Interdisciplinary Approach: Dream Team or Nightmare?

Part Eleven of a Series on the Survey Process

by Steven Levenson, MD, CMD

The OBRA regulations expect nursing facilities to take an interdisciplinary approach to care. The effective application of this approach typically promotes good care. But often, the execution of the interdisciplinary approach is seriously flawed, resulting in major care problems. The survey process has had some helpful and some unintended effects on these issues.

Basis for an Interdisciplinary Approach

The basis for an interdisciplinary approach to nursing home care rests primarily on two factors: the complexity of the patients and the need for a systematic care-delivery process. Both of these areas were addressed in this series in the August 2001 issue of Caring.

Complex patients Individuals with significant chronic illnesses and disabilities often have many physical, functional, and psychosocial problems and needs. For example, they may be unable to report significant symptoms of acute illness or they may need help in taking medications, eating, or toileting.

Care delivery process The care of nursing home patients is often complicated by their chronic illnesses and disabilities. Their care requires a systematic "care-delivery process," involving a series of tasks and steps. Implementation of this process requires individuals with certain knowledge, skills, and experience.

Much of the care process must occur sequentially if it is to be effective. For example, a nurse may need to evaluate a patient's pain before a physician can manage it effectively; a physician should identify someone's condition and prognosis before a social worker tries to update advance directives. An improper sequence may lead to wrong conclusions and erroneous or harmful treatments.

An interdisciplinary approach operates on a simple premise: no one individual or discipline can be expected to address all the care-related issues for each patient or manage all the functions and tasks related to delivering services. When the interdisciplinary approach works properly, patients usually benefit. When it malfunctions, patients often suffer.

Good, Bad, & Ugly Interdisciplinary Approaches

A desirable interdisciplinary approach faithfully promotes and follows the care delivery process (see box below). Appropriately trained and skilled individuals effectively collect information and draw pertinent conclusions. They select treatments based on careful analysis of accumulated evidence (the patient's condition, prognosis, wishes, risks, etc.) plus knowledge of important geriatrics and related principles. They also perform functions and tasks within the boundaries of their knowledge and training and know when they need help or additional information before proceeding. For example, nurses check a patient's condition before calling a covering physician to report a lab test result, and physicians help staff identify possibly reversible medical causes of problematic mood or behavior, rather than just giving an order to get a psychiatry consult (see "Drawing Conclusions About Compliance," in the February 2002 issue of Caring, p. 31).

An undesirable interdisciplinary approach is a haphazard assortment of actions and reactions from individuals with inadequate training and skills. They violate the care-delivery process by skipping important steps and drawing unwarranted conclusions. They often speculate about causes of symptoms based on habit and opinion. For example, some staff repeatedly attribute physical symptoms such as weight loss and falling to urinary tract infections, while others blame constipation for many condition changes.

Or, staff and practitioners may mislabel symptoms based on existing diagnoses--for example, they mistakenly assume that a change in level of consciousness in someone with a seizure disorder is due to a seizure, or that someone's Parkinson's disease necessarily causes them to fall repeatedly.

Presenting erroneous conclusions to physicians who do not challenge such conclusions often results in irrelevant, if not harmful, treatment. For example, many physicians are ordering "appetite stimulants" or psychiatry consults based on the recommendations of other care providers without considering or discussing various causes of anorexia (see AMDA Altered Nutritional Status CPG).

An undesirable interdisciplinary approach also emphasizes territoriality. Patient care is fragmented into artificial territories corresponding to the interests of various disciplines. For example, medication issues are considered to be the consultant pharmacist's territory, behavior is the domain of psychiatrists, feet belong to podiatrists, and rehabilitation therapists own impaired function. However, the body operates all together, not in pieces.

Staff in problematic facilities depend excessively on the discipline controlling a particular territory to perform all of the care-process functions (including cause identification, problem definition, and treatment selection), even though the person may lack the requisite knowledge and skills to do so. For example, review of recurrent falls requires knowing about medications that may be associated with falling, and managing someone with a major behavior change requires knowing how to recognize possible causes of delirium.

The ugliest version of the interdisciplinary approach is found in facilities where the care process malfunctions routinely. In such facilities, management asserts little control over territoriality, mistakenly equating responsibility for completing parts of the Minimum Data Set with the ability or right to make proper care decisions.

Care plans often are controlled or written exclusively by one individual or discipline, and care-plan meetings consist of grafting together the inadequate, fragmented approaches of multiple staff and practitioners. In these facilities, nurses are often reduced to little more than telephone triage agents and physicians may be considered "cooperative" if they simply authorize the orders that everyone else desires.

In problematic facilities, patients often suffer the consequences. For example, nurses and physicians should be able to identify when symptoms might reflect an adverse drug reaction (ADR). Consultant pharmacists typically are in a facility no more than monthly and must review many patients quickly. Thus, they may be unaware of an individual's condition changes or acute problems and may not identify problematic medications.

But if nurses and physicians are told that medication issues are the domain of the consultant pharmacist, they may wait for the consultant pharmacist to tell them if the patient is taking a problematic medication. But the consultant pharmacist may be relying on the nursing staff to let them know when a patient is suffering from an ADR.

The result: many patients suffer serious ADRs because physicians and nurses don't look for them and consultant pharmacists aren't around often enough to find them in a timely fashion, or may not seek or recognize symptoms in individual patients that could indicate an ADR.

Consequences of Regulations & Surveys

Ironically, the survey process has often undermined OBRA's principles regarding an effective interdisciplinary approach to long-term care. Why? Because surveyors mistakenly evaluate care based on who participated rather than on the relevance of what they did.

For several valid reasons, the OBRA surveyor regulations and guidelines have heavily emphasized including other disciplines in addition to physicians and nurses. However, the participation of multiple disciplines has too often become an end in itself, instead of a means to an end.

For example, if someone falls repeatedly, surveyors may overlook the failure to seek and address underlying causes because the patient was quickly referred for physical therapy. Or, they may approve of an inadequate review and management of someone with mental status changes because a psychiatrist was called. Or, a dietitian surveyor may agree with the staff dietitian's faulty analysis of the reasons for weight loss simply because the staff dietitian got the nursing staff to persuade the physician to order more lab tests and numerous dietary interventions.

The result? Too often, a careful, thoughtful care process is neglected. Instead, many nursing homes nationwide scramble to get various disciplines involved quickly in the care of patients even if the discipline's services may not be relevant, or conclusions are unfounded, or treatment recommendations are erroneous.

The staff in such facilities either mistakenly fear being chastised, or actually are chastised, for not acting soon enough. But, considering the appropriateness of interventions based on who did them instead of on their relevance to patient care undermines the goal of the OBRA regulations to improve nursing home care.

Time for Major Change

Many nursing home managers and staff complain vehemently about the shortage of skilled individuals to provide care and the failures of physicians to act responsibly. Trouble is, numbers alone do not explain dysfunctional performance.

In fact, regulations cannot fix this serious problem of disorganized, ineffective care processes and poor individual performance. Instead, nursing home management, including medical directors and directors of nursing, must vigorously oversee staff and practitioner performance and prevent or halt the harmful slide towards fragmented, territorial care. To do this, they must clearly define roles and responsibilities of all participants in the care process and hold everyone accountable.

Define & Control Roles & Responsibilities

Management should ensure that everyone performs their own roles effectively, instead of trying to do someone else's job badly. Although, for the most part, administrators don't deliver care, they have the primary responsibility for organizing and reinforcing effective care-related systems and processes. They can't assume that staff or practitioners know their roles or that the regulations can help clarify them.

Staff and practitioners should perform the functions and tasks in the box at right. In most health care settings, practitioners who observe or examine patients also draw conclusions and select treatments. But in nursing homes, physicians and others who are specifically trained to be information analysts are often unavailable or do not participate willingly or appropriately. Meanwhile, the providers who end up making observations or delivering care and treatment may have only limited skill in identifying causes or selecting, reviewing, and adjusting interventions.

Management should ensure that staff and practitioners follow the care-delivery process. The administrator should participate actively in regular patient-care discussions by listening closely for relevant evidence, and be prepared to ask staff if, for example, they reviewed with a physician the current medications of an individual who experienced an abrupt decline in appetite or was falling more often than before. This is process oversight, not second guessing clinical decision making.

Administrators should also review whether staff are describing and discussing symptoms such as pain and agitation in sufficient detail to allow physicians to draw accurate conclusions. Staff should not recommend specific medications; instead, they should work with the medical director to ensure that attending physicians do not neglect meaningful evaluations in favor of uncritically authorizing treatments.

Nursing home management should not permit individuals to unilaterally create care plans. Although care planning should consider diverse perspectives, the ultimate team approach is not a collection of multiple simultaneous independent activities, conclusions, and interventions. Only designated staff should be permitted to call physicians and recommend or request specific treatments. The use of relevant clinical protocols and practice guidelines should be promoted by management to assist staff and practitioners.

We would not be pleased if an airline's management had no idea that otherwise competent flight attendants were trying to find and fix engine problems, or that their maintenance crews were flying planes because pilots were unavailable or unwilling to do their jobs. Yet, it's not uncommon for nursing home owners and key management to be oblivious to equally flagrant performance issues. Nursing homes should use the quality-assurance process to help identify and correct significant breaches in the care process and in individual performance.

It's time to return to basics, emphasizing competent clinical care by primary care physicians and nurses, and a well-defined and controlled care-delivery process. This is essential, if we are to escape excessive regulatory oversight.

Dr. Levenson is a Multi-Facility Medical Director in Baltimore and Chair of Caring's Editorial Board.

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