David Ryan, PhD, Regional Geriatric Program of Toronto, University of Toronto

1. Geriatrics, Inter-professional Practice and Inter-organizational Collaboration (GiiC): Primary Care Lessons David Ryan, PhD, Regional Geriatric Program of Toronto, University of Toronto Cheryl Cott Ph.D. William Dalziel MD, Dr. Iris Gutmanis PhD, David Jewell MSW, Mary Lou Kelley PhD, Barbara Liu MD & John Puxty MD

2. What is frailty? Complex bio-psychosocial and functional difficulties co-occur. Risk of adverse health events is high Independence and self-worth are easily compromised Risk of institutionalization is high A fast growing demographic Frailty brings increased need for health care services and demands high levels of teamwork and inter-sectoral collaboration.

3. “Go to where the puck is going to be” Wayne Gretsky’s Dad

4. Articles on Teamwork in the Journal of Orthopsychiatry by Decade,since the Journal began in 1930 25 20 15 # of Articles 23 10 16 5 8 6 5 5 4 0 30s 40s 50s 60s 70s 80s 90s From moral treatment to mental hospitals The medical model and the orthopsychiatric trinity The trinity won the right to treat Sociotherapy and broadening of the mental health team Community mental health and sociotherapy’s democracy Hospitals emptied and community mental health funding dwindled DRG’s, managed care and mental health fragmentation Integrated care and inter-team collaboration Decades

7. The framework for health systems renewal in Ontario 2007

8. Funding supported 90 interprofessional research & development projects Regulatory Colleges formed an interprofessional care working group Investment in Academic Interprofessional Education & Training eg: interprofessional coaching interprofessional mentoring interprofessional preceptorship stand alone and embedded interprofessional curricula Investment in interprofessional development in the practice environment eg: Interprofessional care of the diabetic foot Accountability Framework for Regulated and Unregulated Health Care Providers in Long Term Care Interprofessional prevention of delirium in the Emergency Department Geriatrics, Interprofessional Practice & Inter-organizational Collaboration (GiiC) Initiatives

9. What we wanted . . . Health professionals still aren’t being sufficiently trained in geriatrics Help us to build the health human resources needed for an aging population Going to where the puck is . . . “Just putting people to together to work doesnt necessarily produce effective teamwork let us help build your 200 new family health teams” “Teamwork is the traditional method of service delivery in geriatrics. Let us use geriatrics as a clinical focus through which we can train family health teams” “We are in the integration era but no-one is trained let us add our inter-organizational collaboration skills into the mix” “Then let us help the entire circle of care work from a common toolkit” . . . Suddenly the puck was on our stick

10. GiiC: Family Health Teams/Community Health Centers GiiCPlus: Community Care Access Centers, Public Health and Community Support Agencies GiiC Plus: Patients Families and Health Care Teams GiiC Hospitals: Seniorfriendlyhospitals.ca

11. Clinical Focus Never Only if symptoms Routinely every 6 months Routinely every year Use of Standardized Tools Continence Screening 12% 68% 0% 25% 9% Drive Safe Protocol 12% 73% 5% 26% 12% Polypharmacy Reviews 5% 35% 19% 41% 18% Cognitive Screening 3% 85% 0% 13% 92% Geriatric Practice in FHTs Delirium Screening 24% 73% 0% 2% 32% 11% ADL/IADL Assessment 74% 3% 18% 41% Depression Screening 0% 74% 78% 2% 20% Falls Risk Assessment 13% 64% 0% 23% 29% Abuse Screening 20% 2% 15% 25% 63%

12. When is a family health team not a high performance team? When it is an organization – some family health teams have 250 people When it is a network - some family health teams have docs in their offices and a new building in the middle of town for allied health folks When it doesn’t take on the qualities of team – one manager had a “closed door policy” When its roles are fixed, leadership hierarchical and everyone does their own thing.

13. When is a family health team not a high performance team? When it excludes unregulated employees from making credible contributions

14. When is a family health team not a high performance team? When the “shadow workforce” is not incorporated in team proceedings • The distinction between “formal” and “informal” care giving does not reflect the reality of the work of many family caregivers who are often: • Geriatric Case Managers • Mobile medical records • Service gap fillers • Continuous care providers • Acute change of condition monitors • Paramedic service providers • Quality Control experts • Inter-organizational boundary crossing • Continuing medical education students • (From Brookman & Harrington: 2007)

15. ‘Edumetrics” and the Knowledge-To-Practice Process In the continuing health professional education world a new model has emerged in the pursuit of practice change outcomes Knowledge translation, knowledge transfer, implementation science and the knowledge-to-practice process emerged as guiding constructs Central to all, is the idea that practice change is more likely to the extent that researchers engage ‘subjects’ more actively in the development of research questions and the dissemination of findings.

16. GiiC researchers wanted to understand the performance of family health teams, standardize a Dimensions of Teamwork Survey (DTEAM) for use by Family Health teams and compare DTEAM surveys with social network analyses, and improve interprofessional practice. Fifty-five participating Family Health Teams wanted information on the quality of their teamwork and how they stood with regard to other similar teams.

18. Dimension of Teamwork Level of Inter-professional Teamwork Below Average Levels of Teamwork (One standard deviation below the group mean ) Teams at Average Levels of Teamwork (Within +/- one standard deviation of the group mean ) High Performance Teamwork (One standard deviation above the group mean ) Patient and Inter-team focus 5 (9%) 40 (73%) 10 (18%) Team members strengths and skills 7 (13%) 40 (73%) 10 (18%) Communication and Conflict Management 9 (16%) 39 (71%) 7 (13%) Roles and Interdependence 9 (16%) 35 (64%) 11 (20%) Clarity of Team Goals 11 (20%) 35 (64%) 9 (16%) Decision-making and leadership 9 (16%) 36 (68%) 10 (18%) Organizational Support 12 (22%) 38 (69%) 5 (9%) Total teamwork 9 (16%) 37(68%) 9(16%) The distribution of high performance teamwork in a sample of 55 family health teams using the Dimensions of Teamwork Survey

19. When environments require complex interdependency the quality of collaborative alliances may predict outcomes better than the internal processes of individual teams (Pfeiffer, 86)

20. And then we started working on the “community care” side of the health system where the world is different and so are teams

21. On Emergence in Community Based Shared Care Initial conditions Health professionals don’t own the space Co-caregivers may not know each other Care providers are inter-organizational Regulated and unregulated providers Unpaid “shadow workforce” prevails Interactions are non-linear Self-organizing Local ecology and regional diversity Strength of ties is variable No single agent knows everything Practice Jazz Lots of surprises No standardization Improvisational Sense-making Local Adaptations Co-evolving Patient Focused Community Based Teamwork

22. Questions for the Interprofessional Academies Are we responding to emerging conditions? Does it matter how the word ‘team’ is used? Are we developing the essential skill sets? What is the relationship between teams and the shadow workforce? How are regulated and unregulated health professionals working together Is ‘knowledge-to-practice process’ in the curriculum? Is ‘team’ the right concept for community based health care collaboration? Are we heading to where the puck is going now? Economic Recession Integration Quality Management Safety

23. That’s all for now Goodnight Irene http://giic.rgps.on.ca david.ryan@sunnybrook.ca