some team members work together at the same site, so communication can be informal and expeditious.

Interdisciplinary teams differ from multidisciplinary teams, from which they evolved (see Table 7-1); multidisciplinary teams create discipline-specific care plans and implement them simultaneously without explicit regard to their interaction. Interdisciplinary teams also differ from transdisciplinary teams, in which each team member must be so familiar with the roles and responsibilities of other members that tasks and functions become, to some extent, interchangeable.

Core members of a geriatric interdisciplinary team represent geriatric medicine, nursing, social work, and pharmacy (see Table 7-2). Other members may represent physical or occupational therapy, home health ("visiting") nursing, psychiatry or psychology, nutritional counseling, or podiatry as needed (on an ongoing basis or for consultation). The roles of these other members are discussed elsewhere in this manual.

To be effective team members, physicians must be knowledgeable about geriatric medicine, familiar with the patient, dedicated to the team process, and have good communication skills. As team members, physicians offer and explain the medical conditions and differential diagnoses that affect care; they then incorporate the team advice into medical orders. In general, physicians must write medical orders agreed on through the team process. The physician should alert the patient, family members, and/or caregivers about team decisions.

A formal team structure and ongoing maintenance are necessary at all stages. Teams should set deadlines for reaching their goals and have regular meetings to discuss team structure, process, and communication. These meetings are essential to maintain efficiency, continuous improvement, and respect for the process and for other team members, including patients and their caregivers. In general, team leadership should rotate, with the key provider of care reporting on the patient's progress. For example, if the major concern is the medical condition of the patient, a physician should lead the team meeting and introduce the team to the patient and family members. Frequently, the nurse practitioner or social worker updates the team on the patient's progress. Team effectiveness should be defined by specific goals at the outset and monitored by continuous quality improvement measures.

Patient and caregiver issues: Patients and caregivers are part of the team. For example, patients can help the team set goals (eg, advance directives, end-of-life care). They can also discuss drug treatment, rehabilitation, dietary plans, and other forms of therapy. If the team learns that the patient will not take a particular drug or change certain dietary habits, care can be modified accordingly. The team and patient must develop ways to communicate honestly to prevent the patient from suppressing an opinion and agreeing to every suggestion.

Caregivers, including family members, can also enhance the team's goals by identifying realistic and unrealistic expectations based on the patient's habits and lifestyle.

To effectively incorporate patients and caregivers as team members, teams must listen, communicate genuine interest, consider ideas provided by patients and caregivers, respect differing opinions, and follow up with all other members of the team. Methods to better incorporate patients and caregivers should be established at the beginning of every team meeting; the team should later review these methods to determine if they were successful.