ICMEInterprofessional Case Management Experience

The Joe and Thelma Hedgepath CaseLearners, go to this site and make sure you are registered for ICME and have taken the pretest.

https://medapp.louisville.edu/iCCOA/iccoa.cgi

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant

number 1 U1QHP28732-01-00, Geriatric Workforce Enhancement Program.

ACollaborationofMany

TeamIntroductions

InyourteamsintroduceyourselfbyNAME&DISCIPLINEandanswerthefollowingquestions:

•Whatdoyouwanteveryonetoknowaboutyourdiscipline?•Whatstereotypedoyouhatethemostaboutyourdiscipline?

InterprofessionalCaseManagementExperience

ICME

Inthissessionyouwilllearnaboutintegratedpatient-centeredgeriatriccommunitycare,conductagoalsofcare/familymeetingand“practice”workingwithaninterprofessionalteamtoplanthecareofacouplecopingwith

seriousillnessandmultiplesocialissues.

ActivitiesforToday• Youwill:– Participate inteamdiscussionsandactivitiesrepresentingyourdisciplineasateammemberinvolvedinthecareofthecouple,Mr.andMrs.Hedgepath.

– Observe videotapedinteractionsbetweenmembersofMr.andMrs.Hedgepath'shealthcareteam

– Critiqueanddiscusstheseinteractions.– Participate inafamilymeeting.

“Ground Rules”

•Turn electronic devices OFF—this is a time for personal interaction

•Participate in all discussions

•Respect one another—allow others to speak, do not interrupt

•Keep confidentiality related to team discussions

•Ask for clarification if you do not understand

•Have FUN!!

WorldHealthOrganizationDefinitionsofHealth

• Health=“astateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity”

• Socialdeterminantsofhealth=theconditionsinwhichpeopleareborn,grow,live,work,andage

WhatDeterminesHealth/Well-Being?

SocialandEconomicFactors

• Caregiving• Supportsystem• Independence• Housing• Income• Insurancecoverage• Previouslosses• Copingstyle• Overallqualityoflife

HealthBehaviors• Diet• Medicationadherence

• Substanceabuse• Exercise• Sleephabits• Smoking&smokinghistory

• Homesafety

HealthOutcomeDeterminants

Booske,BC, Athens,JK, Kindig,DA, Park,H, & Remington,PL. (2010). Different perspectives for assigning weights to determinants of health. University of Wisconsin Population Health Institute.

HowShouldSocialDeterminantsofHealthInformCareoftheOlderAdult?

• Ifweaddressonlythephysiologicalchangesandtreatmentofthedisease,wearemissing88%ofthefactorsimpactingpatientoutcomes

• Holisticpatient/family-centeredcareisessentialifwearetoobtaindesirableoutcomes

• Ittakesateam!

MembersoftheCommunityTeam• PatientandCaregiver,FamilyMembers• ClinicalCareTeam- PhysicianorNursePractitioner,RN,Clinical

SocialWorker• CommunityHealthNavigator• CommunityOrganizer• CareManagers• PeerMentor• DentalHealthProfessionals• Attorneys• Pharmacists• Otherprofessionalsdependingonthepatient’splanofcare

(homehealth,PT,OT,specialistMDs,etc.)

AnExampleoftheModel

MultidisciplinaryTeam• Strong,focusedleadership

• Individualaccountability

• Individualizedworkproducts

• Efficientmeetings• Success=influenceonothers

Adapted from: the Discipline of Teams by Katzenbach and Smith, 1993.

InterprofessionalTeam

• Sharedleadership• Individualandmutualaccountability

• Open-endeddiscussions,activeproblem-solving

• Success=collectivework-products

Introducing:JoeandThelmaHedgepath

Learners read case summary

WhatsocialdeterminantsofhealthwillimpactMr.andMrs.Hedgepath’s care?

Baseduponthewrittensummary,eachteamwillexploredifferentissuesofMr.andMrs.Hedgepath'scase.• IdentifyMr.andMrs.Hedgepath's mainissues

asdeterminantsinthearealistedonyourteam’schartpaper.

• Listtheseonchartpaper.• Selectareportertoshareyourideaswiththe

fullgroup.

Whoshouldbeontheintegratedcommunity

careteamforMr.andMrs.Hedgepath?

Mr.andMrs.Hedgepath'sCareintheCommunity-Video

• In-HomeAssessmentbyCommunityTeam

• FlourishCaseConceptualizationMeeting

BREAK10minutes

What’sNext?

TeamAssignment• Youwillroleplayafamilymeeting.• Yourfacilitatorwillassignyouaroleonthisteam.• Youwillbegivenadescriptionofthatroleandwhatthatteamorfamilymemberwillcontributetothemeeting.

• Basedonyourrole,youwillinteractaccordingtoyourrole.

• Yourmeetingwilllast15minutes(unlessyoufinishsooner.

Mr.andMrs.Hedgepath'sCareintheCommunity-Video

• BriefFamilyTherapyMeetingwithHospiceClinicalSocialWorker

• Youwillnowdebriefandevaluatehowwellthisteamdidinassessing,planningandimplementingcareforthiscouple.

• Howwelldidtheteamhonorthepatientandfamilymembers’valuesandperspectives?

ThankyouTEAMFACILITATORS:•Thankthelearnersfortheirparticipation.LEARNERS:Beforeleavingcompletethesurvey&consent•IfyouarenotaULuser:https://medapp.louisville.edu/iCCOA/iccoa.cgi•IfyouareaULuser:http://medapp.louisville.edu:9000