1. MULTIDISCIPLINARY TEAM MANAGEMENT

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1 1. MULTIDISCIPLINARY TEAM MANAGEMENT David Burke, Jennifer Kelly, Zeeshan Shahnawaz, Danielle Gately, and Elizabeth Love ST VINCENT S HOSPITAL PSYCHOGERIATRIC MENTAL HEALTH SERVICE The St Vincent s Hospital (SVH) Psychogeriatric Mental Health Service serves a population of approximately 15,000 people aged 65 years and over living permanently in the inner-city area of Sydney. The area is quite diverse, including a relatively high concentration of very wealthy older people, as well as one of the highest concentrations of older homeless people of any inner city in Australia. It has a significant number of older people from culturally diverse, non-english speaking backgrounds, a small number of older Aboriginal and Torres Strait Islander people (aged 55 years and over), and a unique concentration of older gay and lesbian residents, Holocaust survivors, HIVpositive individuals, illicit-substance users, and sex workers. The area also attracts a significant number of older people to the central business district for shopping, recreational, and tourist activities. The Service was established in 2003 with the appointment of a psychiatrist two days per week, and developed over ten years to include one full-time equivalent (1.0 FTE) psychiatrist, 1.0 FTE psychiatry trainee, 2.0 FTE clinical nurse specialists, 2.6 FTE psychologists, 1.0 FTE social worker, and a 0.6 FTE occupational therapist (a total of 8.2 FTEs shared by 11 people). In addition, the service has access to two inpatient beds located in the SVH geriatric medical ward. The growth and development of the Service commenced with a strategic plan that was informed by relevant government mental health policy and planning documents, and by the published recommendations of national and international bodies, including the World Health Organisation, the Royal College of Psychiatrists, the American Psychiatric Association, and the Royal Australian and New Zealand College of Psychiatrists. A broad consultation was conducted with key clinicians, consumers, and managers in hospital administration, community mental health, geriatric medicine, primary care, community aged care, and residential aged care across the area, to assess

2 stakeholders needs, to inform them of the proposed direction of the Service s development, and to enlist their support. Funding for the development of the Service came from within the existing resources of the hospital mental health budget, and subsequently from the state and commonwealth governments. The SVH Psychogeriatric Mental Health Service rests on the principles outlined in the WHO consensus statement on the organisation of care in psychiatry of older people, and in summary involves providing a comprehensive, accessible, responsive, individualised, transdisciplinary, and accountable service (WHO, 1997). The aim of the Service is to provide appropriate, flexible, high-quality, cost-effective care to the older people in the local area and thereby improve their health outcomes and quality of life. The Service is designed to meet the needs of the local older population by providing timely, coordinated, integrated, comprehensive, multidisciplinary mental health promotion, prevention, early intervention, evidence-based treatment, rehabilitation, and relapse prevention; and to deliver this through a collaborative, shared-care model in cooperation with the general practitioners (GPs), and the geriatric medical and other aged-care services who provide care to older people in the area. The other aims of the service are to deliver mental health care (as above) to older people with mental health problems and mental illness, regardless of gender, socioeconomic status, ethnicity, and cultural background; to reduce, as much as possible, the burden of mental health problems and mental illness on older individuals and on their families and their carers; to advocate for the rights of older people in relation to their health, housing, income, education, employment, and justice; and to promote clinical research, education, and service innovation relevant to the mental health of older people. To achieve these aims, teamwork is essential. This chapter will address the essential components of our model of teamwork in psychogeriatrics and our concept of team management (as opposed to case management) that underpins our model of care.

3 MULTIDISCIPLINARY TEAMWORK Multidisciplinary teamwork in psychogeriatrics is about delivering high-quality patient care to older people with mental health problems and mental illness, across inpatient, outpatient, and community settings. The structure and function of the multidisciplinary team, and the model of care adopted, are vital to the achievement of the best possible patient outcomes, and the professional culture developed in the team will determine the team s effectiveness and its longevity (Opie, 1997; Hennessey & West, 1999). Mental health problems and mental illnesses are complex bio-psycho-socio-cultural disorders that have a similarly complex impact on individuals, their families and carers, and on the community around them. It therefore makes sense that the health service response to mental health problems and mental illness should be delivered by a multidisciplinary team that can assess and manage the physical, behavioural, interpersonal, and environmental issues that are responsible for an older person requiring mental health care. The psychogeriatric multidisciplinary team, therefore, should include clinicians with medical, nursing, psychology, social work, and occupational therapy expertise in psychogeriatrics, who have strong professional links to GPs, geriatricians, physiotherapists, speech pathologists, and nutritionists, and the support of health-care interpreters, residential aged-care workers, and other providers, as required. Effective service delivery by the multidisciplinary team then requires a team culture that is agreed on and shared, which governs how the team functions. The team culture determines how the team approaches the assessment and management of patients with mental health problems and mental illness to achieve the best possible patient outcomes. The culture is fashioned by the goals, the strategic objectives, and the operational mode of the team, which are largely determined by the needs and characteristics of the target population. To be effective, the psychogeriatric multidisciplinary team requires strong leadership by a clinician who has a clear vision of the team s charter, a clear concept of how the team functions, and a clear idea of how to guide and oversee the team s activity; and to achieve this, the person needs to be respected as a clinician, as a manager, and as a colleague by all members of the team. The team should have a clear, geographically defined catchment area that allows for an

4 accurate count of the population, an accurate description of the socioeconomic and cultural characteristics of the population, and an accurate count of the number of GPs and the number of residential aged care facility (RACF) beds. These are the factors that should then guide the service planning, including staff numbers, the mix of staff, and the service model adopted by the team. The model of care should be comprehensive and seamless across the inpatient, outpatient, and community-outreach settings, focusing on expert assessment and diagnosis, and short- to medium-term management, in liaison with the patient, the family, the carers, and the GP, and utilising the GP as the central primary carer. THE CONCEPT OF TEAM MANAGEMENT Central to the multidisciplinary team model of care is the concept of team management. This means that when a patient is referred to the team, the members of the team who become involved will be determined by the patient s needs, as agreed by the team and the GP. That is, the patient will be seen by the members of the team best equipped to achieve the best possible outcomes for the patient, with the GP in a pivotal role. This is therefore not a case management model, which usually involves assignment of the patient to one clinician on the team, who is then responsible for involving other team members, as he or she sees fit. In contrast, the team management model involves the team discussing and deciding who on the team is professionally best equipped to meet the current needs of the patient, reviewing this on a regular basis, and making changes to these arrangements from time to time, as required. This involves the team frequently, formally reviewing the patient s progress and making appropriate adjustments to the management plan, including which clinicians remain involved or withdraw from care, and which other clinicians might need to become involved, with the involvement and approval of the GP. In a practical sense, team management will usually involve two or three team members at any one time, working with the patient, his or her GP, and the family and/or carers. This model also helps to smooth the disruption that can arise if the case manager is unavailable, for whatever reason. The patient s sense of continuity of care then comes from the feeling that he or she has a relationship with the team (Coles et al., 1991) and an ongoing close relationship with the GP.

5 For the model to work well, each member of the team must have a certain level of common expertise or core competency in clinical psychogeriatrics, such that all members of the team can perform an initial assessment (Colligan et al., 1993), can recognise the signs and symptoms of mental health problems and mental illness, and can identify when their or their colleagues discipline-specific expertise is required. Beyond these core competencies, each team member s major contribution to team management is the discipline-specific expertise they bring to the psychogeriatric team. This core competency plus discipline-specific expertise model also then distinguishes our team management approach from the notion of the generic mental health worker. The latter implies that all mental health clinicians are equal, and that all can be expected to function at the same level. In our opinion, this runs the risk of a lowest-commondenominator approach that then leads to the dumbing-down of the subtleties of mental health care and risks devaluing the discipline-specific expertise that individual clinicians have acquired over many years of study and training. The core competency plus discipline-specific expertise model, on the other hand, encourages clinicians to explore, understand, and utilise some of the expertise of their clinical colleagues, and promotes collaboration between disciplines and a respect for each other as specialised fellowclinicians. Ultimately, effective team management in psychogeriatrics promotes communication and innovation, and gives meaning and social value to the day-to-day work of the clinicians on the team. In other words, the effective functioning of the multidisciplinary psychogeriatric team relies on healthy, functional, professional relationships between the team members, with each individual feeling he or she is an integral part of the team and that he or she is supported by the team, known as social reflexivity (West, 2012), and each member of the team must feel he or she can rely on the leader for appropriate guidance and support, when needed. To provide flexible and tailored care, the multidisciplinary psychogeriatric team should be able to respond to the needs of the patient, the GP, and the family and/or carers in a timely and appropriately intensive fashion, across the inpatient, outpatient, and community-outreach settings. In other words, the team must be able to function in a crisis intervention mode, an early intervention mode, an acute care mode, a subacute

6 care mode, a rehabilitation mode, an assertive outreach mode, and/or a consultationliaison mode, as dictated by the patient s needs. This is the true meaning of flexible, tailored, patient-focused care. The team should always be clear about its aims but should also have the ability to critically review its aims and the ways in which these aims are achieved, and to adapt its mode of operation accordingly, known as task reflexivity (West, 2012). The team should aim to provide the least amount of intervention, in the least restrictive environment, to achieve the best possible outcomes (Orb et al., 2001), whilst ensuring that the appropriate supports are in place to promote independence and the highest quality of life for the individual. The patients of the team need to feel respected, understood, and above all, well managed; the members of the team need to feel valued and effective; and the team s employing and funding bodies need to see a minimum of adverse events and a maximum of good outcomes. However, multiple stressors can affect the function of the team, including a lack of resources and various forms of health service beauracracy. On the other hand, the rewards of working in a well-functioning multidisciplinary team come from the stimulation of working with colleagues whose professional perspectives can enhance one s clinical experience, and similarly enhance one s patients outcomes. THE MODEL OF CARE IN PRACTICE The SVH Psychogeriatric Mental Health Service operates during business hours Monday to Friday. During this time an intake person, who is a clinician on the team, is responsible for receiving and triaging referrals to the service. Referrals can be made by phone, fax, online or , and come from GPs, hospital and community clinicians (including aged-care teams), residential aged care staff, family members, and carers; and there are occasional self-referrals. In all cases, the intake person verifies that the GP is aware and supportive of the referral. If not, appropriate arrangements are made to address this. The referral is then discussed immediately with at least one other member of the team, and appropriate arrangements are made for the person to be assessed that day, or within one to two working days. This avoids the need for waiting lists and prevents a referral from becoming a crisis or an emergency department presentation.

7 Alternatively, and if appropriate, the person referred can be booked into an outpatient clinic, usually within a week. Irrespective of these outcomes, the referral is listed for discussion by the team at the next weekly case review meeting (CRM). Further subjects discussed in this chapter include: Team Professional Development Goals for the Future IF YOU WOULD LIKE TO READ MORE, PLEASE CLICK HERE TO PURCHASE THE TEXTBOOK. BIBLIOGRAPHY Arie, T., & Jolley, D. (1998). Psychogeriatric services. In R. C. Tallis (Ed.), Brocklehurst s Textbook of Geriatric Medicine and Gerontology (5th ed., pp ). London: Churchill Livingstone. Arie, T., & Jolley, D. (1982). Making services work: organisation and style of psychogeriatric services. In R. P. Levy (Ed.), The Psychiatry of Later Life (pp ). Oxford: Blackwell Sciences. Banerjee, S., Shamash, K., MacDonald, A., & Mann, A. (1996). Randomised control trial of effect of intervention by psychgeriatric team on depression in frail elderly people at home. British Medical Journal, 313, Coles, R., Von Abendorff, R., & Herzberg, J. (1991). The impact of a new community mental health team on the inner city psychogeriatric service. International Journal of Geriatric Psychiatry, 6, Colligan, G., MacDonald, A., Herzberg, J., et al. (1993). An evaluation of the multidisciplinary approach to psychiatric diagnosis in elderly people. British Medical Journal, 306, Goldman, L.S., & Klugman A. (1990). Psychiatric consultation in a teaching nursing home. Psychosomatics, 31, NSW Department of Health. (2006). NSW Service Plan for Specialist Mental Health Services for Older People (SMHSOP) Sydney: NSW Health. Opie, A. (1997). Thinking teams thinking clients: issues of discourse and representation in the work of health care teams. Sociology of Health and Illness, 19, 3,

8 Orb, A., Davis, P., Wynaden, D., & Davey, M. (2001). Best practice in psychogeriatric care. Australian and New Zealand Journal of Mental Health Nursing, 10, Royal College of Psychiatrists Faculty of Psychiatry of Old Age. (2006). Raising the Standard: Specialist Services for Older People With Mental Illness. Royal College of Psychiatrists, London. West, M. (2012). Effective Teamwork: Practical Lessons from Organisational Research (3rd ed.). Oxford: Blackwell Publishing. Hennessy, J. & West, M. (1999). Intergroup Behavior in Organizations: A Field Test of Social Identity Theory. Small Group Research, 30, Wolfs, C., Verhey, F., Kessels, A., et al. (2007). GP concordance with advice for treatment following a multidisciplinary psychogeriatric assessment. International Journal of Geriatric Psychiatry, 22, World Health Organization. (1997). Organization of Care in Psychiatry of the Elderly A Technical Consensus Statement. Retrieved from World Health Organization: