Teamwork and the Interdisciplinary Group (IDG)

Teamwork and the Interdisciplinary Group (IDG) Hospice Aides will receive 1.0 credit of in-service education. Licensed professionals will not receive continuing education credit (CEUs, contact hours, etc.) for attending this program. Internal Use Only Highlights DISCUSS HOW NEEDLESTICK INJURIES OCCUR. OUTLINE WAYS NEEDLESTICK INJURIES CAN BE PREVENTED. DISCUSS THE POTENTIAL INJURIES FROM NEEDLESTICKS. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 1

Preparing for the IDG: Effectively Conducting Assessments and Developing a Patient-Centered Care Plan The care planning process begins well before the Interdisciplinary Group (IDG) meeting. The importance of the initial assessment by all the disciplines cannot be stressed enough it is the foundation for future planning. The sections of the assessment include the Comprehensive Assessment Part I (which is the initial assessment); the Comprehensive Assessment Part II (psychosocial assessment); and the Spiritual Assessment. While these assessments are discipline-specific, there is often an over-lap, especially in the approach to the assessment. In all cases, the disciplines should use multiple data sources, including the person(s), significant others, and direct observations. The initial intake/interview/assessment with a patient is one of the single most important devices for collecting information. If handled skillfully, securing information can be empowering because that information helps patients to understand the severity of the problem in relation to life events and, later, the extent to which changes have been made and to which they have made changes. The exchange of this information at the IDG will only strengthen the care-planning process. Initial and Comprehensive Assessment of the Patient Comprehensive Assessment I - Nursing This condition of participation specifically names the nurse as the IDG member to complete the initial assessment of the patient s immediate needs. The nurse must complete the initial assessment within 24 hours of the date of hospice election, followed by the comprehensive assessment which must be completed within 5 calendar days of the date of hospice election. (7) The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient s wellbeing, comfort, and dignity throughout the dying process. Completion of a comprehensive assessment is more about assessing what the patient/family needs might be. (7) The Case Manager must fully review the assessment before making their initial visit (if admitted by the Admissions Coordinator). Remember, the initial visit made by the CM is a continuation of the Comprehensive Assessment. Comprehensive Assessment II Social Worker During the assessment process, collect information about all the critical dimensions of the changing configuration of person and environment. In the assessment process, attempt to see the situation from a variety of perspectives. Allow people to tell their own stories, and pay attention to how they describe the pattern and flow of their person-environment configurations. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 2

Focus more on conversational skills than interviewing skills when completing an assessment with a patient or family. Link intervention strategies to the dimensions of the assessment. In general, expect more effective outcomes from interventions that are multidimensional, because the situation itself is multidimensional. In assessment, consider: Any recent role transitions that may be affecting the client. Assist families and groups to renegotiate unsatisfactory role structures. Develop networks of support for persons experiencing challenging role transitions. Begin your work by understanding how clients view their situations. Engage clients in thinking about the environments in which these constructions of self and situation have developed. When working in situations characterized by differences in belief systems, assist members to engage in sincere discussions to negotiate lines of action. Assist clients in expressing emotional conflicts and in understanding how these are related to past events, when appropriate. Assist clients in developing self-awareness and self-control, where needed. Assist clients in locating and using needed environmental resources. Be aware of the potential for significant differences between your assessment of the situation and the client s own assessment; value self-determination. Focus on strengths rather than pathology. In assessments and interventions, recognize that interior environmental conditions of health and illness are influenced by the exterior environmental social, political, cultural and economic context. Look for the ways that behavior affects biological functions and the ways biological systems affect behaviors. Evaluate the influence of health status on cognitive performance, emotional comfort, and overall well-being. Develop a working knowledge of the body s interior environmental systems, their interconnectedness, and the ways they interact with other dimensions of human behavior. Be sensitive to cultural factors honor diversity and seek to assist people in involvements that hold meaning for them. Always seek to incorporate humor, joy and laughter into the helping process. Most clients are competent and able to participate in the care planning and delivery process. Doing so brings renewed self-confidence and independence precipitated by moving with the elder in the direction he or she chooses and in situations and contexts where the person feels capable and willing. Helping patient s manage their own inevitable aging process and the physical and emotional losses involved assists them to be better equipped to make sound decisions regarding what type of help they desire. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 3

Spiritual Assessment Chaplains When beginning the initial assessment, be respectful of different religious or spiritual paths and be willing to learn about the role and meaning of various beliefs, practices, and experiences for various client systems (individuals, families, groups). The information needed to complete the spiritual assessment can often be obtained by asking open-ended questions or simply observing and building your questions around what you see. Be sure to conduct your assessment in a conversational tone. Make the patient and family feel that they are sharing information with you, not that you are conducting an inquisition! Be creative in obtaining information and keep your eyes and ears open for clues and cues. Use information that you see and hear as an opportunity to gather a better sense of the patient and their family. The Spiritual Assessment What is the patient s view/experience of God? How has the current illness affected the patient s spiritual view? Questions that may facilitate conversation may include: I see that you have a (religious symbol/picture) over the fireplace. Does that have special meaning for you? Earlier you said you were raised in the faith but had not practiced since you got married. Is this something that is important to you now? (Some people return to their religious upbringing as they face a life-threatening illness/their death. Others looks to new or non-traditional sources of strength and meaning nature, poetry, massage) You have told me you find (religious/spiritual practice) helpful. Would you like me to contact a clergy person from your own religious tradition to help you sustain this practice, meet this need? What has helped you cope with in the past? What is your source of strength during your current illness? Is there anyone I should contact to help you explore this further, to help alleviate your fears, etc.? (9) Are there any rituals or practices that would help you feel less alone/calm your anxiety? What do you miss most as a result of this illness? Has your illness/prognosis/pain caused any confusion or doubts about your religious beliefs? Do you have any feelings of anger, bitterness, resentment? Do you have any unresolved feelings about the life you ve lived or unfinished business? (9) How has the current illness affected the PCG s spiritual view? Questions that may facilitate conversation may include: What is the effect of your s illness on your religious beliefs and practices? Have your beliefs or practices changed since their illness? Is the support you are receiving from your religious community or clergy adequate? Can you talk with your spiritual leader openly about these decisions? About your fears, concerns, needs during this time? What are you hoping for during this time? How will you feel if that hope is not fulfilled? Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 4

Are there members of your faith community who could also help you sustain your religious practices? What helps you maintain a sense of hope when there is no immediate apparent basis for it? (9) Current spiritual concerns/fears. Questions that may facilitate conversation may include: You said your greatest fear is that you will suffer. What would that look like? What do you mean by suffering? Are you suffering now? How has this illness affected you physically? Emotionally? Spiritually? Most people find that a serious illness affects their lives in many unexpected ways. What are some of the ways this illness has affected your life? What is hardest about being ill? Has being sick made any difference in what you believe/in how you view life/in how you see yourself/in your relationships with others? (9) Any cultural, spiritual or religious concerns r/t patient care regarding end-of-life issues? Questions that may facilitate conversation may include: You mentioned that your imam/priest/pastor/rabbi has visited you only once since you ve been home. Could he/she come more often if you wanted? (9) Bereavement Risk Assessment An initial bereavement assessment is necessary to identify the needs of the patient s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient s death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care. (12) Young children/adolescent in home? Questions that may facilitate conversation may include: I noticed your granddaughter was here earlier. Does she live with you? Comment on family pictures. Ask if they live close by. Dependent adults in the home? Questions that may facilitate conversation may include: I noticed there are several pairs of shoes by the door. Do others live with you or do others visit often? Is the patient or family experiencing anticipatory grief? Questions that may facilitate conversation may include: Tell me about your s (patient) life before he/she became ill. Take note of any comments regarding the patient s loss of ability to meet family responsibilities. Was the patient the leader of the household and now must be taken care of? Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 5

Will the family experience a loss of financial and/or emotional support as a result of the patient s death? Questions that may facilitate conversation may include: It sounds like you and your are really close. It must be hard for you to see him/her so ill. Ask about the patient and caregiver s former professions. This may lead to questions like: Did the caregiver have to stop working to care for the patient? Did the illness cause the patient to quit working before expected? It must be hard making ends meet. Do they have family support? Community support? Questions that may facilitate conversation may include: What resources do you use (community, church, etc.) when you need support? Do you ever feel alone, isolated or sad? Who do you lean on for support during these times? What steps can the chaplain and IDG to address these potential issues? How do we expect the bereaved to cope? IDG Basics: The Medicare regulations, the purpose and the benefits to an IDG approach. The IDG is composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. The group includes the hospice physician, registered nurse, social worker and pastoral or other counselor. The IDG works together to meet the needs of the patient and family and establishes/revises the plan of care (POC). It coordinates care and services and develops a system of communication. There is ongoing sharing of information with other non-hospice healthcare providers. Care and services are provided in accordance with the POC and based on all disciplinary assessments. (2) End-of-life is a very important time for the patient and their family. With pain and symptoms under control, they can attend to other pressing issues such as: Life review: time to reflect on and take inventory of their life. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 6

Document this review as desired by the patient and family. Completing unfinished emotional issues. Saying goodbye. Making financial arrangements. Completing an advance medical directive (Living Will, DNR, HCPOA). Identification of life s spiritual meaning. Funeral and burial pre-planning. This is where the team approach becomes so important. Instead of one person, the attending physician, providing care, patients and families also have access to the combined expertise of a team of health professionals from several disciplines. With its many skills, the hospice team looks at the situation holistically, considering not only the physical condition, but also the social, spiritual and emotional concerns. Medicare Hospice CoP: 418.56 Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. The hospice must designate a registered nurse that is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care. (11) Standard: Coordination of Services Respectful interaction between team members is critical to the effective delivery of hospice services. The hospice must develop and maintain a system of communication and integration, in accordance with the hospice s own policies and procedures, to: Ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided. Ensure that the care and services provided are in accordance with the plan of care. Ensure that the care and services provided are based on all assessments of the patient and family needs. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. (11) SouthernCare Policy and Procedure: The Interdisciplinary Group The [IDG] group will be comprised of (at a minimum) the Medical Director, Attending Physician (if any), RN, Social Worker, Chaplain/Spiritual Counselor, as well as the patient, primary caregiver and the patient s family. Other disciplines that will be utilized as required include: Hospice Aides, Volunteers and other specialized medical personnel. The attending physician and all contracted agencies will be invited to IDG meetings. The patient, family members and other caregivers will be advised of their right to attend and participate in IDG meetings involving the care of the patient. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 7

The IDG will work under the direction of the Medical Director and be supervised by the Clinical Director. The Clinical Director is an RN duly licensed to practice in the state of the hospice. He/she is responsible for coordinating the implementation of the Plan of Care for each patient. He/she will communicate on an ongoing basis with other team members and will be aware of the current status and treatment of all patients and families. The IDG, in collaboration with the attending physician (if any), must prepare a written plan of care for each patient: The plan of care must specify hospice care and services necessary to meet the patient and family s specific needs identified in the Comprehensive Assessment Part I and Part II and the Spiritual Assessment as related to the terminal illness and related conditions. The plan of care will be reviewed and revised as frequently as the patient s condition requires, but no less frequently than every 14 calendar days. Names/titles of IDG members participating in the review/ revision plan of care will be documented on the Care Team Meeting Summary Sign-In Sheet. Medicare Hospice CoP: 418.56 IDG Regulatory Requirements: Content of the POC Hospice care and services must follow an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and primary caregiver in accordance with the patient s needs if any of them so desire. The patient and primary caregiver should receive teaching appropriate to their care and services identified in the POC. The POC must reflect patient and family goals and interventions based on problems identified in the assessments (initial, comprehensive and updated). The creation of the care plan should stem directly from the goals of the patient and family and guided by the initial and comprehensive assessments. The plan of care must include all the services necessary for the palliation and management of the terminal illness, including the following: Members of the IDG identify interventions to manage pain and symptoms. Drugs and treatment necessary to meet the needs of the patient. Medical supplies and appliances necessary to meet the needs of the patient. Detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Care plans direct specific interventions to be utilized. Care plans provide measureable outcomes anticipated from implementing and coordinating the POC, and which evaluate the effectiveness of interventions. The IDG reviews and revises the POC as frequently as the patient s condition requires but no less frequently then every 15 days. IDG documentation of the patient s or representative s level of understanding, involvement, and agreement with the POC. Care plans communicate the IDG s understanding of the patient/family s priority issues, goals or problems to be addressed. Revisions to the POC must include information from updated comprehensive assessment and must note progress toward outcomes and goals. (2) Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 8

Documentation Compliance Care planning is an ongoing process that encompasses initial care of the patient, the death of the patient and continues throughout the bereavement follow-up. Descriptions of interventions are usually in verb form: SW, RNCM, CH assessed, educated, advocated, assisted. Revisions to the POC should be based on the patient and family response. Identified needs, and the measures taken to address them must be documented in the POC. The team needs to ensure that the goals and interventions on the POC are family/patient oriented and reflect the needs of the patient. Furthermore, are those goals and needs being met? Are the interventions to manage pain and symptoms working? Are the scope and frequency of services necessary to meet the specific patient and family needs actually meeting their needs? Have measurable outcomes resulted from implementing and coordinating the plan of care? Are you providing the drugs and treatment necessary to meet the needs of the patient? Are the medical supplies and appliances being provided meeting the needs of the patient? Does the interdisciplinary group's documentation reflect the patient's or representative's level of understanding, involvement, and agreement with the plan of care, in accordance with the hospice's own policies, in the clinical record? Is the POC individualized to the needs and goals of the patient and family? Does the POC identify goals, needs and strengths? Are you providing ongoing assessment and monitoring of interventions? Are you reviewing and updating the POC regularly? Most importantly, care plans provide for a continuity of care across the team and, in the event of staffing changes, provide a clear plan of what interventions have been initiated!!! Medicare Hospice CoP: 418.56 Plan of Care: Scope and Frequency Suggestions for Clinical Compliance Ensure that all members of the IDG have access to the patient s chart and the current plan of care. Ensure that the IDG provides care and visits per the visit frequency listed on the patient s plan of care. Complete a review of the plan of care during the IDG meeting and change the plan of care visit frequency*, interventions, etc., per the updates to the comprehensive assessment. A range of visits is acceptable in some states as long as it continues to meet the identified needs of the patient and family. ALL FRQUENCY CHANGES REQUIRE A PHYSICIAN ORDER. For states that allow ranges, small intervals are acceptable (i.e. 1-3 visits/week; 2-4 visits/week) but ranges that include 0 as a frequency are not allowed. Remember, if the patient requires frequent use of PRN visits, the plan of care should be updated to include the need for additional visits. (3) Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 9

Documentation Compliance If the visit frequency on the patient s plan of care was not followed, be sure that the IDG documents the reason and includes a physician s order for any missed visits. The IDG may change the visit frequency or exceed the number of visits in the visit range to address patient and family needs. Ensure that there is documentation to support the adjusted visit frequency and that the entire IDG was informed about the adjustment. (3) Document all care plan updates! Messages that alert IDG members of plan of care updates, for example, are usually not recorded in the clinical record. All communication between team members, including these alerts, should be documented as it further demonstrates coordination of care. Even communication that seems relatively un-important should be recorded. Medicare hospice CoP: 418.56 Review/Update of the Plan of Care Standard The Update of the POC is essentially an update to the comprehensive assessment. All members of the IDG must be involved with completing and updating the POC. Individual disciplines must consider changes that have taken place since the initial assessment. The Update to the POC must include information on the patient s progress toward desired goals/outcomes, as well as a reassessment of the patient s response to care. The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. (12) The Update to the POC Should include a thorough evaluation of the caregiver s and family s willingness and capability to care for the patient. A comprehensive assessment is about assessing WHAT the patient needs, not about WHO completes the assessment or particular form. Should evaluate and document the patient s response to care. It s purpose is to make sure the IDG has the most recent and accurate information to care planning decisions. The RNCM, social worker, chaplain and volunteer coordinator are responsible for documenting the patient s status as it relates to each problem identified on the Update to the Plan of Care related to their specific discipline and area of involvement. No changes noted or condition stable are NOT acceptable on the Update to the Plan of Care. The update should include revisions to: Visit frequency Staff assignment Code status Fall and nutrition risk New/worsening wounds Changes to risk factors such as new onset diabetes New co-morbid conditions For tips on the Update to the POC see Update to POC Handout available on Zimbra under Handouts. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 10

Clinical Compliance Ensure that the IDG is communicating and collaborating continuously regarding the patient s care both internally and externally. Communication should include the attending physician, community resources and the patient, caregiver and family. Be sure that the patient, caregiver and family are included in the process to update the plan of care. (3) Documentation Compliance Review documentation of IDG meetings to update the patient s plan of care against individual notes. Were all changes captured? Is the plan of care individualized? Ensure that care plan goals and interventions reflect collaboration with the IDG, attending physician, patient and caregiver, and facility staff. (3) Summary The purpose of an IDG meeting is to utilize the discipline specific skills and knowledge of each member of the IDG. It is the opportunity to develop, evaluate and revise the plan of care to meet the patient s and family s unique needs, based on the comprehensive assessment of the patient and family. Remember, it s ALL about the patient and family!! The chemistry and communication amongst team members is not just what happens during team meetings. Care planning should be ongoing outside of IDG meetings. Everyone must be aware of patient s goals of care at all times. The IDG Meeting Process SouthernCare P&P: Conducting an IDG Meeting IDG meetings are held every 14 days at a designated date and time. The IDG works under the direction of the Local Medical Director (LMD) and the meetings are conducted by the Clinical Director (or designee). Mandatory attendance at the meetings is required of the core team members, which include a Registered Nurse (RN Case Manager and Clinical Director or designee), Social Worker, Chaplain, and Hospice Physician. The Volunteer Coordinator, while not designated a core team member, must also attend all meetings. Hospice Aides are strongly encouraged to attend. Other team members (therapy services, admission coordinator) may attend as appropriate. The Update to the Plan of Care is completed by every case manager for every patient PRIOR TO EACH IDG MEETING. This includes all patients currently on service, even those patients who have just been admitted. The RN case manager notes the primary problems and changes in the patient s condition that have required intervention during the previous 2 weeks. The case manager documents clearly the patient s decline and why the patient is hospice appropriate. Other team members, including the Social Worker, Chaplain, and Volunteer Coordinator, must also document and sign the Update to the Plan of Care, noting any patient problems and their interventions. The Update to the Plan of Care is used to document the overall assessment of the patient s condition and patient/family comments as they relate to the hospice diagnosis. This is an excellent opportunity for the Clinical Director to listen to team members justification and documentation of decline. After the IDG meeting, all Updates to the Plan of Care are faxed to the attending physician and then filed in the appropriate patient s medical record as addendums to the care plan. Prior to each IDG meeting, the RN Case Manager will complete the Care Team Meeting Summary. At the IDG meeting, each RN Case Manager goes in turn reporting per the order of the Care Team Meeting Summary. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 11

The RN Case Manager or Clinical Director use the Care Team Meeting Summary as a guide for the meeting order. The Care Team Meeting Summary addresses: Acute/Respite Inpatient Care: patient name; facility name; dates of stay; in/out POC CTC: patient name; facility name; dates of stay ER visits & MD visits: patient name; diagnosis; type of visit; visit dates; in/out POC Admissions since last meeting: patient name; diagnosis; admission date Re-certifications: note status: C for continued; D for discharge; Pending Discharges/Discharge Planning Routine Care Patients Deaths since last meeting: patient name; diagnosis; date of death Bereavement Activity: patient name; date of death; activity. The date bereavement letters were mailed should be noted monthly. How to Effectively Manage the IDG and Strategies to Improve it Bring the clinical record to IDG meetings and ensure that everyone has the same information and that it is documented the same way in the clinical record. During the meeting, be sure to stay on topic. Discourage side conversations and topics that draw away from the main topic. Encourage all care team members to participate. During the meeting, the LMD makes recommendations for care. The LMD must document on the Update to the Plan of Care and make recommendations (as needed) for changes in care. The IDG meeting is a good time to discuss volunteer needs and utilization as well as opportunities to exceed patient and family expectations. Each member of the IDG will sign-in on the Care Team Meeting Summary Sign-In Sheet at each IDG meeting noting their job title. This form indicates that all patients have been reviewed, their Plans of Care updated as appropriate, and that all core team members were present in accordance with the Medicare Hospice Conditions of Participation. IDG Meetings The Medicare CoPs require that the POC be updated every 14 days to update the Comprehensive Assessment. The IDG meeting encourages team members to: Work together to meet the needs of the patient and family. Establish/revise plan of care (POC). Coordinate care and services. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 12

Communicate. A significant component of this system of communication is to review and revise the plan of care to meet the needs of the patient and family based on all comprehensive assessments. (2) An IDG meeting is a process which includes an evaluation and review of the problems, goals and interventions to improve outcomes. It addresses changes which might include new problems, goals and interventions, level of care, visit frequency, additional services, medications and DME. There is documentation and review of all current admissions, deaths, bereavement needs and re-certifications. It provides an opportunity to share expertise and to problem-solve the more challenging cases, as well to anticipate possible crisis in the disease progression for proactive care planning. It allows time to assess the eligibility of patients and their appropriate level of care. (2) While the IDG is a process, there are things the IDG should NOT be.and they include: Form-speak (recital of the plan of care). Just how many times do we need to hear that the constipation is managed? A whine session, A support group for staff, A gossip session about patients and families, An opportunity to criticize the medical care of others. (2) In hospice, the IDG is the basis for decisions involving patient s care and services. If the team is not functioning well, then it is the patients and their families who suffer. There are a number of problems that occur frequently during the IDG. Do these sound familiar? Time runs on and on and on Staff are not prepared It s a nursing report SW and Chaplains are marginalized It s a report solely on eligibility It s the story of the last visit Extraneous activities take away from the focus (2) Barriers to Full Use of All Disciplines on the IDG Lack of Knowledge of the Expertise of Other Professions One barrier to full use of all professions on the IDG is a lack of knowledge, on the part of each member, of the other professions' expertise, skills, training, values, and theory. This is the result of training health care professionals in isolation from each other. (10) Each profession may want to handle the case on its own, without fully involving the other members, because of their lack of understanding of what the other professions can contribute. Sometimes, out of a desire to defend the territory of one's own profession, a team member may hesitate to share professional knowledge with the rest of the team. This further alienates team members rather than improving services for the client. (10) Strict division of roles goes against the very nature of hospice and its holistic approach. An example in this area is a team meeting in which a nurse reports that a patient got upset when the social worker initiated discussion of family conflicts. Team members may blame it on the social worker's lack of expertise, rather than a process to be expected to occur during psychosocial intervention. The nurse may avoid future social work involvement for this reason. This problem could have been prevented by an explanation to the team by the social worker of typical client reactions during counseling. (10) Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 13

Solutions Successful interdisciplinary collaboration involves recognizing and respecting the expertise of colleagues. Another approach to creating a cohesive team is to communicate without the jargon of one's own profession. The sharing of professional knowledge with team members can create a cohesive team. Orientation to the role of each profession is important not only to promote competence, but also to understand how the roles can successfully interact. Such orientation to roles may be included in the training of new staff members or in continuing education programs. A joint home visit may be conducted with each profession as part of training of new members to observe what each profession contributes. Role Blurring A second barrier is the overlap of roles on the interdisciplinary team. Often, expertise and services provided may be similar between professions, and it may not be clear who addresses which issue in a certain case. There are times that nurses or chaplains provide social work functions. Role blurring may lead to competition between professions and can make the unique functions of each discipline unclear. (10) Solutions The team may develop administrative procedures that call for automatic referrals to specific team members in certain case situations. Roles must be flexible, geared to the individual case, and based on the overall goal of service rather than individual professional perspectives. (10) Negative Team Norms One of the principles of group theory is that groups develop a set of norms that guide the group's behavior. It is possible for negative group norms to develop in the IDG that hinder the group's purpose (National Rural Health Association, 1993). Lack of Commitment to the Team Process: Sontag (1995) noted that some team members may be more focused on personal agendas than on the success of the team. For example, a team member may promote his or her own profession and exclude others through comments by team members such as "They don't want a social worker.", "I don't think they could handle discussing psychosocial issues." or She's not religious; she wouldn't want a chaplain visit." Some team members may exhibit negative behaviors that indicate protecting their own roles. This may also indicate a lack of genuine personal interest in each other, without concern for the effect on the cohesion of the team. Lack of Willingness to Share Equally in the Work of the Team: The perception of a discipline s responsibilities as unnecessary can work to the detriment of the team. Effective interdisciplinary work incorporates the goals and opinions of all professions in the treatment plan and each profession shares responsibility for carrying out the treatment. Full participation of all members is necessary for the team to develop a total function. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 14

Scapegoating: Team members may demonstrate a lack of responsibility for their own actions and decisions made by the group and blame it on the individual professional who carried out the treatment plan. Power Differentials on the Team: Differences in status between professions may be a source of conflict and higher status professions' perspectives may sway the treatment plan. Members of a certain profession may far outnumber members of other professions. Leadership may fall under certain professions. For example, social workers may be supervised by physicians or nurses, which could be a source of conflict. Physicians may oppose the full use of other professionals on the team. Client Stereotyping: Failure to fully use all members of the team sometimes stems from the unwillingness of clients to agree to sessions with certain team members-often the social worker or chaplain. This may be based on stereotypes or misperceptions held by clients about these professions. For example, clients may think that social workers only visit to qualify them for welfare payments, or to conduct a protective services investigation, or send them to a SNF. They may think chaplains will proselytize [convert] rather than approach spiritual questions from the client's own viewpoint. (10) Solutions When conflict occurs, the team leader should discuss expectations according to the established team rules. Another suggestion is for the leader to guide the team in establishing a plan of action in which all members of the team share responsibility. In such a plan, clear assignments are made and accepted, using the abilities of each member fully, and the leader reminds the team of their holistic perspective and the importance of including all members in the service plan. It is important in this approach for the team leader to recognize success consistently. When failure occurs, it is important to respond by revising the plan of action rather than blaming an individual member (National Rural Health Association, 1993). The team should encourage members to discuss patient concerns about seeing a social worker or chaplain with clients to help resolve misconceptions. This again is a part of recognizing each member s role and contribution to the team and to the plan of care. (10) Once again, if the team is not functioning well, then it is the patients and their families who suffer. When the team comes together to overcome these barriers, everyone wins! Roles of Hospice Team Members Clinical Director The Clinical Director should not hesitate to delegate when appropriate. It is of utmost importance that they maintain two-way communication with all team members. Team members must continuously update the Clinical Director of decisions that impact the patient s care. They need to have the information prior to decisions being implemented! Attending Physician This is usually the patient's own primary doctor who works directly with the hospice team in the day-to-day management of the patient's care. The attending physician's role in hospice is consistent with the role of the physician in general - providing appropriate care to meet the presenting medical needs of patients. In hospice care, the physician continues to be responsible for providing the primary medical care of patients, but the physician is supported through the hospice interdisciplinary team. The attending physician's responsibilities include approving the hospice admission; agreeing to remain the primary physician and giving permission to visit. They will approve the initial interdisciplinary plan of care, sign the initial physician orders, and certification of terminal illness, once the initial hospice assessment is complete. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 15

Other duties include: Being available for consultation with hospice RN when medical problems arise. Continue to prescribe all necessary medications for pain and symptom management. Receive and review regular progress reports. Participate in the development, revision, and approval of the interdisciplinary plan of care. Inform hospice of any significant changes in patient/family status. Maintain confidentiality in all communications. The Hospice Medical Director reviews, coordinates, and is responsible for the management of clinical and medical care for all patients in the program. Other services and responsibilities include: Being available for consultation with hospice RN when medical problems arise. Consult with the attending physician regarding pain and symptom control. May prescribe medications for pain and symptom management when requested by the attending physician. Review patient eligibility for hospice services. Acts as a medical resource for the IDG and other physicians. Acts as a liaison to physicians in the community. Review the MAR at every meeting for every patient. Conduct or approve face-to-face visits for re-certifications on all patients on service for over 180 days. Nurse The RN case managers coordinate the care offered by the hospice team with the patient's attending physician. Their main role is to provide regular patient assessments and manage the patient s care including help with pain relief and symptom management. They provide education to the patient and caregiver regarding the patient s condition and prescribed care. They provide an ongoing evaluation of the effectiveness of the medical POC and ensure that all hospice caregivers are providing care in accordance with the prescribed plan. The nurse provides care and ongoing assessment. Must include documentation of any change in the patient s status that occurred in the prior 2 week period. Clearly reflect the patient s continued hospice appropriateness & evidence of decline. Establishing and updating the hospice POC. The RNCM must verify that all information on the Update to the POC is correct including changes for the following areas: Falls Diabetes Visit frequencies Weights/measurements New/worsening wounds Any new physicians orders **ANY changes in condition must be reported to the Attending Physician. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 16

The RNCM must review the effectiveness of all medications (including any interactions and duplicate therapies) and document this review on the updated MAR. New MAR printed with each medication change and every 2 weeks for IDG Reviewed, signed and dated by RNCM and LMD. Each signed MAR is maintained in the medical record as proof medications were reviewed. All MARs printed between IDG meetings are to be removed and shredded. **COP reviews and interactions/duplicate therapies are to be on hand at IDG for review purposes but no longer need to be placed in the medical record. Hospice Social Worker A hospice social worker is a member of the IDG whose primary function is to provide psychosocial support to the patient/family unit, define social service goals for alleviating identified problems, and provide both counseling and casework to meet the established service goals. Hospice social workers help develop and implement the interdisciplinary plan of care with the goal of delivering the highest quality social services to patients and families. This plan of care should aim to ensure that continuity and comprehensive care are provided. Other SW responsibilities include: Facilitate family communication, arrange support for caregivers, and help find financial and legal assistance. Assess the patient and family's emotional, cultural, psychological and social needs, including coping skills, financial counseling and assistance, and support systems. Provide emotional support and make referrals to other services or community agencies. Help with issues related to Medicare, private insurance, and advance directives. Provide emotional and practical support to patients and their families, when helping with benefit applications and documents such as living wills, advance directives, and funeral plans. Help patients and family members cope with social, emotional, psychological, financial, and other related issues experienced by families caring for a loved one in the last months of life. Communicate with hospitals and SNFs related to billing issues. As needed, arrange for respite, coordinate with the SNF SW for patients residing in their facilities and attend SNF care team meetings. Social workers rely on information from other team members, as well as provide information related to social work intervention and other bio-psycho-socio-cultural-spiritual and team issues. Therefore, respectful interaction between team members is critical to the effective delivery of hospice social work services. (12) Hospice social workers responsibilities, as members of the IDG include: Administering a psychosocial assessment and consultation. Providing patient advocacy (on the team, in the program, in the community). Educating the family and team on psychosocial issues, family and group dynamics. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 17

Working toward fostering team collaboration. Arranging group meetings with multiple members of the family, facility, and hospice care team. Participating in the on-call rotation/schedule in order to meet the needs of patients and families. Maintain appropriate documentation in the hospice patient chart. Assist in developing and coordinating relations between the hospice agency and outside medical/health care services. (4) Social workers must follow agency policies and procedures and have a professional commitment to enhance team collaboration in the following ways: Social workers are active participants in the IDG meetings. Social workers incorporate their multiple roles as counselor, educator, broker, case manager, mobilizer, mediator, facilitator and advocate as integral members of the hospice team. Social workers document all interactions with other team members related to patient care. Social workers recognize how patient and family dynamics are reflected in the work of the team and identify appropriate responses. Social workers identify opportunities to work with other team members to facilitate joint visits, family conferences and team consultations to better understand the patient situation, to effectively use the skills of all team members to improve the quality of care. Social workers are familiar with principles of group and organizational dynamics when working with teams and other small groups. Social workers provide education about how to effectively utilize social work services. Social workers assures social services are offered to all patients/families. (12) Social workers provide a critical element to achieving the hospice care mission by providing insight to the patient s, caregivers, and/or families psychosocial needs, and are essential in helping to both prevent and cope with crisis and deal with issues as the illness progresses. The NASW Code of Ethics and NASW s Standards for Practice in End-of-Life Care calls hospice social workers to act as an advocate for the patient and family members and to strive to include them in developing treatment plans that work to meet the biological, social, emotional, and spiritual needs of both the patient and family. Social workers must engage the interdisciplinary team, the family, and at times other outside resources and supports, to help develop a comprehensive plan of care that minimizes unmet needs. Furthermore, social workers must also seek to understand the treatment philosophies and motivations of other disciplines in developing plans of care. (4) Chaplain The non-denominational chaplain can provide assistance in many areas: spiritual counseling for people of all faiths, planning funeral services, offering communion, and serving as a liaison between the family and clergy in the community. Hospice offers non-denominational spiritual support as part of its care. Chaplains can help address issues such as regret, forgiveness, and abandonment. Tough questions such as "Why me?" or "Why now?" may be explored. Referrals can be made to the clergy of their choice at the request of the patient and family. In the role of Bereavement Coordinator, chaplains offer bereavement support to family members and loved ones for more than a year after death. These include support groups, individual counseling, and education on the grief process. The bereavement coordinator/chaplain supports families through the grieving process and assists with funeral planning. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 18

The chaplain may support hospice caregivers through times of stress and grief related to deaths and hospice care needs. Hospice Aide Hospice Aides provide direct personal care which includes: Bathing Mouth care Skin care Socialization Assists with ambulation and range-of-motion On occasion, HAs can be utilized to spend extended time in the home (2-4 hours) with patients and families. They can also provide light housekeeping and meal prep as needed. Aides work under the supervision of the RN case manager and report any changes in the patient's condition. At the same time, HAs should always keep the RNCM in the loop. Since they are the ones that spend the most time with the patient and in the most intimate ways, they are the ones most likely to provide the best insight about the patient and family dynamics. Volunteer Coordinator Volunteer Coordinators are a part of the IDG and should attend the meetings. They should report on current volunteer activities, including recruitment and updates to the POC. The Volunteer Coordinator recruits and supervises trained volunteers who are an important part of the hospice team. These team members receive special training and provide socialization, visitation and active listening for patients and families. They can be friendly visitors for those with limited support from family or friends. Volunteers also assist with emotional support for the family both before and after the death of the patient. They support the patient and family by sitting with patients to allow breaks for families. Their duties include respite care for family members and other caregivers, running errands, light housekeeping, preparing meals, and providing emotional support, comfort and companionship to a patient and family. IDG Participation & Role Conflicts IDG team members should continually strive to be integral members of the interdisciplinary care team and remain active and engaged in developing and maintaining the patient s plan of care. Each member should increase their awareness and understanding of each team member s valuable role in hospice. While role conflicts are not always the case, in some instances role conflicts do occur sometimes between the social worker and the nurse, and in some cases between the social worker and pastoral counselor or other spiritual/religious provider. Efforts to enhance IDG functioning includes: Hold regular trainings about increasing team functioning and educating each team member about the responsibilities and perspectives of all the professions in hospice care. Stress the uniqueness and responsibilities of each team member in providing quality hospice care. Address tensions between different team members and provide a framework for resolving disagreements related to assessing and treating a patient s needs. Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 19

Encourage all team members to provide quality documentation of their efforts in developing, implementing, and evaluating care plans. Focus on the Patient: Throughout the Plan of Care Focusing on the patient through the POC is the main source of documented communication both internally and externally. When planning care, set goals that are patient and family directed; measurable; and flexible with the ability to change as the situation requires. Goals should be reviewed any time there is a significant change in status. When setting patient- centered goals consider: What does the patient want? Research shows patients want adequate pain/symptom control and want to avoid inappropriate prolongation of dying. They wish to achieve a sense of control and strengthen relationships with loved ones Don t ask what are your goals since they may not know how to define goals. Instead ask What is important to you now? ; What are your needs today? What would you like to get accomplished over the next couple of weeks? A Key Question to Ask at Every Team Meeting How does this patient want to die?, then, How will this patient die? Asking pertinent questions helps the team to determine that they are on the right tract with care planning. Other key questions to ask include the following: What does the patient want and what does the patient need in relationship to the want? Can you tell me more about that? Help me understand how that might relate to the issue we re discussing? What do you find most difficult about this situation? Do we need to look at this from another perspective? Are goals being met? You only know through the comprehensive assessment If you are meeting the patient and family goals, keep doing it and document that it is working. When goals are not being met, has the problem changed? Are the goals in alignment with the patient and family? What s not working? What interventions need changing? What interventions need to be added? Are the actions taken resulting in a favorable outcome for the patient and family, i.e. are they achieving the goals? What is the evidence from the comprehensive assessment that shows the interventions are working? How does the patient want to die? How prepared is the family for the patient s death? Does the family know what to expect? (2) Teamwork and the IDG Handout - September 2012 - SouthernCare, Inc. 20