Many seniors enjoy good health and independence well into their ninth and tenth decades. However, some develop illnesses and functional impairments that require intensive or prolonged health care and supportive services at home, in hospitals, or in long-term care facilities. Family, peers, friends, volunteers, and other caregivers provide assistance and support, and in Western countries most seniors can access physicians and other primary-care practitioners who provide the first point of contact with health and social support services. When health issues are complicated and require specialized knowledge or resources not available to the primary-care team, seniors may be referred to specialist practitioners or to specialized multidisciplinary geriatric teams in the community, in hospitals, or in long-term care facilities. Such referrals may result in a brief intermittent contact, or there may be prolonged involvement with such specialists. In some cases, specialized teams assume primary-care responsibility, either for a defined period or indefinitely.
The skills and knowledge of many health disciplines are needed to conduct a comprehensive multidimensional assessment of the physical, mental, emotional, functional, and social status of a frail older person. The composition of teams vary, therefore, depending upon the population the team serves and the needs of a particular individual. A nurse, a physician, one or more rehabilitation therapists, and a social worker—each having specialized knowledge in gerontology— constitute a prototypical core team, although in practice the composition of teams may vary. Other professionals, such as counselors, nutritionists, speech and language pathologists, pharmacists, spiritual-pastoral caregivers, psychologists, other medical specialists, case managers, coordinators, and others may also be included in the core team, or they may be consulted on an ad hoc basis, reflecting the nature of the clientele referred to the team or the particular needs of an individual client.
Historically, the practice of many health professionals has been characterized by unidisciplinary thinking, and individualistic and sometimes competitive behaviors have emphasized the roles and boundaries of each discipline. However, care of older persons with complex and interactive health, social, and functional needs is best achieved when the knowledge and skills of various health disciplines are shared and integrated. Multidisciplinary, collaborative health care practice is an effective means to plan, coordinate, and implement care of frail older persons. Family members and caregivers should be participants in this process, although they may not be present at all meetings of the multidisciplinary team. Their contribution to the assessment process, to problem solving, and to identifying and selecting appropriate goals and acceptable outcomes is vital.
Health professionals providing senior care require strong discipline-specific knowledge, as well as an understanding of and respect for the contribution of other health disciplines and the ability to function well in interprofessional teams. Education programs increasingly recognize the need for preparing students for new models of professional practice. Interprofessional education affords students and practitioners from various disciplines an opportunity to learn about common issues in gerontology and the care of older people. Interdisciplinary education and education in teamwork provides theoretic and practice-based learning to prepare for working as a member of a health care team.
The term multidisciplinary also describes team interaction within a multiprofessional team. Other team processes include interdisciplinary and transdisciplinary teamwork. Multidisciplinary team process implies that team members practice relatively independently with respect to goal setting and treatments. Members of multidisciplinary teams may meet regularly or communicate in other ways, but their lack of common goals and their autonomous practice can result in lack of coordination and conflict over priorities and decision making.
Teams that adopt an interdisciplinary modus operandi evidence a stronger focus on integration of activities to meet shared goals. Team members contribute assessment data and convene to synthesize information, to identify issues, and to plan to meet goals that are shared by the team and the older person. Each subsequent treatment or rehabilitative intervention by a team member is related to achievement of overall goals. Both interdisciplinary and transdisciplinary teamwork require considerable educational preparation of team members. They must agree on leadership, team process, priority setting, and methods to resolve conflicts.
The term transdisciplinary has been used to characterize a further evolution of teamwork that is highly collaborative and in which role boundaries are often blurred and skills transferred across professional boundaries. The terms cross-disciplinary and multiskilled have been applied to teams where members extend their skills well beyond the boundaries of their parent discipline. For example, a social worker may collect medical histories or a rehabilitation therapist may record the social and occupational history of patients.
Teamwork theorists have recognized four stages of team development: forming, storming, norming, and performing. In the first stage, the team develops its identity and an understanding of its purpose in a wider context. In the second stage—often an unsettling period for team members—they search for ways of working together that reflect common values and an understanding of the role of the team. In the norming phase, team members develop a shared understanding and commitment to their task, and improved communication within and outside the team develop. In the final stage (performing), a mature, effective team develops that is capable of fulfilling the task for which it was created.
While common principles underlie effective teamwork, similar teams—even within the same health care organization—often function differently. The culture of teams derives from and reflects the values and history of the parent organization, as well as the professional and personal backgrounds of founding members and team leaders. Team membership changes over time as new members are recruited, and a process of education and acculturation to the team is necessary. A common terminology for problems and for goal setting that incorporates functional and psychosocial problems, as well as medical diagnoses, is helpful and facilitates communication within and among teams. Other professionals and health care teams may be involved simultaneously or sequentially in the care of an older person, and timely communication among all those involved in care of the older person and his or her family is important.
Effective team work—that is, teamwork utilizing the resources of a multiprofessional team to achieve optimal results for older persons and their families while using available human and other resources prudently—provides a continuing challenge for health care organizations and health professionals to critically examine current practices and to study and evaluate innovative ways of working together.
See also Assessment; Case Management; Frailty; Geriatric Assessment Unit; Geriatric Medicine; Gerontological Nursing; Occupational Therapy; Physical Therapy; Rehabilitation; Social Work.
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