Overview of ACE Interdisciplinary Team ( IDT ) Model of Care

Overview of ACE Interdisciplinary Team ( IDT ) Model of Care

Overview of ACE Interdisciplinary Team (“IDT”) Model of Care

Interdisciplinary team work is essential for managing patients with complex health care needs. Hospitalized elderly patients with multiple conditions can be better managed when every health professional involved in their care works together as a team to develop a smart plan of care. A team is capable of achieving results with patients that individuals who constitute the team cannot achieve in isolation. Simply forming a team comprised of several disciplines does not, however, guarantee a team will function well or that the outcome of the process will be the desired one. Any team can be “multidisciplinary,” but the most desired outcomes require an “interdisciplinary” approach – one which recognizes certain rules, attention to issues of leadership, and respect for one another’s expertise.

Our ACE Team hopes that in your time on service with us, you come to understand all team members’ roles & contributions, and especially feel comfortable using the interdisciplinary team (IDT) to help provide comprehensive evaluation, assessment, and care planning for frail hospitalized older adults. To help you achieve this goal, ACE has focused on twelve critically important areas you should address when seeing new consults, prior topresenting onteam rounds. Having this information ready for rounds doesn’t imply YOU must collect all the information on your own; you can always depend on the various IDT members to assist you. This list was compiled by our local experts – geriatricians, nurses, therapists, and pharmacists – as well as your peers who have previously worked with us. We are open to your feedback and suggestions for future improvements! Please note that these twelve items are not meant to be prescriptive or all-inclusive. This document provides the foundational elements of care recommended in most patients who receive ACE consultation. However, there clearly may be other appropriate recommendations to apply as every patient is a unique individual.

In summary, there are inherent differences between “conventional” medicine roundsand the approach of a consultant geriatrician on ACE. Much of this involves gathering a complete picture of what the patient looked like beforehospitalization, often requiring the help of your IDT colleagues, as well as whoever knows the patient best. This might be a spouse, adult child, pastor, home health care worker – often these opinions will “fill in” the blanks remaining when you interview a cognitively impaired patient. Our aim is that you will not only feel comfortable understanding and utilizing IDT members in the short time you are with us on ACE, but also start incorporating these assessments into your daily rounds when you are NOT on geriatrics – they will be helpful to you in any field of medicine you ultimately practice!

REFERENCES:

Palmer, Robert M., Steven R. Counsell, and Seth C. Landefeld. Practical considerations for optimizing health outcomes. Dis Manage Health Outcomes 2003; 11(8).

Kripalani, Sunil, Amy T. Jackson, Jeffrey L. Schnipper, and Eric A. Coleman. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Medicine 2007; 2 (5).

1) Anorexia / Decreased Oral Intake:

  • Does the patient even have (any) diet ordered?
  • Is the patient in need of oral dietary supplementation?
  • Is a swallowing study or speech therapy indicated?

2) Delirium

  • Delirium protocol needs to be placed on chart
  • Are there mood-altering or anticholinergic meds contributing?
  • What prn medications have been given during the night/previous 24 hours?
  • Does the patient have restraints? A sitter? Tethers?

3) Dementia /Cognitive Impairment

  • Delirium protocol needs to be placed on chart
  • Collateral (caregiver) history: what is the real baseline function/ behavior /previous MMSE score?
  • Has reversible workup been ordered recently? (Vit B12, folate, TSH, U/A, imaging, RPR)
  • Any features that might indicate type of dementia (personality changes, hallucinations, alcohol use, etc.)?

4) Difficulty in Walking/Falls/ Gait Disturbance

  • Are activity orders appropriate and reflect patient’s abilities?
  • Are there fall precautions? Have orthostatics been checked?
  • Are PT and OT already ordered?
  • Has a vitamin D level been checked?

5) Constipation

  • Does the patient have bowel regimen on medication list, and is it SCHEDULED?
  • Is the patient on any opiate therapy (vicodin, morphine, etc)?

6) Insomnia

  • Is polypharmacy contributing? Is a sleeping medication indicated?
  • What hospital based interventions might be contributing to interrupted sleep?

7) Osteoporosis

  • Is the patient on adequate dose of calcium / vit D? Has a vitamin D level been checked?
  • Is the patient a candidate for outpatient testing and/or additional therapy?

8) Pain/OA

  • Is there pain medication ordered? Is it working?
  • Is patient capable of requesting prns, or should medication be scheduled?
  • If the patient on opiates, has a bowel regimen been implemented?

9) Pressure Ulcers

  • Has ALL of the patient’s skin been examined?
  • Is the patient able to turn on his/her own, or should a turning schedule be ordered?

10) Urinary Incontinence

  • What does the patient do at baseline?
  • Is there REALLY a need for that foley?
  • Are there bladder medications already on board (that might not be working)?
  • Consider scheduled toileting in anyone ambulatory enough or able to use bedpan

11) Social Needs/Disposition/Long term goals of care:

  • What is best/safest site of care for this patient at time of discharge? (try to determine & plan for this the FIRST DAY you see patient, adjusting plan accordingly throughout hospital stay)
  • What equipment/services would maximize the patient's functional independence?
  • If the patient is going home, is there an appropriate caregiver?
  • Is the patient/family more focused toward quality or quantity of life? Does the current code status reflect these choices? Does the patient have advance directives?
  • Are there any overwhelming social barriers preventing a successful hospital discharge?

12) Other medical issues

  • How do patient co-morbid conditions impact geriatric functional syndromes, & vice versa?
  • Are any current treatments for acute illness possibly impacting the patient’s baseline functions?
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