Module 4: Interdisciplinary Collaboration in the Primary Care of the Older Adult - Overview

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This module was developed by Robin I. Miller, MS, RN, CNS, APRN-BC. For additional background on Ms. Miller, select the name.

Introduction

Older adults are challenging clients because they present a complex clinical picture, a composite of the interactions between normal aging changes, chronic illness, functional change, and at times acute illness. Interdisciplinary teams (IDTs) have been found to be particularly effective in dealing with the management of complex chronic illness, and therefore have become extremely common in geriatric evaluation and management programs (Fulmer & Abraham, 1998; Powers et al, 2000). Multiple studies have demonstrated the effectiveness of interdisciplinary teams in providing higher quality care and improving outcomes for frail elders with complex care needs (Sommers, Martin, Barbaccia, & Randolph, 2000; Burns, Nichols, Martindale-Adams, & Graney, 2000; Kresevic & Holder, 1998).

In this module, you will learn about the interdisciplinary provision of services to older adults.

• Which clients most benefit from this approach?
• What makes interdisciplinary geriatric care different from "care as usual"?
• How are the roles of the different professions determined?
• What are the issues in developing and maintaining an effective interdisciplinary team?
• How can an advanced practice nurse develop the skills necessary to lead a team of diverse professionals?

To answer these questions, the module introduces four topics. The first topic, What Do IDT's Offer to Geriatric Patients? will provide an overview of the philosophy behind IDT care of elders. You will develop criteria to help you determine when this approach is appropriate and likely to be beneficial. The second topic, The Care and Feeding of Interdisciplinary Teams, will explore the development and leadership dynamics of geriatric care teams. In this topic you will learn how to analyze team dynamics and work to improve team processes. The third topic, Implementing Interdisciplinary Collaboration in Primary Care, addresses some of the practicalities of this approach to geriatric care in a clinic setting. In this topic you will develop a plan for assigning roles to team members depending on the availability of the health professions and on the needs of your older patients. In the fourth topic, Putting It All Together: The APN as a Leader in IDT Care for Elders, the specific roles and skills that advanced practice nurses bring to the table will be discussed. You will develop an understanding of your clinical and leadership abilities in an IDT context, and be prepared to implement IDT principles in your clinical practice with older adults.

Objectives

• Describe the interdisciplinary team approach and differentiate it from other models of geriatric care.
• Explain the need for and the importance of interdisciplinary collaboration and teams in the care of the older adult.
• Identify characteristics of patients most likely to benefit from an interdisciplinary team approach to assessment and planning.
• Describe the typical phases of team development.
• Analyze interdisciplinary team dynamics and make recommendations for improvement of team processes.
• Articulate strategies for managing conflict in an interdisciplinary team.
• Analyze the role of the patient and family (or informal support network) in the ID team.
• Outline the key components of a holistic, functionally oriented IDT geriatric assessment and care planning process.
• Identify potential team members and describe their potential roles and functions on the team based on their discipline's range of expertise.
• Describe how care plans are formulated and goals set in an interdisciplinary team process.
• Analyze the functions and roles of the APN within an interdisciplinary geriatrics team.