JUDE BARBACK looks at ongoing research into the effectiveness of a multi-disciplinary team approach in aged residential and home-based care.
Meet Doris*. Doris is 96 and occupies one of the four palliative care beds at Althorp Private Hospital in Tauranga.
Now meet those who provide her care: a specialist doctor and a nurse supplied by Waipuna Hospice, a social worker from Tauranga Hospital, the Althorp nursing staff, and the patient’s GP. Together, they form a team responsible for the provision of care for Doris.
Theirs is a multi-disciplinary team (MDT), comprising a wide range of clinical specialities, and according to Althorp general manager Ginni Cashell, is hugely effective. Such a team could potentially include general practitioners (most likely geriatrics specialists), nurses, nurse practitioners, pharmacists, nutritionists, carers, and allied health professionals such as physiotherapists, occupational therapists, speech therapists, and audiologists. Social workers are also included when necessary.
MDTs have long been a part of secondary care for older people. Dr Elizabeth Spellacy, senior gerontologist from Tauranga, says MDTs are integral to the whole speciality.
“You cannot provide specialist services for older people without working as a multi-disciplinary or inter-professional team,” she says.
However, in other settings, namely the aged residential care arena, community settings, and in home-based care, the concept and workings of MDTs is not as well integrated.
The Aged Residential Care Service Review, carried out by Grant Thornton New Zealand Ltd and published in September 2010, recommended MDTs as one of four proposed models of aged care. The review found that through the close integration of health services, this approach makes it possible to improve the resident’s experience, improve provider coordination, and reduce unnecessary services and costs. Indeed, MDTs in aged residential care seem to get the ‘thumbs up’ from every angle.
The proposed model is founded on a raft of research, including an article in leading medical journal Gerontologist (46:227-237 (2006)), which says, “Long-term-care patients have multiple needs, requiring a complex set of services provided by many individuals with different training. There is a general perception among many health care providers and health policy makers that interdisciplinary teams are better able to coordinate and provide such services, resulting in better health care and outcomes.”
MDTs in ARC: an emerging success story
Dr Michal Boyd, nurse practitioner for Waitemata DHB, believes there is huge potential for MDTs to have a positive effect in aged residential care facilities. Building on the Residential Aged Care Integration Programme (RACIP) evaluation research at Waitemata DHB and research conducted by Counties Manakau DHB, led by Dr Tim Kenealy and published in the New Zealand Medical Journal, that showed how effective a gerontology team could be in an aged residential care setting, the Waitemata DHB is now conducting its own research to explore further options for MDTs in aged residential care.
As part of Waitemata DHB’s RACIP, a group of nurses, gerontology specialists, and members of DHBs came up with 18 geriatric issues. These provided the basis for the RN Care Guides, which proved to be immensely popular with aged care facilities. These evidence-based guides were used by RACIP Gerontology Nurse Specialists (GNS) to provide clinical education onsite for DHB facilities. The RACIP programme also provides quarterly study days for aged residential care, for instance, for manual handling and wound care.
Boyd describes the involvement of the aged care staff in the early stages of the programme development as “extremely important”. Due to their involvement from the outset, the aged care facilities were subsequently very supportive of the programme. In turn, they became more trusting of the DHB partnerships. In addition to advancing aged care initiatives, the development of the residential aged care integration programme was an unintentional diplomatic exercise in building important and strategic relationships between the DHBs and the sector.
“It had nothing to do with auditing and everything to do with partnerships,” says Boyd.
Partnerships which Boyd hopes can be further utilised following the completion of their current research, including a randomised controlled trial presently at intervention stage. The study, led by geriatrician Professor Martin Connolly, involves an MDT intervention held within aged care facilities that includes the DHB geriatrician, GP, gerontology nurse specialist, facility senior nurse, and pharmacist. The team meets three times at an aged care facility to discuss who among the residents is ‘high risk’. The GNS also work closely with the facilities for nine months to help establish a baseline assessment of the facility’s strengths and weaknesses, and what education plan is needed. Boyd, a co-investigator of the study, admits there is a lot of work to be done at the beginning but becomes less intensive after the initial assessments and more maintenance-driven.
Although Boyd is not a member of the MDT that has been formed for the purposes of this research, she agrees there is great potential for the role of nurse practitioner, which is still being developed in New Zealand.
“They have a huge part to play with MDTs,” says Boyd.
While Waitemata’s research is yet to be completed, the results may confirm that MDTs in aged residential care settings are the way forward. Waitemata DHB is certainly a success story. However, Boyd says other DHBs are developing their own variations of the RACIP model.
Do MDTs have a place beyond ARC?
But could the MDT model work as effectively for older people in community settings, such as retirement villages without care facilities? And beyond that, for people who have elected to remain in their own homes and require home-based care and support?
It appears this is ultimately what the government is striving for, as indicated by the Ministry for Health’s policy direction: Better, Sooner, More Convenient Primary Health Care. The policy is aimed at creating an environment where primary health care professionals in the community work with one another and with hospital-based clinicians to deliver co-ordinated care to people in their own community – without a lengthy wait. It is clearly consistent with the model of multi-disciplinary teams in the primary care settings.
Better Sooner, More Convenient also reflects a shift in professional boundaries. Treatments that traditionally fell under the responsibility of hospitals are increasingly being performed in the community by GPs and practice nurses who have received additional training from hospital specialists. Intravenous antibiotics to treat cellulitis and surgery to remove skin lesions are two examples cited by the Ministry where clients no longer need to go to the hospital for their treatment.
The policy is consistent with the findings of the Grant Thornton review. The focus group participants considered it important that teams follow residents across different settings, from residential care to home support and in acute settings when necessary. Teams also need to be able to meet after hours and urgent response demands. The review identified the need for tighter integration between home support and residential care.
Boyd says that care is becoming more consumer-driven. “Older people are staying in the community with greater disability than ever before, and many older people with high needs are choosing retirement villages over residential aged care.”
She believes MDTs could play more of a role in communities of older people, such as retirement villages.
Given that not all ageing people can afford to live in retirement villages, and given the Government’s push for remaining in home for longer, it will be interesting to see how MDTs will play a part in home-based care.
Julie Haggie, chief executive of New Zealand Home Health Association (NZHHA), believes there is room for improved integration between home support and other health services.
“People living at home need to get access to clinical care at home and after hours to reduce the likelihood, frequency, and duration of hospital attendance. There should also be more intensive support to help them rehabilitate after an event such as a fall or stroke,” she says.
Obviously, it isn’t cost-effective for MDTs to collectively visit individuals in their homes. However, other countries are exploring alternative solutions. The PACE programme in the United States has found some middle ground in their community centres, which give elderly people access not only to health care but to aspects of home-support services such as meals, laundry, bathing, and even transport to the clinic.
Boyd thinks we would struggle to replicate this approach in New Zealand due to the barriers between public and private care. Coordination between the DHBs and councils to provide an older adult-friendly transport service is also likely to prove difficult in achieving such a model –but not impossible.
However, the medical centres that provide a wide array of services and can be found in many townships around New Zealand are a step in the right direction. Older people, particularly those still in their homes, are big proponents for these ‘one-stop shops’.
Val O’Sullivan of Matamata finds the local Pohlen Medical Centre invaluable. Having recently fallen and broken her wrist, she has found the team approach at Pohlen extremely useful, allowing her to see the doctor, nurses, physio, and pharmacist all under the one roof.
This is also consistent with the Grant Thornton review, which reveals a need for a ‘home base’ for the services provided by members of a multi-disciplinary team. The review suggests this could be a single organisation employing all or most team members or perhaps a lead practitioner with links to others.
With changing settings and the involvement of so many people, clear and accurate communication is a vital component in the success of multi-disciplinary teamwork. Case conferences and the use of electronic medical record platforms are often essential in coordinating the care of residents. A common platform for assessment, such as interRAI, would facilitate standardisation, consistency, and communication flow across the team.
Lessons to learn from the US
If we consider what other countries are doing, we are inevitably drawn to the United States, where there is much to be learned from the aforementioned PACE programme. The programme was profiled in the publication, Long term care in the USA: lessons for New Zealand?
Among its many functions, the PACE programme demonstrates the ability to shift resources from acute to non-acute care settings. It allows the community-based provider access to the resources.
The PACE programme generally works well because the providers are incentivised to work with clients to determine their actual needs – and only deliver the services that will enhance wellbeing. This has resulted in lower utilisation of secondary services and pharmaceuticals but only if there are sufficient community-based resources to support client needs in aged residential care facilities and the community.
Future directions for MDTs in aged care
The Grant Thornton review considers two variations of the MDT approach that might help iron out any aspects of the current system that aren’t promoting the desired levels of efficiency and coordination.
Aged care services teams
The first of these is aged care services teams, whereby a group of aged care professionals come together with common incentives, tools, and a shared philosophy. This variation of the model presumes that the team will take full responsibility for all aged care services provided to clients, including home support, day care services, residential care, hospice, clinical management, acute hospitalisation, and social work.
Given the wide range of providers and circumstances around the country, adoption of this model would likely result in several different organisational approaches. However, a key feature of aged care services teams – and what separates this model from the current state – is the alignment of incentives. Focus group participants suggested there should be shared incentives for team performance to avoid members being paid on a fee-for-service basis, which undermines the concept of this approach. However, this could be problematic as the current culture would not support sharing financial risk across the boundaries of organisations.
The success of this model would also depend on the alignment of the operations of all providers involved. The integration of the clinical services for home support and residential care is a vital component. For example, the activities of the nursing staff at residential care facilities would need to be tightly integrated into the activities of the doctor, other ancillary professionals, and other services being provided by the team.
Naturally, many questions present themselves. What form would the team take? It was suggested that a community-based organisation that employs all or most of the clinicians – whether a free-standing organisation, a special purpose primary healthcare organisation, a current provider of residential care or home support, or the DHB itself – would best meet the needs of this model.
Another major decision would be whether to absorb the clinical staff of residential care providers into the team at the community level, with those services then being provided directly to the residents of the facility by the community-based organisation or taken on by the aged residential care provider itself.
It is also likely to prove difficult to introduce such changes into the current practice arrangements and scopes of practice, which do not tend to support collaborative, team-based approaches across organisational boundaries.
Other concerns raised by the focus groups were how such teams would align the philosophies of care and work processes, how to adapt this model in both urban and rural settings, availability of sufficient staff at all levels, and how to overcome the current paradigm of provider competition which inhibits a client-centred approach.
Primary care-based teams
Some of these concerns are also relevant to the review’s other proposed variation of the multi-disciplinary team – the primary care-based team – where residential care residents would be one subset of patients in the primary care system connected into a virtual community-based web of services; the teams based within broad-spectrum Primary Health Organisations (PHO).
According to the review, while the philosophy of ‘patient-centred’ care is similar to that which underpins the aged care services teams model, the structure and approach differs markedly.
By the nature of the primary care system, the connections between providers are all, by necessity, virtual, and primary care organisations have a wide range of priorities, of which aged care is just one.
The prioritisation of aged care is certainly a key determinant for the success of this proposed model, as is the allocation of resources for aged care.
If aged care is prioritised and resourced effectively, it should be possible to achieve the same benefits likely to be derived from the aged care teams model, such as cost savings from avoiding utilisation of other parts of the health system and improved outcomes as measured by things like greater longevity, increased satisfaction, improved quality, and better allocation of resources.
However, the most significant benefit of the primary care-based approach is that it is consistent with the primary care strategy and leverages other investments already being made in the primary health care system, such as capitation funding arrangements and information technology initiatives to provide for connectivity and sharing of medical information.
If we look to success stories like the Waitemata DHB, it is clear we are on the right track to utilising MDTs to provide a better model of care for older people. However, as the Grant Thornton review indicates, there are many factors to be considered and coordinated, hurdles to leap, and infrastructures to be challenged. Change, as it is proposed here, is a huge task. But not impossible, and by all accounts, certainly worth it.