Emergent, inter-organizational, senior sensitive teamwork in the community Prepared by

1. Emergent, inter-organizational, senior sensitive teamwork in the community Prepared by Dr. David Ryan, Director of Education & GiiC Initiatives Regional Geriatric Program of Toronto July, 2010

2. Objectives Examine senior sensitive care from a communications perspective Examine senior sensitive care from a psychological perspective Reflect on the role of family caregivers Examine a model of families and health care Explore the circle of care and teamwork in the community Understand ‘emergence’ as it applies to community based care

3. Communication at the heart of senior sensitive health care

4. No matter what we say or do, even if we say or do nothing we cannot not communicate

5. We all know this but still: 1. Miscommunication is the rule rather than the exception and 2. A major source of complaints and dissatisfaction with care

7. First some general observations on seniors, health care providers and communication

8. What Seniors Like in Health Conversations (Greene et al, 1994) Questions & support about their concerns Questions worded positively Information after questions on their topics Orientations to each step of the visit Longer visits Sharing laughter Satisfying us

9. Communication Patterns of Primary Care Physicians (Roter et al., 1997) Patient Satisfaction Frequency of occurrence Physician Satisfaction (1 = most satisfying 5 = least) 1. Narrowly biomedical 32% 5 5 2. Expanded biomedical 33% 3 4 3. Bio-psychosocial 20% 3 3 4. Psychosocial 7% 3 1 5. Consumerist 8% 1 2 Biomedical patterns were used more often with more sick, older, and lower income patients by younger, male physicians.

10. Being on the same page(Christensen et al, Journal of General Internal Medicine 2010) Symmetrical attitudes about health locus of control between patients and providers promote adherence, and symptom management Symmetrical attitudes occur about 38% of the time

11. Seniors Contribute to the Communication Dilemma Seniors are likely to have ageist attitudes towards medical interventions. Older patients are less likely to challenge authority Less likely to ask questions Less inclined to take a participatory or controlling role in the health care process Less effective in getting their physicians to attend to their concerns Less likely to acknowledge psychological issues

12. Now some notes on health communication in general

13. Communication is such a complex process 2. Non-verbal Behavior 3. The situation Controllable Predictable Sound/light Safety Drugs 4.Cultural diversity Preferences/expectations Practices Language Proxemics & Posture Prosody Facial Expression & Gaze Turn-taking 5. Individual Difference 1.The words we use Self efficacy Control beliefs Reaction to novel stimuli Emotional expressiveness Medspeak Everyday language Linguistic Relativity Intended Meaning The communication gap Perceived Meaning

14. 1. Just saying what we mean can be a challenge Doctor: “Do you have a history of cardiac arrests in your family?” Patient: “No, we have never had any trouble with the law” Nurse: “Do you have varicose veins?” Patient: “ I have veins, but I don’t know how close they are” “If you think our staff are bad you should see our manager.”

15. 2. Non-verbal communication is a message about the message Far Preferred distance for conversation Near Young Adult Middle Age Old-Old Adult The relationship between age and personal space usage is curvilinear (Ryan et al., 1986)

16. 3. Health situations present different challenges Consider the following differences Seriousness Disease controllability Illness predictability Symptom visibility Cognitive demand

17. 4. Cultural diversity presents a double jeopardy “Handicapped by losses in physical and cognitive functioning, the inability to use their native language doubles the risk” of not having health care needs met. (Saldov & Chow, 1994)

18. 5. Individual difference: where adherence is moderated by: Cognitive Processes Age related changes in information processing Understanding and valuing the outcomes promised Temperament: Reaction to change Emotional expressiveness Social Learning: Self-efficacy and the expecting to be able to achieve goals Control beliefs, particularly health control beliefs

19. The "So simple you can't make a mistake and if you do its no big deal Guide to Understanding Reactions to Practically Everything” React quickly and hate to wait J DRIVERSprefer to move ahead calmly, watching results, staying organized and asking “what’s next” ENTHUSIASTSlike to jump into new things, sets everyone on fire by “just doing it” and asking “Why not?”. 4 3 2 1 Stay cool calm and collected no matter what Let feelings and emotions show C 4 3 2 1 0 1 2 3 4 E 1 ANALYSTS like to hear the details, see facts and figures and asks “How is this going to work?” HARMONISTSlike to give everyone the opportunity to express themselves and their opinions often asking “how is everyone feeling?” 2 3 4 S Wait, watch, hear all sides

20. Like to get on with things Like to see results Like everything to be organized Most frequent question: “What's next” When our patients are Drivers Want to face the problem and put a plan in action Want timelines, goals, precision and specifics We do not want any delays We want information and we want to see results We like handouts We prefer one to one rather than a group

21. Like to set people on fire with new ideas Jump in and lead by doing Like to explore new possibilities Most frequent question “Why not” When our patients are Enthusiasts Likely to quickly become frustrated if professionals ask too many questions Specific information on things they can do right away They want to be able to see results quickly We will probably already have gathered information But we can easily get frustrated if people don’t move fast enough More likely to appreciate a group approach Open to new approaches and do not need evidence base to use new therapies Likely to look for help from different sources

22. Like to hear the details Like to see facts and figures Likes to have a clear plan Most frequent question: “ How is this going to work” When our patients are Analysts We want the facts “just the facts” We like written information preferably with statistics We want predictable outcomes and a clear plan to achieve them We want evidence based information We want to be able to compare approaches and benefits. We want to know everything about the illness Don’t expect us to follow your recommendations without a lot of thought

23. Wants to avoid conflict and be friendly Likes to talk things through and hear all sides Most frequent question: “How does every one else feel? When our patients are Harmonizers We want to know everything We want to know how it will affect our families We will not be rushed We need time to ask lots of questions Our emotions will be much more visible We will need time to talk about how we feel about it all . We will want to know if it is going to hurt We might need more than one session

24. A Psychological Structure for Patient Engagement Control Beliefs Self-efficacy Temperament Value outcome Adherence Symptoms managed Satisfaction Patient Autonomy Informed Choice Opportunities for behavioral control Preferences

25. Focus on Control Beliefs, Self-Efficacy and Controllability

26. Control and Health(Adapted from Schultz 1976, Schultz & Hanusa 1978) Control Predict 7 Random No treatment 6 Health status ratings 5 4 10 24 30 42 4 Time elapsed in Months Mean health status ratings by treatment conditions presented at four points in time

27. Control and Well-Being(Adapted from Schultz 1976, Schultz & Hanusa 1978) Control Predict 7 Random No treatment 6 zest for life ratings 5 4 10 24 30 42 4 Time elapsed in Months Mean zest for life ratings by treatment conditions presented at four points in time

28. Optimizing Patient Focused Care in More Controllable Health Situations Sense of Self-Efficacy Control Beliefs Internal External High Low Self Management Participatory control Information and behavioral control Reliance on higher power Support Dependency

29. Optimizing Patient Focused Care in Less Controllable Health Situations Sense of Self-Efficacy Control Beliefs Internal External High Low Control over reaction, Depression Control through predictability Control through information Challenge to faith Support Dependency

30. Who is the “shadow workforce”? Why are they in the shadow? Are they part of the team? How can we think about families?

31. Family Caregivers: the shadow workforce and team player • 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 crossers • Continuing medical education students • An understanding of this work should prompt us to seek joint action • (From Brookman & Harrington: 2007)

32. Family Caregivers: why the shadow workforce and team player The focus has been on decision making largely in the context of mental capacity Less about mentally capable older persons working together with their families “The autonomy model of a lone individual . . . stems chiefly from experience in acute care settings” (Kapp 1991) Paternalistic professionalism We underestimate the amount and value of family care giving - $90 billion (Brown 2010) . We underestimate the sophistication of family care giving that is required (Brookman & Harrington, 2007) We understate the quality of family caregivers contributions. Instead of saying “two thirds are correct” we say “Surrogates incorrectly predict patients’ treatment preferences in one-third of cases” (Shalowitz et al 2006, cited in Kirchoff et al 2010)

33. Family systems are complex and in the context of stressful health care encounters the characteristics of these family systems are sometimes dramatically revealed and often quite challenging. . Yet our clinical encounters with families is often unguided by systemic thinking and each situation is encounter appears as if it were the first. What follows is one simple model of many that are available to help us think about and engage families in our work.

34. A family’s sense of order and controllability in the outside world moderates its ability to seek and use new information High Low High Environmentally Enriched Family Consensus Sensitive Family A family’s ability to coordinate itself Achievement Focused Family Disorganized Family Low A Model of Family Adaptation: Adapted from David Reiss (1980) The family meets the hospital, Archives of General Psychiatry, 37, 141-154.

35. The Environment Sensitive Family: Able to ask for and use new information Able to coordinate action both within the family and with a treatment team Normal adjustment process Prescription: Move ahead normally

36. The Consensus Sensitive Family Perceives the environment as threatening Avoids conflict and seeks agreement May disagree but is unable to voice concerns Has difficulty making hard decisions and resists passively Clinicians are surprised when plans go awry May be threatened by other families Often one family member has the role of communicating with the outside world and if that person is the patient the family can become quite disabled

37. The Consensus Sensitive Family: Prescriptions Assign a team member to be the families ally Stage the delivery of stressful information The ally can give voice to the families hidden disagreements Avoid precipitous involvement of family members in family support groups and etc.

38. The Achievement Sensitive Family Usually all family members are high achievers Family members are status oriented If special relationships develops between a family member and team members others may undermine it. Often family members compete with the team regarding who is the best caregiver Consensus may be very difficult as each family members asserts the value of their own opinions Illness/injury may mean failure

39. The Achievement Sensitive Family: Prescriptions Recognize high achievement See coping with illness as a success Talk to the family as a group to avoid unbalancing the family power structure. Avoid assigning one person as a family spokesperson Be sensitive to care-giving competitions Maintain control by giving it away Pose arriving at consensus as a challenge. This will prompt motivation to meet the challenge.

40. The Disorganized Family The family is unable to problem solve together despite being highly enmeshed Often each member is involved with their own social agency Although well-meaning the family is unable to follow-through with family plans Family members are often vigilant for signs that the team sees the family as disorganized

41. The Disorganized Family: Prescriptions Getting the family together is often a struggle and is best avoided. Do not rely on apparent family agreements to translate into follow-through especially if the plans are complex. Often finding the strongest person and making them the family contact person is best. Like the achievement sensitive family, these families need explicit recognition though for different reasons.

42. Informal care giving and volunteerism(Choi et al 2007) Seniors who are informal care givers are more likely to volunteer and the more intense the care giving the greater the amount of volunteering Care giving brings them into contact with volunteer opportunities Formal volunteering provides a less guilt free break from care giving Volunteering seems to balance the stress of care giving and enhances health and well-being

43. On our teams and inter-organizational teamwork

44. Management Teams Emergent Inter-organizational Senior Sensitive Shared Care Teams Continuing care and Rehabilitation teams TYPES OF TEAMS Acute Care Teams Specialized Geriatric Services Teams Primary Care Teams CustomerFocusedOutcomes InternalFocusedOutcomes OUTCOMES OF TEAMWORK FinancialFocusedOutcomes InnovationFocused Outcomes Communication&ConflictManagement Team Member Skills & Strengths CustomerNeeds &InterteamIssues PerceivedSupport fromOrganization DecisionsAuthorityAccount-bility Clarity/Coherenceof Goals Roles &Inter-dependence THE DIMENSIONS OF TEAMWORK A framework for examining teamwork

45. On the distribution of high performance on co-located health care teams

46. Dorothy 86 year old woman living alone. Widowed from a 62 year marriage 24 months ago. No children. A niece (PofA) lives in the west and visits every few months to take care of finances. Neighbors do shopping. Both veterans of WWII, her husband was an enthusiast she an analyst and careful planner. Traditional, Dorothy asserted influence indirectly and despite a continuing sense of loss, she has also experienced some increased freedoms since the death of her husband. Resourceful and humorous, she laughs at adversity. Picking up dropped blueberries with her grabber on berry at a time is hilarious for her. She is hardy: in control, committed and unfazed by challenge. Medico-Functional Status Severe osteoarthritis arthritis in hips and knees. Ambulates in-house within her home with a walker. She has an elevator chair, stair-glide and a front porch elevator. She has high blood pressure and cardiac insufficiency Independent in ADLs except footcare IADLS compromised by mobility and pain Meds include pain killers, blood thinners, celebrex, stool softeners,

47. A network analysis of Dorothy’s circle of care: Is it a team? Line color legend Aware Send Information Discuss

48. Emergent Inter-organizational teams for Dorothy and Mrs X Line color legend Aware Send Information Discuss

50. Community care giving is unique Care givers are not typically co-located Care giving is typically inter-organizational Care givers include both professionals and non-professionals Care givers are both paid and unpaid Unpaid care givers do a lot of the work Different subsets of paid caregivers convene for each client