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Fall 2014
Supervision in Care Management: Managing Quality

Providing Care Management with a Multidisciplinary Team: Managing Quality

About the Author

Harriette Grooh is a Clinical Psychologist and a certified care manager who has worked in geriatric and mental health care all her professional life.  In the late 1970’s as Geriatric Coordinator in the Transitional Services unit of Marin County Community Mental Health Services she created the county’s first inter-disciplinary Marin Mobile Geriatric Evaluation Team, comprised of a gero-psychiatrist, physician, geriatric nurse specialist and mental health counselor.

In 1983, she entered the private sector by establishing HGA Personal Care Consultants, a unique private, for-profit multidisciplinary consultation and care management firm, specializing in serving the behavioral, bio-psycho-social needs of elderly and disabled beneficiaries of individual trusts and family offices in San Francisco and the Greater Bay Area.   Dr. Grooh has a private psychotherapy practice in San Francisco and Kentfield, California. Her specialization is in geropsychology.

She served on the Board of Directors for the National Association of Professional Geriatric Care Managers, was a founding director of the Western Regional Chapter of NAPGCM, and is a Past President of the Western Regional Chapter.  She is one of the founding directors of the Alzheimer’s Association of Northern California and Northern Nevada.  From 2010 through 2013 Dr. Grooh served on the Board of Directors of the San Francisco Psychotherapy Research Group.  She is member of the San Francisco Bio-Ethics Forum.

Dr. Grooh is a member of the American Psychological Association, The Society of Clinical Geropsychology, California Psychological Association, California Association of Marriage and Family Therapists, Gerontological Society of America, American Society on Aging, The National Association of Professional Geriatric Care Managers, and the San Francisco Psychotherapy Research Group.

Harriette R. Grooh, PhD, CMC
HGA Personal Care Consultants
10 Funston Avenue
San Francisco, CA 94129
hgroohhga@cs.com
Website
415 924-8311

Harriette Grooh, PHD, CMC

Summary

The complex needs of some older clients demand the attention of an array of professionals in order to formulate and execute comprehensive care plans. Geriatric care managers employ a variety of methods in solving complex problems of the elderly. One modality is the team approach to assessment, care planning, and on-going care coordination. Some teams comprised of representatives from different disciplines can address both client needs and potentially harmful changes in the client’s status. This article makes the distinction between work groups and team units. It describes the evolution, makeup, and processes of a high-performance team, leadership duties, and suggestions for supervisors embedded in multidisciplinary teams of geriatric care managers.  Several variations of multidisciplinary teams are described.

Providing Care Management with a Multidisciplinary Team: A Holistic Approach

As a mental health professional (an inveterate problem-solver), I believe that older adult clients represent the most intriguing of all client populations. The challenging problems this population presents are many: fragmented health care and social services systems; complicated, sometimes distant, or dwindling families who are un-informed, in conflict, or exhausted; the fundamental questions about life, death, obligations, and choice; profound spiritual and ethical dilemmas; complex legal options; and the sheer cost of funding a life that is longer than may have been expected.

Geriatric care managers take a holistic approach to solving these problems because they understand the interdependence of the bio-psycho-social-environmental-financial-legal variables and the impact they have on the safety and autonomy of each client. Care plans are devised to take all of these factors into account and to recommend feasible resources to address a myriad of needs. When a care manager pulls together all needed resources on a case-by-case basis, it may result in an ad hoc group of providers representing various disciplines; but this is not the same thing as leading a multidisciplinary team of care managers.

A comprehensive approach to geriatric assessment is designed to screen basic medical, psycho-social, environmental, and safety concerns. These screenings should be performed by clinically trained care managers, because geriatric clients can present with atypical symptoms. Care manager teams comprised of licensed clinical professionals (nurses, social workers, psychologists, and others) have the education, training, and instruments necessary for making assessments within their scope of practice that will indicate the need for further evaluation and possible treatment interventions.  A classic example of the need for these teams is the referral of the older person who presents with cognitive / behavioral changes:  confusion, agitation, dizziness, falling, or hallucinations; but with no fever, no pain, or other typical symptoms of a treatable urinary tract infection (UTI). Another example is the client who has significant weight loss, sleep disturbance, and has difficulty planning or remembering things. If no medical causes are found, it may be these changes are due to a major depressive episode. It would be a mistake to treat only the symptoms, overlooking the underlying problem, which may be treatable.

A comprehensive assessment deserves a comprehensive care plan

To implement and manage holistic care plans that address resolution of maladies, rehabilitation from injuries, and prevention of further complications, the professional care manager may be coordinating an array of treatment plans representing the efforts of medical and psychiatric providers; ancillary professionals (speech therapists, physical therapists, occupational therapists, nutritionists, and dietitians); and adjunctive providers (music therapists, art therapists, massage therapist, and oral history recorders). Additionally, the geriatric care manager may involve social, community, and spiritual services to maintain successful plan implementation and to create or sustain quality of life. The geriatric care manager may be called upon to design and implement a team of non- or para-professional providers (including family members) for home care duties consistent with the care plan. In addition to the bio-psycho-social assessment and development of the care plan, the care manager may be the on-going implementer of the plan to ensure it continues to be within reasonable financial and legal limits and congruent with the client’s on-going preferences.

How to deliver the package – care management teams

Clearly, for the professional geriatric care manager this is a whole lot of coordination!  While some geriatric care managers operate as solo providers, it is a great benefit to have the ability to use a multidisciplinary team model for assessments and care management. However, it can be very challenging to supervise people who come from different professional perspectives so that efforts are maximized and the outcomes are successful.

It is important to distinguish between managing personnel and supervising the individual team members’ work. Managing entails human resource duties: recruiting, hiring, firing personnel. Supervising involves leadership and oversight that aims to direct and support team members to accomplish work duties in accordance with certain parameters.

The evolution of high performance teams as an organizational unit

Before discussing the team model as it might be applied to geriatric care management, some background might be helpful. Highlights from Leonard and Freedman’s (2000) succinct review of the development and study of work groups yields a sweeping perspective and demonstrates how recently the concept of teams appears in the workplace. Before the 20th century, work teams that were not primarily families, were rare and not highly valued with the exception of governmental and military units, orchestras, and theaters. The advantages of teamwork became apparent as nation states evolved and the Industrial Revolution emerged; although the integration of work, interpersonal communication, cooperation, and problem-solving was still limited. Because cheap labor was abundant, efficiency and integration of effort was less important.

Psychologists engaged in the study of human behavior, including the behavior of humans in groups. In the late 19th to early 20th century the focus was on the psychology of collective behavior, e.g. the regressive nature of groups or crowds. In the 1930s, 40s, and 50s, Social Psychology emerged, studying the effect of people on other people and the interactions between people, generating exciting new observations of how groups worked, including feedback loops, sensitivity training, participatory leadership, and an interest in group dynamics and applied social change. Beginning in the 1960s social psychology turned its focus from social growth toward personal growth. “In business and corporations, organizational leaders were willing to allow behavioral scientists to work with their subordinate teams but not with their organization’s larger subsystems or governance process. As a result, early organizational development (OD) practitioners often focused change efforts on smaller units. Team building seemed more achievable and realistic than efforts to enrich jobs or democratize the workplace.” (Leonard and Freedman, 2000)

By the mid-60s, researchers recognized “the impact of the characteristics of the work itself had on the way work was organized…One could not effectively institute significant changes in the technical aspects of work without involving the people who had to work in this new environment in planning for the changes.” (Leonard and Freedman, 2000)  The best way to do a job was not determined by top-down scientific management. Rather, teams that could self-organize and regulate, that exhibited “responsible autonomy,” could determine the best way to do a job and lead to greater creativity, personal motivation, and work commitment. By the 1970s team-based techniques and strategies were developed and refined. Tuckman’s (Tuckman 1965) stages of group development (forming-storming-norming-performing) became a widely known model of group development.

In the 1980s the economy was mired in recession. With downsizing and the death of the economic contract, i.e. loyalty of workers and managers in exchange for life-time employment, and re-engineering that leveled the managerial pyramid; business needed new ways to achieve efficiency and motivate workers. Teams seemed to be the answer. By the end of the 20th century team-based structures, in particular high-performance and cross-functional teams, were relied upon to improve productivity and quality. (Leonard and Freedman, 2000)

This was the time when the pioneers of geriatric care management started their entrepreneurial practices, and began to develop multi-disciplinary teams to serve their clients. After 30 years of development of the team approach, some geriatric care managers now use an emergent model in teams: the trans-disciplinary team. In the trans-disciplinary team, members of different disciplines are not only proficient in their own specialties, but through cross-training and working on the team, become knowledgeable in other specialties as well, resulting in overlapping competencies among team members. Trans-disciplinary training and teamwork permits the care manager to see a more complete picture of each client, and to a certain extent allows for assessment and care planning with skills and knowledge from a discipline other than one’s own. (Hobbs, M.D., 2005)

Building a better team

Not all high performance professionals are equipped to work well in a team setting. Ideally, individuals with a proven track record of teamwork are recruited to the team. Key characteristics to look for and to develop in an effective team member include respect for the team leader and for other team members, regular attendance at meetings, honesty, and patience to listen. It is desirable that the member knows one’s personal abilities and limitations, understands each member’s respective roles and responsibilities, and embraces the client-centered mission of the organization. A resilient team member is open to constructive criticism and has the ability to empathize and to see another person’s point of view. Ideally, the professional can manage personal stress by recognizing the early signs of burn-out and has a willingness to seek assistance or to delegate tasks to ease the strain. Closely related to stress reduction is having a sense of humor, which helps maintain perspective during challenging times. Intellectual generosity is the willingness to share one’s knowledge and resources and to communicate information in non-technical language with other members of the team. It is an essential component of the multi-disciplinary team model. In some teams, members operate with a kind of emotional reciprocity or camaraderie which the whole team experiences as professionally supportive.

As the team supervisor, one may act as a teacher, counselor (but not therapist), consultant, monitor, and gatekeeper. The supervisor is responsible for developing the organization’s program, policies and procedures; managing referrals, assigning cases, and monitoring the size of caseloads; and overseeing the quality of service. If the supervisor is not the owner/manager, he or she serves as liaison to the management/owner of the organization. In addition, the supervisor is responsible for ensuring that performance targets are met; for example, achieving expected response times for setting up an initial client interview, writing documentation in a timely manner and meeting project objectives within the expected and reasonable number of hours billable.  (Munn, G. and Forsythe, D., 2013)

A good supervisor is an excellent team member who models the team process well by exemplifying all the key characteristics of the individual team members. The supervisor motivates and supports the team, providing opportunities for staff development and training, ensuring that team members have current knowledge and refreshed skills. Sometimes individual supervision is needed to augment group supervision, especially for new members of the team.

The supervisor needs to build and sustain a trusting team culture, which includes practicing transparency, for example, enforcing a policy prohibiting the use of blind copies. Team leaders devise and participate in bonding activities, provisioning and managing resources effectively, criticizing constructively, praising in public, and reprimanding or correcting in private. A good supervisor is approachable, a good listener, takes initiative in improving the team’s methods, is friendly, pleasant, reassuring, and celebrates team successes. As a contributor to team discussions, it is important for the leader to possess relevant knowledge, skills, and resources to share. The responsible supervisor will train a relief supervisor, possibly another member of the team, to cover in his or her absence.

Most importantly for successful group dynamics, the leader creates an atmosphere of mutual trust and safety through purposeful and goal-directed communication, clear expectations, and genuine respect. The supervisor nurtures a safe environment by establishing clear, well-defined, consistent boundaries and by developing a sound structure that focuses on the client. The supervisor needs to understand the different scopes of work, standards of practice, professional ethics, and legal regulations by which each discipline on the team is bound.

Good supervision includes accepting individual differences, discouraging groupthink[1], encouraging introverts to speak, respectfully restraining extroverts to make space for others, embracing positive conflict through facilitating open and honest differences of opinion or style. The effective supervisor acknowledges the team members’ differences in cultures and backgrounds, theoretical constructs, opinions, expectations and needs, personalities, egos, interests, communication styles, and competencies.

Challenges of managing a team

Because collaboration is not a widely held norm in work settings, team members may need guidance to develop a collaborative approach. Collaboration includes listening to everyone’s views, developing trust in each member’s expertise, methods, and judgment.

The supervisor must also take responsibility for mediating conflicts, which can be caused by a team member’s difficult personality or stressful life challenges. Conflict is normal, and it can be managed. Conflict can lead to positive results and to negative results, to win/win solutions, or to needed change in the makeup of the team. Signs of team conflict can include name calling, gossiping, sarcasm, increased absenteeism, verbal complaints or critical emails, overt anger or clique formation, refusal to share information, lack of results, and missed deadlines.

The first rule of managing conflict is to acknowledge the conflict – it is not self-healing. The supervisor can make resolving the conflict a team effort. This would begin by having the team define the conflict, focusing on the situation, identifying the causes, and not taking the conflict personally. The team can brainstorm solutions, establish common ground, agree on a plan to resolve the conflict and execute the plan.

A strong leader knows he or she is fallible, and does not expect perfection from the team members. How a leader admits to making mistakes and actively goes about rectifying errors serves as a powerful model for team members. A demonstration of how to learn from one’s mistakes, can give courage to a team member who may have erred and is too embarrassed or afraid to seek help. An experienced supervisor discretely guides a valued team member toward solutions to performance problems, thereby overcoming the inevitable trauma of making mistakes.

Finally, a well supervised, high performance multidisciplinary team eventually becomes a cohesive, successful entity and a source of pride and job satisfaction for the leader and the team members. Team members trust their supervisor to see the big picture and “to have their backs” when a case becomes impossibly challenging. Because they believe the supervisor knows their work and worth, they feel more valued and appreciated, which in turn makes the worker want to step back and find ways to improve their own performance. Solid productivity and exceptional quality may ensue. Understandably, when a teammate leaves a tightly knit group, the supervisor should be prepared for a significant shift in the group, because members are likely to experience a profound sense of loss. At these times it is best to recall Tuckman’s phases of group development which predicts a regression to earlier phases of forming and storming when a person leaves or is added to the team.

Current models for multidisciplinary care management teams – variations on a theme

There are at least four models of multidisciplinary teams currently in use in various care management organizations at this time: the Focused Care Manager Team; the Interdisciplinary Team; the Multidisciplinary Care Management Team, and the Multidisciplinary Consultation Team.

The Focused Care Manager Team – In this team all care managers are of the same discipline, which may not be a clinical discipline. Each care manager carries a caseload, assessments are generally functional with more depth from the perspective of the care manager’s discipline. This group may operate as a single unit of separate service providers, but it may operate as a collaborative team. Examples of Focused Care Manager Teams are (1) a nurse-owned care management group, staffed with nurse care managers who provide functional assessments and care plans with an emphasis on medical issues; or (2) a care management team led by a gerontologist, staffed by non-clinical certified care managers who provide only functional assessments and recommendations.

The Interdisciplinary (Inter-professional) Team – In this team each team member has a different discipline. All members may be assigned the same client, but the primary care manager is the team leader determined by which discipline is seen as top priority based on the client’s needs at any given time. The lead care manager role can rotate over time depending on case priorities. Assessments are generally comprehensive. The group may operate more as a unit of rotating professionals. The Interdisciplinary Team is more likely found in an integrated primary care or rehabilitation care setting, than community-based geriatric care manager setting.

The Multidisciplinary Care Manager Team – In this team members are of different disciplines. The care manager may take the primary care manager role for a caseload and / or serve as the back-up care manager for a teammate. Usually, these dyads, or nested teams, of primary and back-up care managers are comprised of different disciplines.[2] Assessments are both comprehensive and clinically oriented. They may include functional, medical, psycho-social, behavioral, and environmental assessments and screenings. These teams are the most cohesive model for clinical assessments and care planning. These multidisciplinary teams may evolve into trans-disciplinary teams; if not by design, then by intra-team teaching and learning.

The Multidisciplinary Consultation and Care Management Team – This team includes a multidisciplinary team of care managers and a nested multidisciplinary team of clinical consultants and other specialists. The consultants do not see the clients or carry a caseload. They may discuss clients with the decision makers or the client’s treatment team. Mainly the consultants counsel the care managers on formulating case specific assessments and care plans. An example of the composition of this team may include: consultants – pharmacist, geriatric nurse practitioner, disabilities specialist, public benefits specialist, gero-psychiatrist; and care managers: clinical psychologist, clinical social worker (mental health and substance abuse focus), clinical social worker (medical and disabilities focus), geriatric nurse specialist, palliative care nurse, general nurse care manager. In this case the psychologist is the team supervisor.

The multidisciplinary team model for geriatric assessments and care management offers one of the most comprehensive approaches to problem-solving and quality care planning for one of the most challenging client populations. While there is a growing acceptance of this modality among professionals and the clients they serve, it is not well studied and it is expensive. More investigation into the home and community-based multidisciplinary team is warranted particularly as this segment of the population expands exponentially. Supervising a multidisciplinary team is also a challenge, but if run well, this team model can give the team leader and care managers alike an enriching and satisfying environment in which to do very hard, but rewarding work.

References

Article References

[1] “Groupthink” is a psychological phenomenon that occurs with a group of people, in which the desire for harmony or conformity in the group results in an irrational or dysfunctional decision-making outcome. Group members try to minimize conflict and reach a consensus decision without critical evaluation of alternative viewpoints, by actively suppressing dissenting viewpoints, and by isolating themselves from outside influences.” <https://en.wikipedia.org/wiki/Groupthink>

[2] De Stampa, Matthieu, et al (2014) found in their qualitative study of multidisciplinary case manager teams for the elderly in France that most of the case managers “had organized themselves within the multidisciplinary teams so that case management would continue even if a case manager was absent.” P.5

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