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Caring with Compassion, Domain 2: Bio-psychosocial Care 14. Interdisciplinary Team Care

4. Interdisciplinary Team Care

Knowledge Objectives:Learners will be able to describe:

1. Training, licensure, and scope of practice of nurse practitioners, physician assistants, and pharmacists.

2. Training, licensure, and scope of practice of social workers and case managers. 3. Scope of practice of addiction counselors and mental health providers4. Outreach, team-based health care delivery models of demonstrated effectiveness

among homeless persons.5. Specific team skills and communication approaches essential to high-functioning,

interdisciplinary care teams.

2 Caring with Compassion, Domain 2: Bio-psychosocial Care4. Interdisciplinary Team Care

Objective 1: Training, licensure, and scope of practice of nurse practitioners, physician assistants, and pharmacists.

Case 1A 25 year-old homeless woman has difficulty accessing the nearest primary care physician’s office for herself and for her 2 children, because the physician’s building is not on a public bus route. Her case manager provides her with a pamphlet introducing a nearby clinic run by a collaborative group of volunteer healthcare professionals. The clinic pamphlet lists the names of the core clinical team members.

Which of the following professionals is most likely to be able to independently function as her family’s primary care provider?

1. Sheryl Brown, ANP2. Mark Perez, PA3. Luanda Smith, LPN4. John Rodriguez, PharmD5. Holly Chang, RN


Case 1 Answer

Which of the following professionals is most likely to be able to independently function as her family’s primary care provider?

1. Sheryl Brown, ANP. Correct. In most states, advanced nurse practitioners may be recognized as primary care providers, although some states require that they establish a collaborative agreement with a physician in order to practice.

2. Mark Perez, PA. Incorrect. Physician assistants must practice under the supervision of a physician.

3. Luanda Smith, LPN. Incorrect. Licensed practical nurses perform clinical support services under the supervision of a registered nurse (RN) or physician.

4. John Rodriguez, PharmD. Incorrect. Pharmacists do not function as recognized primary care providers, although they often support provision of preventive services and chronic care management.

5. Holly Chang, RN. Incorrect. Registered nurses cannot perform independent primary care practice, although they often provide essential primary services within a primary care team.

To meet the spectrum of bio-psychosocial needs of homeless and medically underserved patients, multiple health care providers with complementary skills must work together effectively and efficiently. A remarkable range of responsibilities and skills are represented in members of the health care team. The following brief descriptions introduce the scope of practice for clinical health professionals who commonly care for homeless persons.

Nurses

Licensed Practical Nurse (LPN)

Training: LPNs have completed up to 12 months of basic nursing skills training from an accredited School of Nursing.

Licensure and Scope of Practice: LPNs must take a national licensing examination and must obtain a state license to practice nursing. They practice under the supervision of a registered nurse (RN) or physician. LPNs are limited in scope of practice (e.g. they may not start blood products on patients or complete admission assessments in hospitals), but they excel in day to day management of patient needs.

Clinical Team Roles: LPNs may may function as an office nurse in a primary care clinic, provide bedside care in a tertiary care center or skilled nursing facility, or fill the role of case manager. In underserved clinics, LPNs may be essential to provision of routine direct patient care, such as placement and reading of PPD tests. As clinical team extenders, they may be essential for routine communication and patient management needs, including telephone follow up and triage.


Registered Nurse (RN)

Training: RNs may be educated at the diploma (hospital-based), associate, or bachelor’s level. Today, most RNs are prepared through associate (2-year) and baccalaureate (4-year) degree programs.

Licensure and Scope of Practice: RNs must graduate from an accredited school of nursing and must pass a national licensure exam (NCLEX). Upon successful completion of the NCLEX, RNs must obtain a license to practice nursing from the state. State requirements for maintenance of licensure vary; most require that RNs complete a minimum number of continuing education hours.

Clinical Team Roles: RNs play an integral role in community clinics, ranging from providing essential services to the provision of home-based services through the public health department and private agencies.

Nurse Practitioner (NP)

Training: NPs are bachelor’s prepared RNs who have additionally completed two to four years of graduate degree education in nursing. As part of their education, NPs complete a minimum number of direct patient care hours. NPs can be trained in primary care, acute care, midwifery, or anesthesia. Furthermore, NPs may specialize by population: pediatric, adult/gerontology, women’s health, or family care.

Licensure and Scope of Practice: After graduation from an accredited school of nursing, NPs sit for a national certification examination for their population and setting specialty (eg: Adult-Gerontology Primary Care, Pediatric Acute Care). After obtaining national certification, NPs must obtain an additional license to practice advanced nursing in their state. NPs must complete continuing education hours and direct patient care hours to maintain both licensure and certification. NPs are trained in health care systems, disease prevention and management (including mental health), and health promotion. As such, NPs are capable of practicing independently to diagnose common illnesses and chronic diseases, initiate treatment plans, and prescribe medications (2). Actual NP scope of practice varies widely between states, due to legislated restrictions. In some states, NPs may practice entirely independently, without any collaborative agreement with a physician, while in other states NPs have limited authority. In nearly all states, NPs may serve as primary care providers and may bill for services under Medicare and Medicaid, but are not reimbursed at the full physician rate. In some states, NPs may prescribe controlled substances, but must have their own DEA registration. One useful compendium of state-based scopes of practice is available at: http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/.

Clinical Team Role: In caring for the homeless and medically underserved, NPs most often act as primary care providers. They may provide care out of a free clinic, Federally Qualified Health Center, or Nurse Managed Center. NPs can care for patients’ acute needs, such as cold and flu symptoms and musculoskeletal injuries,

http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/

http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scope-of-practice-laws/


as well as manage chronic illnesses and common mental health problems. NPs consult with physician collaborators, mental health workers, and social workers as needed to provide holistic care to patients. Additionally, in most states NPs can complete assessments and paperwork for Social Security Disability and Supplemental Income (SSD and SSI) and insurance claims. NPs can also serve as caseworkers, often dealing with the most complex or difficult patients.

Physician Assistant (PA)

Training: Several science pre-requisites are required prior to enrolling in a PA program. For this reason, PAs generally hold a bachelor’s degree, often in science, earned prior to enrollment in PA training. PA programs vary by institution in length, but must be at least one year long with at least four months of classroom instruction. In addition to classroom training, PAs complete rotations through several medical areas including sub-specialties. On completion of training, PAs have usually completed the equivalent of a Master’s degree in total instruction.

Licensure and Scope of Practice: Upon graduation, PAs must pass the Physician Assistant National Certifying Exam. After initial certification, PAs must complete continuing education requirements to maintain their credentials. PAs are licensed by states, and must pass recertification exams to maintain licensure. PAs work under the supervision of a physician. Unlike a NP who may practice independently in many states, a physician must be on-site for PA practice. PAs must have a documented collaborative relationship with a physician to obtain prescriptive authority. Similar to NPs, PAs may bill insurance companies, however they are reimbursed at a reduced rate to physicians.

Clinical Team Role: PAs may work in acute or primary care. They may care for the acute needs of patients or manage common chronic illnesses. Because their care is directly supervised, their team role is primarily determined by the needs and skills of the supervising physican; they may order and interpret diagnostic tests, provide treatment, and complete insurance paperwork.

Pharmacists Training: Pharmacy schools require a broad range of college level science pre-

pharmacy prerequisites, so pharmacists usually possess a bachelor’s degree in science prior to pharmacy school entrance. The Doctor of Pharmacy degree (PharmD) requires a four-year program after the pre-pharmacy curriculum. Course work includes classroom work and supervised clinical work experiences. Further training – a 1 or 2 year residency program – is available.

Licensure and Scope of Practice: All states require a license to practice pharmacy. Pharmacists must pass two exams: a general pharmacy exam, and a state-specific pharmacy law exam. Pharmacists dispense drugs and medications prescribed by authorized clinicians. While they often make suggestions to prescribing clinicians, they may not prescribe medications independently.

Clinical Team Roles: Pharmacists are highly valuable team members in the care of medically underserved patients. Their roles have been expanding, particularly for care of patients with chronic illnesses. They can assist with identification of


medication resources, advise clinicians regarding cost-effective regimens, instruct patients on the use and proper dosage of medications, and monitor medication use for patients with chronic illnesses. They often serve an essential role in identifying expected side effects and interactions with other prescription and nonprescription medicines. These professionals also order and maintain inventories of medications and medical supplies required for use in the clinical setting.

Clinical teams comprising nurses, physician assistants (under physician supervision) and pharmacists can provide a broad range of services for patients with complex biospychosocial care needs. (Figure 1)

Figure 1: Clinical Team Roles: Nursing, Physician Assistant, and Pharmacist

Role Education Common Clinical Roles

LPN 1 yearRoutine direct patient care, case management, and patient communications under under RN or physician

RN2-yearor 4-year (BSN)

Direct patient care, home care services, and outreach care, under physician supervision

NPBSN + Master’s degree (MS)

Primary care practitioner, advanced office practice, complex case management; practices independently or with a physician in a collaborative relationship

PAPrerequisites and 1+ years (MA equivalent)

Physician supervision required, and clinical role is determined by arrangement with the supervising physician

Pharmacist Pharm DIndependent clinical dispensing practice, or collaborative clinical team relationship, including chronic care management

Key Points: LPNs have more limited formal training compared with RNs, but serve many

essential roles in responding to routine patient needs and addressing administrative necessities.

RNs play an integral role in community clinics, ranging from providing essential services to the provision of home-based services through the public health department and private agencies

Nurse practitioners may have independent practice rights, or may prescribe within a collaborative physician relationship, depending on state regulations. In many states, nurse practitioners may function as primary care clinicians, and this role is particularly common in care of the underserved and homeless population.

Physician assistants work under the direct supervision of a physician. The responsible physician determines their scope of practice. Therefore, they have highly variable roles.

The role of pharmacists is expanding, with more emphasis on patient assessment, monitoring and modification of chronic medication regimens, and patient counseling.


Objective 2: Training, licensure, and scope of practice of social workers and case managers.

Case 2You are meeting with a community service group that wishes to set up a free healthcare clinic for the local underserved population. They ask you to comment on the potential role of a case manager who has expressed interest in working at the clinic.

Which of the following is a correct statement regarding the field of case management?1. The prerequisite degree for case management is a nursing degree (RN or higher) with

advanced practice training in case management.2. The prerequisite degree for case management is a social work master’s degree (MSW)

with advanced practice training in case management.3. There is no licensure requirement for case management.4. The focus of case management is on cost reduction through utilization review, hospital

discharge planning, and outpatient utilization management.5. Case managers are employed by insurance companies, not by health care delivery

systems or by specific clinics.


Case 2 Answer

Which of the following is a correct statement regarding the field of case management?1. The prerequisite degree for case management is a nursing degree (RN or higher) with

advanced practice training in case management. Incorrect. There is no prerequisite degree for case managers, although a degree in social work or nursing is common.

2. The prerequisite degree for case management is a social work master’s degree (MSW) with advanced practice training in case management. Incorrect. There is no prerequisite degree for case managers, although a degree in social work or nursing is common.

3. There is no licensure requirement for case management.4. The focus of case management is on cost reduction through utilization review, hospital

discharge planning, and outpatient utilization management. Incorrect. Case management focuses on care planning, facilitation of services, care coordination, functional evaluation, and social advocacy. Improved care quality and reduced cost can both be obtained through effective case management, but cost is not the primary focus.

5. Case managers are employed by insurance companies, not by health care delivery systems or by specific clinics. Incorrect. Case managers may be hired by diverse organizations to improve the quality, continuity, coordination, and costs of care

Complementing the clinical health care team, social workers and case managers provide particular expertise in psychosocial and aspects of patient care needs. In settings without onsite social workers and case managers, such as student-run free clinics, clinicians often have increased responsibility for triage of patient support needs and identification of appropriate and available community resources. Engagement of other interdisciplinary team members, such as LPNs, RNs, and pharmacists, may be possible to assist with some care needs.

The following brief descriptions introduce the usual scope of practice for social workers and case managers. Due to institutional variability of job descriptions, clinicians should additionally learn the scope of practice for these roles as defined within their own institutions.

Social Worker Training: Professional social workers hold a bachelor’s or a master’s degree in

social work (BSW or MSW). Social workers trained in providing mental health services and counseling are called Clinical Social Workers.

Licensure and Scope of Practice: Master’s prepared social workers may become licensed clinical social workers (LCSW) after completing supervised work experiences, additional coursework, and a licensure exam. Licensure is regulated at the state level and permits social workers to bill insurance companies for counseling services.

Clinical Team Roles: All social workers can provide counseling interventions to address social needs, and licensed clinical social workers (LCSWs) can provide more extensive mental health counseling and crisis intervention. Team care roles may include: provision of short term mental health counseling; accessing community resources such as housing, financial assistance, medication assistance programs, insurance application, or transportation; coordination of care with


Community Mental Health agencies; safety and violence interventions; substance abuse education; and access to substance abuse treatment resources.

Case ManagerCase management involves ongoing, proactive involvement in assessing a patient’s

needs and developing a therapeutic relationship in order to effectively implement plans, coordinate care, and address care barriers. For high risk and homeless patients, case managers may be helpful in advocating for safe, permanent housing, access to health care and medications, income security, and care for psychiatric and behavioral problems. Case managers strive to meet these clinical and social needs while promoting quality, cost effective care.

In contrast to a social worker, the case management role tends to be more longitudinal, with a focus on coordination of care for high risk and high need individuals. Case managers additionally address appropriate utilization and cost-effectiveness of care; therefore, case managers often play an essential role in the care of homeless and medically needy populations. The specific functions of a case manager will vary by the particular setting and employer: hospital, community, clinic, or government/insurance company.

Training and Licensure: Case managers are most often social workers but may be nurses or even persons without specific health professions licensure. Certification in case management is available but not required through the Case Management Society of America (http://www.cmsa.org/). There is no licensure requirement, although many case managers are separately licensed through their nursing or social work professions.

Scope of Practice: Responsibilities can be limited to short-term resource management (e.g., hospital utilization review) or resource acquisition (e.g., transportation, medications) but usually include longer-term or continuity enhancing activities. Long-term care roles include ongoing coordination of care among multiple health professionals and healthcare systems. A case manager can develop a longitudinal and consistent relationship with high risk and high need patients, facilitate transitions of care, and even accompany patients to care visits to minimize fragmentation of care. As such, case managers can be uniquely capable of providing longitudinal, continual assessment of patients’ medical, psychological, and social needs in order to obtain resources and limit social and medical episodes of decompensation. They may also provide direct care, such as coaching behavioral change or supervision of medical adherence.

Clinical Team Roles: The broad skills of a case manager are particularly important for high risk and high utilization patients. Because of their focus on continuity and patient coordination, case managers can promote improved care quality [1, 2], with data suggesting increased cost-effectiveness[2] and improved clinical outcomes, even for patients with severe mental illness[3]. Engagement of case manger services may be particularly critical for patients with multiple biomedical, psychiatric, and social-behavioral comorbidities who need support over time. In contrast, standard social work services are more appropriate for discreet and time limited needs. For instance, case management may be particularly helpful for a patient treated by Community Mental Health providers, medical providers, and substance treatment centers who requires support for adherence with a complex

http://www.cmsa.org/


neuropsychiatric treatment plan in order to minimize inappropriate utilization of emergency or high cost services.

Figure 2: Clinical Team Roles: Social Worker and Case Manager

Role Education Common Clinical Roles

Social WorkerBachelors (BSW) or Masters (MSW)

Short term counseling, crisis intervention, access to community resources, and access to substance abuse treatment

Case ManagerNot specified (often trained in nursing or social work)

Longitudinal coordination of care for high risk and high utilization individuals

Key Points: Social workers, while often focusing on helping patients acquire resources or

insurance, are also qualified to perform advanced psychosocial assessment and counseling.

Case managers can facilitate care coordination and quality for complex, vulnerable patients.


Objective 3: Scope of practice of addiction counselors and mental health providers

Case 3A 26-year-old man is discharged from an acute care hospital following admission for alcoholic hepatitis. He reports daily use of oral opioids or heroin in addition to binge alcohol use. On discharge, his case manager assists him in scheduling a visit with an addiction counselor.

All of the following services can be provided by an addiction counselor EXCEPT which one?1. Cognitive behavioral therapy to identify and alter his negative behaviors.2. Substance replacement treatment with methadone.3. Peer substance use counseling to modify his relationships. 4. Examination and modification of his daily environment to reduce substance use

‘triggers’.5. Identification of childhood experiences leading to substance abuse.


Case 3 Answer

All of the following services can be provided by an addiction counselor EXCEPT which one?1. Cognitive behavioral therapy to identify and alter his negative behaviors. Incorrect.

Many addiction counselors provide psychological counseling including CBT.2. Substance replacement treatment with methadone. Correct. Addiction

counselors are not licensed to prescribe medications.3. Peer substance use counseling to modify his relationships. Incorrect. Addiction

counselors often facilitate peer counseling relationships among their clients.4. Examination and modification of his daily environment to reduce substance use

‘triggers’. Incorrect. Addiction counselors help patients examine and modify social and environmental triggers, and develop alternatives to limit ‘triggers’ to substance use.

5. Identification of childhood experiences leading to substance abuse. Addiction counselors may incorporate psychodynamic counseling as one component of a treatment program.

Homeless and medically underserved persons often require not only biomedically and socially supportive care provided by physicians, nurses, case managers, social workers and pharmacists, but also ongoing, concurrent care provided by addiction counselors and/or mental health specialists. Although these mental health services usually occur in times and places separate from other health services, it is important for clinicians to understand the types of mental health and behavioral services provided.

Addiction counselors Training and Licensure: Addiction counseling centers and addiction counselors are

regulated by state requirements, so licensure or certification is required by each state. Certification standards are often broken into achievement levels, (e.g. Counselors I and II) which are determined by the quantity of hours spent in classrooms and in supervised clinical training. Minimum degree standards vary from high school equivalency to masters’ degree; most addiction counselors have completed significant higher education, such as a MSW (masters in social work.)

Scope of Practice and Team Role: Addiction counseling addresses not only the identified addiction but also any co-existing psychosocial issues, physical health, mental health and legal concerns. The counselor and client develop mutually agreeable treatment goals and determine appropriate strategies for achieving those goals. Treatment may include individual or group counseling sessions, inpatient rehabilitation, or outpatient programs. Outpatient sessions generally include assessment and evaluation of progress, education, planning and coping strategies, supportive counseling, and targeted treatment recommendations.[4] For reasons of confidentiality, addiction counselors may not share the details of a client’s care, but team communications may occur with clinicians, social workers, and case managers in order to ensure that biomedical complications are stabilized and psychosocial supports are addressed.


Mental Health ProvidersAn array of professionals may provide mental health care: psychiatrists, clinical

psychologists (clinical psychology PhD or PSY.D), licensed clinical social workers, psychiatric clinical nurse practitioners, licensed counselors with a master’s degree in counseling, or individuals with no formal training.[4] Selection of a professional will depend on care needs. Psychiatrists or psychiatric clinical nurse practitioners may be required for prescription medication management, while clinical psychologists are skilled in psychotherapy techniques, psychoanalysis, behavioral therapy, family therapy, cognitive retraining (e.g. cognitive behavioral therapy), biofeedback, and social learning.[5] As noted previously, licensed clinical social workers can provide general mental health counseling and crisis intervention, with particular expertise in problem solving and identification of support services.

Key points Addiction counselors address not only the identified addiction(s) but also any co-

existing psychosocial issues, physical health, mental health and legal concerns. Addiction counseling treatment may include individual or group counseling

sessions, inpatient rehabilitation, or outpatient rehabilitation programs. Outpatient sessions generally include assessment and evaluation of progress, education, planning and coping strategies, supportive counseling, and targeted treatment recommendations.

Mental health providers include physician psychiatrists, PhD psychologists, psychiatric clinical nurse practitioners, licensed clinical social workers, and master’s degree counselors. Clinical psychologists have expertise in formal psychotherapeutic and cognitive/behavioral retraining techniques, but do not prescribe medication.


Objective 4: Outreach, team-based health care delivery models of demonstrated effectiveness among homeless persons.

Case 4Which of the following interventions has NOT been demonstrated to improve the health of homeless persons?1. Case management2. Assertive community treatment teams3. Same-site medical and mental health care4. Free access to medications5. Access to ‘dry’ housing


Case 4 Answer

Which of the following interventions has NOT been demonstrated to improve the health of homeless persons?1. Case management2. Assertive community treatment teams3. Same-site medical and mental health care4. Free access to medications5. Access to ‘dry’ housing

Early studies from the 1970’s and 1980’s demonstrated that outreach-oriented, team-based interventions among homeless persons can improve mental health and substance abuse outcomes. In systematic reviews of specific interventions to improve the health of homeless persons published in 2005 [6] and updated in 2011[7], successful interventions included:

Case management Early housing after hospital discharge Engagement with mental health care providers (for the mentally ill) Engagement with substance abuse services (for substance abusers) Health promotion programs

Outcomes included utilization of mental health / substance abuse services, achieving stable housing, decreasing risk behaviors, and clinical outcomes such as functional improvement and abstinence. Many studies were of limited methodological quality, and none addressed physical health.[7]

Multiple studies have demonstrated clinical benefit for co-location of medical services at the same site where mental health services are provided. Medical services may include special services for those with substance use disorders, although traditional co-location models focus on primary medical and mental health care. This supports access to necessary care for mental health patients with significant co-morbidities, with the goal of increasing preventive care utilization and improving chronic care management. Co-location reduces hospitalizations, improves access to care, and improves health status in a cost-neutral manner.[8]

It is not surprising that programs to provide housing have been associated with improved housing status. However, controversy remains regarding the best approach for housing provision that supports health and recovery for homeless individuals with substance dependence disorders. Recent studies have emphasized the central role of abstinence-dependent housing in improving not only housing status but health, especially following acute medical events.[7] In contrast, “housing first” intervention programs remove barriers such as sobriety from shelter and housing requirements in order to support subsequent efforts at behavior change and medical adherence.[9, 10] Therefore, is possible that successful housing intervention programs depend not simply upon on the sobriety status for individuals, but on the total care program supporting the housed individual.

“Street Medicine” Outreach ProgramsStreet medicine programs provide mobile services for “hard sleeper” homeless and others

who are unable to obtain shelter, while also providing services to sheltered persons. These


programs are particularly prominent in major urban areas, but smaller programs exist in many non-urban communities. Street medicine outreach teams usually consist of two or more health care professionals, often including nurses and social workers but sometimes including physicians. They go to the homeless in the streets, under bridges, and in tent cities. Their primary goals are to establish relationships, provide contact information, and address immediate needs when possible. In some models ongoing therapy (e.g., medication administration) and monitoring (e.g., limited physical examination, blood pressure or blood sugar monitoring) are performed in the field as well.

Unfortunately, research evidence for morbidity or mortality benefit related to street medicine outreach for “hard sleepers” is quite limited, despite significant coordinated team efforts[11], but data has demonstrated improved process quality measures such as flu shots, Pap tests, and mammograms.[11] Importantly, street medicine teams function out of a deep desire to directly address the moral frameworks of social justice and altruism/compassion that are essential to clinical care. In addition, outreach team members have been essential voices in advocating more globally for compassionate treatment and provision of essential subsistence services for our most needy and vulnerable populations.

Assertive Community Treatment Assertive Community Treatment (ACT) is a type of intensive community-based mental

health service provided to individuals with serious mental illness who have high psychiatric hospital utilization and/or needs for crisis stabilization.[12] ACT was developed in the 1960’s during the shift of psychiatric care to the outpatient setting, around the time that the Community Mental Health system was established. Rather than utilizing a case manager who visits the patient to encourage and facilitate adherence with separate office-based care, ACT incorporates direct provision of psychiatric care and rehabilitation services in residential and community settings by ACT team members for a small, defined caseload of individuals. Therefore, ACT multidisciplinary staff are the direct providers of psychiatric and rehabilitative treatment.[13]Elements of the ACT model [14]:

Services are targeted to persons with serious mental illness Services are provided directly by the ACT team Team members share responsibility for the individuals served Small staff to consumer ratio (1 to 10) No time limit on the team’s involvement with an individual Services are available 24 hours a day, 7 days a week Interventions are provided in the location where the problem occurs rather than

in the clinic or office Treatments and services are comprehensive, flexible, and individualized Team members are assertive in engaging individuals in treatment

Randomized controlled trials have demonstrated that ACT decreases hospitalizations, increases housing stability, and increases patient and family satisfaction.[14] In homeless populations, compared to standard case management, ACT reduces homelessness and symptom severity among severely mentally ill patients.[15]

ACT is delivered through Community Mental Health (CMH) departments; because CMH systems often function separately from the rest of the health care system, clinicians caring for


homeless persons or persons with severe mental illness should ask whether their patients are also under care of an ACT outreach team.[12]

Key points Outreach-oriented, team-based interventions of demonstrated success in

improving the health of homeless persons include:o Case managemento Engagement with mental health care providers and/or substance abuse

services as necessaryo Co-located medical and mental health careo Access to housingo Assertive community treatmento Health promotion programs

Street medicine outreach programs have demonstrated improvement in clinical process measures while addressing principles of social justice and compassionate care, although research evidence to date for clinical outcome improvement is limited.

Assertive Community Treatment (ACT) is team-based, outreach oriented care for severely mentally ill persons; it emphasizes direct provision of necessary care, rather than care facilitation or case management.

ACT has demonstrated effectiveness in decreasing hospitalizations, increasing housing stability, and increasing patient and family satisfaction.

For the severely mentally ill homeless population, compared to standard case management, ACT reduces homelessness and symptom severity.


Objective 5: Specific team skills and communication approaches essential to high-functioning, interdisciplinary care teams.

Case 5A local student-run clinic is seeking to establish an interdisciplinary team care program for high-risk homeless patients who frequent their clinic. You are asked to provide leadership in the planning phase of this initiative.

Which of the following is NOT considered to be a key component of high functioning, inter-disciplinary, team-based health care?

1. Established systems for shared financial resources and costs between disciplines.2. Shared goals that are established by the team, patient, and patient’s support persons.3. Clear expectations for each team member’s functions, responsibilities, and

accountabilities.4. Specified channels for communication that are used by all members across all settings.5. Measurable processes and outcomes for feedback on team function.


Case 5 Answer

Which of the following is NOT considered to be a key component of high functioning, inter-disciplinary, team-based health care?

1. Established systems for shared financial resources and costs between disciplines. Correct. While financial realities clearly affect teams, the key components of interdisciplinary team function are generally considered separately from any financial arrangements between team components.

2. Shared goals that are established by the team, patient, and patient’s support persons.3. Clear expectations for each team member’s functions, responsibilities, and

accountabilities.4. Specified channels for communication that are used by all members across all settings.5. Measurable processes and outcomes for feedback on team function.

When complementary clinical and allied professionals work together as a highly collaborative team, such care is termed “interdisciplinary team care.” Interdisciplinary teams comprise expertise across the biopsychosocial spectrum and can be essential to the care of highly complex patients, including medically complex homeless persons. Yet, the mere involvement of multidisciplinary providers does not ensure success. Effective teamwork is not spontaneous; it requires specific skills.

A large body of research exists on the factors constituting and promoting good teamwork. For healthcare purposes, care teams can be highly variable in composition, size, setting, and communication methods. Yet, essential team-based care principles can be seen in groups that embody “teamness.”[16, 17] (Figure 3)

Figure 3: Five Principles of Team-Based Health Care[16]

Shared Goals Care team, patient, and family/support persons work to establish shared goals reflecting the patient’s and family’s priorities. Goals should be clearly articulated, understood, and supported by all team members.

Clear Roles Clear expectations for each team member’s functions, responsibilities, and accountabilities, which optimizes the team’s efficiency and divides labor as possible

Mutual Trust Team members earn each others’ trust and create strong norms of reciprocity

Effective Communication

The team prioritizes and continually refines its communication skills, maintains channels for candid communication that are used by all members across all settings.

Measurable Processes and Outcomes

The team agrees on and implements reliable and timely feedback on both team functioning and achievement of team goals, to track and improve performance.


In ideal circumstances, teams are proactively designed within a group planning process that allows for direct and explicit attention to each of the five team-building principles. Practically speaking, it may be helpful to approach the principles of team-based care from the point of view of common challenges to team function in less-constructed settings. The following challenges should be kept in mind[13, 16]:

Goals. Do patient and team member goals appear to be congruent? Are family/support members sufficiently engaged in the patient’s goals? Are there conflicts in goals between care team members that need to be resolved?

Roles. Are team members aware of potentially overlapping competencies and responsibilities? Are there professional preconceptions regarding role competencies that need to be addressed or corrected by clarifying the scope of practice of team members? Is there inefficiency or conflicting care related to unnecessary overlap of roles?

Trust. Do team members express shared values of honesty, discipline, and humility? Is there a need to clarify scope of practice to improve trust in the division of labor? Are active and reciprocal communications in place to support reciprocity of trust? Have providers had honest communication regarding their capacity to complete necessary tasks?

Communication. Is there a common language among team members, avoiding jargon specific to particular professional roles? Is plain language used to engage the patient and support members? Do communication systems allow free flow of information across all settings and individuals?

Measurable Processes and Outcomes. Are problems clearly identified and described, allowing for effective decision making? Are decision-making and leadership roles clear when necessary, and flexible when needed? Is a timeline in place if appropriate? Do team members reflect shared values of creativity and curiosity, seeking to solve problems and reflect on lessons learned?

Putting it All TogetherTo conceptualize potential team roles in a clinical setting, consider the team care

necessary to meet the needs of the following patient:

You are providing care at a local homeless shelter’s medical clinic when a case manager approaches you for assistance in the care of a 75 year-old Japanese man. He is living in the country as an illegal immigrant, has no health insurance, no job, and no family. He rotates between living outdoors and living in warming centers. The shelter administrative staff and caseworkers would like you to evaluate him because many shelter residents have complained about his smell. They state that while he appears only slightly dirty, the smell is "like rotting flesh". The patient, who has only intermittent and scattered contact with the shelter clinic, reluctantly presents for evaluation.

Your patient’s English is limited, but you determine that he has severe mental illness as well as bilateral trench foot. He reports that he had trench foot in the past and that he knows the best way to treat it is to "keep it moist". Despite repeated education as to the correct treatment for trench foot (drying, not moisture), the patient refuses to stop "soaking" his shoes in efforts to maintain a moist environment


for his feet. In addition, he declines treatment for mental illness. After consultation with the shelter administrative team, the case manager, the social worker, your medical director, and the clinical support staff, your team establishes goals of care: resolution of severe trench foot, necessary treatment of his mental health disorder, and establishment of hygiene necessary for non-disruptive continued residential care at the shelter. Your team institutes the following plan:

He will be presented with a contract for continued care and housing at the shelter. In partnership with the patient, measurable outcomes are established: in order to continue care and housing at the shelter, he must present to the hospital for admission as required for intensive care of his severe trench foot.

While he is hospitalized, the clinician and social worker will communicate with an inpatient psychiatry team, who will evaluate him and document their findings.

Meanwhile, the patient’s mental health case worker and the shelter social worker will collaborate with you (the clinician) and start the process to obtain a court order for the patient’s necessary medical and mental health treatment.

Once the client is discharged from the hospital, the case manager, social worker, and clinician will provide documentation and testimony as needed to obtain the court order and implement care necessary for his mental and physical health.

Patient mental health, physical health, housing status and social supports will be monitored for success.

In this scenario, all members of an interdisclipinary team are integral to the achievement of the desired measurable outcomes. A collaborative effort, defined goals, ongoing open communication, effective distribution of roles, and respect for each member’s expertise and scope of practice is essential to success of the established care plan.

Key Points: Interdisciplinary teams comprise expertise across the biopsychosocial spectrum

and can be essential to the care of highly complex patients, including medically complex homeless persons.

Five key principles can be seen in groups that embody effective team care:o Shared goalso Clear roleso Mutual trusto Effective communicationo Measurable processes and outcomes

Effective team members reflect shared values of honesty, discipline, humility, creativity and curiosity.


References

1. Viswanathan, M., et al., Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med, 2012. 157(11): p. 785-95.

2. Smith, S.M., et al., Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev, 2012. 4: p. CD006560.

3. Dieterich, M., et al., Intensive case management for severe mental illness. Cochrane Database Syst Rev, 2010(10): p. CD007906.

4. Models of Team Practice. 2012 [cited 2013 April 25]; Available from: dcahec.gwumc.edu/education/session3/members.html.

5. About Clinical Psychology. 2013 [cited 2013 April 25]; Available from: http://www.apa.org/divisions/div12/aboutcp.html.

6. Hwang, S.W., et al., Interventions to improve the health of the homeless: a systematic review. Am J Prev Med, 2005. 29(4): p. 311-9.

7. Fitzpatrick-Lewis, D., et al., Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review. BMC Public Health, 2011. 11: p. 638.

8. Pirraglia, P.A., et al., Colocated general medical care and preventable hospital admissions for veterans with serious mental illness. Psychiatr Serv, 2011. 62(5): p. 554-7.

9. Collins, S.E., et al., Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health, 2012. 102(3): p. 511-9.

10. Padgett, D.K., et al., Substance use outcomes among homeless clients with serious mental illness: comparing Housing First with Treatment First programs. Community Ment Health J, 2011. 47(2): p. 227-32.

11. O'Connell, J.J., et al., The Boston Health Care for the Homeless Program: a public health framework. Am J Public Health, 2010. 100(8): p. 1400-8.

12. 2013 [cited 2013 April 29]; Available from: http://improvingmipractices.org/practices/assertive-community-treatment/.

13. King, T.E. and M.B. Wheeler, Medical management of vulnerable and underserved patients : principles, practice, and populations. 2007, McGraw-Hill Medical Pub. Division. p. 151-158.

14. Phillips, S.D., et al., Moving assertive community treatment into standard practice. Psychiatr Serv, 2001. 52(6): p. 771-9.

15. Coldwell, C.M. and W.S. Bender, The effectiveness of assertive community treatment for homeless populations with severe mental illness: a meta-analysis. Am J Psychiatry, 2007. 164(3): p. 393-9.

16. Mitchell, P., et al., Core principles & values of effective team-based health care, I.o. Medicine, Editor 2012, National Academies: Washington, D.C.

17. Wynia, M.K., I. Von Kohorn, and P.H. Mitchell, Challenges at the intersection of team-based and patient-centered health care: insights from an IOM working group. JAMA, 2012. 308(13): p. 1327-8.


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