5: The Interprofessional Team

Nationally and worldwide, interprofessional teamwork is increasingly recognized as a means to address the challenges of the current health care system. Patients with complex problems and diverse needs require the expertise of different health professionals, ideally working together. A series of landmark Institute of Medicine reports recommended interprofessional teams and training of all health care workers in teamwork as a key mechanism to increase health care safety and quality. Additional factors driving the need for effective teamwork include patient expectations; a primary care workforce shortage; new models of team care that demonstrate efficiency, lower cost, and improved outcomes; and national policy changes that incentivize the creation of these models.

Older adults, with their high prevalence of chronic conditions, functional decline, geriatric syndromes, and terminal illness, are high utilizers of the health care system and its teams. The American Geriatrics Society has developed and supported 2 position statements that underscore the benefits of interprofessional team care for older adults, and endorses interprofessional team training for all professions. This chapter defines the multiple types of interprofessional work in health care, describes practice-based interprofessional geriatrics innovations, reviews the evidence for interprofessional collaboration in the care of older adults, provides resources for building interprofessional skills and teams, and discusses barriers and future steps to improve interprofessional teamwork in geriatrics.

The teamwork literature consists of a wide array of terms, used interchangeably, to describe this phenomenon—from interdisciplinary, to multidisciplinary, to interprofessional. In addition to this terminologic uncertainty, different authors describing “interdisciplinary teamwork” often employ very differing conceptualizations related to team composition, function, and outcome. It is possible, however, to distinguish the different types of teamwork as follows: “interprofessional teamwork” involves different health care professionals who share a team identity, have clarity of roles, work in an interdependent and integrated fashion, and have a shared responsibility to solve problems and deliver services. This contrasts to “interdisciplinary teamwork,” which is seen as a collaborative activity undertaken by individuals from different disciplines, such as psychology, anthropology, economics, medicine, political science, and computer science. This, in turn, contrasts with “multidisciplinary teamwork,” which is regarded as an approach like interprofessional teamwork, but different in that the team members come from different academic disciplines (psychology, sociology, mathematics) rather than from different professions, such as medicine, nursing and social work. In health care, “multidisciplinary team” also refers to teams in which health professionals may share information regarding a patient, but do not formulate a treatment plan together. Although the term interdisciplinary teamwork has been prevalent for the past 30 years in U.S. medicine, including in geriatrics, scholars increasingly contend that applying this term in a health care setting is conceptually incorrect, as the notion of interprofessional teamwork more accurately describes the essence of health care teams (including geriatric teams) who work together to deliver services.

It is also important to distinguish interprofessional education, an increasingly common learning activity in health care, from interprofessional practice. “Interprofessional education” is an activity that occurs when members (or students/trainees) of 2 or more health care professions engage in learning with, from, and about each other to improve interprofessional teamwork and the delivery of care. Interprofessional practice centers on the provision of patient care and has a range of differing configurations. Interprofessional teamwork is a “tighter” more integrated type of work where members share a team identity and work in an integrated and interdependent manner to provide care to patients. Examples of interprofessional practice teams include geriatrics teams, intensive care teams and emergency room teams. This is a different arrangement to interprofessional collaboration which is a “looser” type of work, where membership is more fluid and shared membership less important. Examples of this type of work can be found in primary care and general medical settings.

In the United States, the care of older adults has been a major impetus for innovations in interprofessional education and practice. Accordingly, there are many geriatric models of care where teamwork is fundamental (Table 5–1). These teams vary widely with respect to their goals, procedures, setting, number and type of professionals, and membership stability.

The earliest training initiatives, Interdisciplinary Team Training in Geriatrics, were developed by the Department of Veterans Affairs in the 1970s. This was followed by the creation of 2 programs administered by the Health Resources and Services Administration of the U.S. Department of Health and Human Services. Geriatric Education Centers, founded in the 1980s, support collaboration between health professions schools and health care clinics, facilities, and systems to provide training in geriatrics and team care that must be offered to 4 or more professions. Geriatric Academic Career Awards, which originated in the 1990s, support the career development of junior faculty to become academic geriatricians and to provide clinical geriatrics training to interprofessional teams.

The John A. Hartford Foundation has significantly supported the development of team training and models of care for older adults. In 1997, the Hartford Geriatric Interdisciplinary Team Training (GITT) initiative funded 8 institutions to develop innovative models of formal team training, resulting in a repository of teaching materials and a collectively produced curriculum and implementation guide described in more detail under “Resources” below. In 2000, Hartford funded the Geriatric Interdisciplinary Teams in Practice initiative that supported the design and testing of models of interprofessional team care of older adults with chronic illnesses. Four models that transformed team care in everyday practice and demonstrated positive impact on patient outcomes and cost have been widely adopted nationally: (a) the Care Transitions Intervention, developed at the University of Colorado Health Sciences Center; (b) the Care Management Plus model, developed by Intermountain Health Care and Oregon Health & Science University; (c) the Senior Health and Wellness Clinic model developed by PeaceHealth Oregon Region; and (d) the Virtual Integrated Practice model, developed at Rush University Medical Center.

Geriatrics also has led innovations in team-based models of care. The Program of All-Inclusive Care for the Elderly (PACE) is a capitated, joint Medicare-Medicaid program that provides comprehensive, team-based care for frail, nursing-home-eligible older adults living in the community. In the inpatient setting, the Acute Care for Elders (ACE) unit provides hospitalized older adults with an interprofessional team that aims to preserve function and to avoid unnecessary procedures and medications. As of 2011, there are 82 PACE programs in 29 states, and an estimated 100 ACE units nationally. Both the PACE and ACE models have been shown to improve patient outcomes while reducing costs.

Substantial research shows benefits of geriatric interprofessional team care for specific diseases and geriatric syndromes, across models of care, and in settings from acute care and skilled nursing facilities to rehabilitation and outpatient clinics. Team-based models of care, such as PACE and the Geriatric Resources for Assessment and Care of Elders (GRACE), have demonstrated improved quality of care and reduced utilization of services. Team care has reduced morbidity and mortality after a stroke, and shown improvement in behavioral and psychological symptoms without a significant increase in medications among patients with Alzheimer disease. Team-based approaches reduce the prevalence of delirium and the incidence of falls and related injuries. Interprofessional teams have also been shown to improve medication adherence and reduce adverse drug reactions.

Overall, results are mixed regarding the ability of interprofessional teams to reduce health services utilization and costs. Boult et al offer possible explanations for the difficulty in demonstrating these reductions in older adults with multimorbidity, which include unavoidable exacerbations requiring acute care in multimorbid patients, and not knowing which patients benefit most from team care or what aspects of team care reduce utilization and costs. Moreover, quality team care may also increase utilization by high-risk patients. Finally, clinical trial duration may be too short to capture the cost savings “downstream” that could offset the initial and operating costs of a team-based model.

In addition to the evidence on teamwork, there exists a deep and intuitive logic for why effective teamwork is needed: patients frequently have conditions that have multiple causes and require multiple treatments from a range of health care professionals with different skills and expertise. As it is unusual for one profession to deliver a complete episode of care in isolation, good quality care depends upon professions working together in interprofessional teams. In general, when a team works “well” it does so because every member has a role. Every member not only knows and executes his or her own role with great skill and creativity, each member also knows the responsibilities and activities of every other role on the team, and understands the personal nuances that each individual brings to his or her role. As has been shown in military training and the aviation industry, when understanding of each person’s role is achieved, interprofessional teamwork becomes an essential ingredient for reducing duplication of effort, improving coordination, enhancing safety, and delivering high-quality outcomes.

Literature describing program development strategies and the educational goals of team training is emerging. In 2010, the Interprofessional Education Collaborative, which consists of 6 national health professions education associations, convened an expert panel to develop interprofessional competencies as a means of providing a framework to move interprofessional education forward. The competency domains identified were:

• Values/ethics for interprofessional practice,

• Roles/responsibilities for collaborative practice,

• Interprofessional communication, and

• Interprofessional teamwork and team-based care.

The competencies identify behaviors that reflect underlying attitudes, knowledge, and values essential for effective, patient-centered teamwork. The domains provide a guide for individual learning and practice improvement, curriculum and program development, and for setting accreditation and licensing standards for schools and professionals alike.

Salas et al detail principles for team training, which include using teamwork competencies to focus the training content, which should align with desired outcomes and local resources; concentrating on teamwork and excluding individual level tasks; providing hands-on practice in as authentic an environment as possible; providing detailed, timely feedback by team skills experts; evaluating knowledge, behaviors, and patient level outcomes; and sustaining teamwork through continued coaching, incentives, and performance evaluations.

The best way to improve an individual’s teamwork skills is in interprofessional teams. Health care teams may improve their teamwork by focusing explicitly on underlying processes and by creating a culture of openness. An initial step is identification of team goals and objectives and what is needed to achieve them, clarification of roles and responsibilities, and specification of team procedures and ground rules. Salas et al provide practical guidelines and tips for improving teamwork based on their framework of communication, coordination, and cooperation. An overarching theme is the creation of an environment that encourages open discussion and input from all members. This includes ensuring time for members to jointly reflect upon their team performance and to give “process feedback” that is descriptive and specific. Team members should also reflect upon their own and other members’ behaviors, while both eliciting and providing constructive feedback along with ideas for improvement.

Two well-developed team training programs offer practical guidelines and tools for teamwork available on the internet. The Hartford Foundation’s GITT Program includes paper-based and video-based complex cases, exercises for discussion, and didactic material on team training in the care of older adults. Although designed for trainees, the content is relevant to practicing professionals. A companion implementation manual offers a synthesis of guidance, lessons learned, and tools from the 8 GITT sites on the implementation of a team training program. The GITT Interdisciplinary Team Training Pocket Card contains 8 principles of successful teamwork, a 7-step meeting process, a team dynamics checklist, tips on how to be an effective team member, and guidelines for dealing with conflict.

The TeamSTEPPS program, developed by the Department of Defense, is not geriatrics-specific but presents an evidence-based teamwork training system for health professionals. Like the GITT Program, it offers a curriculum and implementation guide accessible from the Internet, but the materials are more extensive and contain slide sets with speaker notes, handouts, videos, and assessment and evaluation tools. The training system provides detailed guidance on its 3-step process that includes a local needs assessment, planning and training, and sustainment. Practical communication tools and strategies are a prominent part of the curriculum. Unlike the GITT Program, TeamSTEPPS is an ongoing effort that offers webinars and in-person training sessions nationwide for master trainers.

Despite the potential benefits of teamwork for patients and professionals alike, the underlying processes are fraught with challenges. Teamwork has received relatively little attention in both preprofessional and continuing education; consequently, despite the data on its benefits to patients, most practicing professionals have received minimal or no relevant training, and efforts to increase interprofessional teamwork often meet attitudinal, educational, and fiscal barriers. One challenge relates to the medical profession’s history of unchallenged authority and attitudes toward teams. Physician attitudes towards teamwork in general are particularly problematic. Reasons may include medical training that rewards autonomy and individual efforts, lack of perceived value added by teamwork, and perceived losses of power, time, and money. With a paucity of role models and strong cultural influences, it is not surprising that medical trainees have rated lower agreement with respect to the benefits of teamwork compared with nursing and social work students.

Additional barriers to improving interprofessional teamwork are systems based. First, despite the ubiquity of health care teams, widespread formal education on teamwork has lagged in the United States. Consequently, because teams in practice do not use principles of teamwork, little informal team training occurs. Second, few incentives exist for implementing or improving interprofessional education and practice. There is currently no reimbursement for the implementation of innovative educational programs or for team services provided by practicing health professionals. In addition, few medical schools or medical practices recognize teamwork skills for the purposes of individual advancement or promotion. Third, logistical barriers are a prevalent problem that often centers on finding time for teaching or participating in teamwork. At the trainee level, hindrances include different academic calendars and training sites, while tension in the practice setting centers on balancing release time for team training with staffing needs of hospitals and clinics.

Interprofessional education and practice must develop in tandem to transform the standard of health care in the United States. Widespread implementation of both will require culture change and investment of time and resources. Differences in professional identities and cultures must be reconciled, with the recognition that everyone, from early learners to seasoned professionals, harbors biases, stereotypes, and inadequate knowledge of other professions. Program leaders need to address the practical problems of differences in roles, priorities, service needs, schedules, and licensure and accreditation requirements among health professionals and students. Research is needed to determine the most effective timing, teaching strategies, methods, settings, and assessment tools, as well as the impact of interprofessional education and practice on health service utilization and cost. Professional and faculty development courses should train a cadre of health professionals who effectively teach and role model teamwork skills. Accreditation, licensure, and regulation are powerful ways through which to advance interprofessional education and practice. The Patient Protection and Affordable Care Act of 2010, particularly its support of team-based care via the Patient Centered Medical Home model, has potential to disseminate interprofessional practice in response to public health needs.