Development and Clinical Supervision of Multidisciplinary Teams

1. Development and Clinical Supervision of Multidisciplinary Teams Gary L. Munn, M.D. Naval Medical Center Portsmouth, VA hhhhh Debbie Forsythe, LCSW Southside Counseling Center Suffolk, VA

2. Definitin of MDT Our Goals forToday’s Presentation Understand the benefits of a team [MDT] approach in treating dual-diagnosis patients. Learn how to develop a MDT. Develop understanding in regard to the challenges of supervising and maintaining a MDT.

3. Definition • A Multi-disciplinary Team is a group of professionals with different areas of expertise who unite to plan and carry out the treatment of patients/clients.

4. Benefits of Team Approach • May use resources more efficiently • On intake, client/patient does not have to repeat their story to each member • Decreases “system-inflicted” trauma • Utilizes perspectives of different disciplines – brings in NEW ideas • Enhances communication between the various professionals caring for the same patient/client • Provides continuity and consistency of care • Diffuses transference.

5. More Benefits of a Team Approach • Mitigates splitting • Enhances the overall quality of care and patient satisfaction • Improves success rates • Shortens hospitalizations • Lowers cost of treatment long-term • Reduces burnout among professionals • - allows staff members to compensate for the weaknesses of others • - gives staff the opportunity to process their reactions to particular clients. • Facilitates processing of counter-transference.

6. Stages of Team Development • Forming: a group of people come together to accomplish a shared purpose • Storming: Disagreement about mission, vision, and approaches; team members are now really getting to know each other, which can cause strained relationships and conflict • Norming: The team has [consciously or unconsciously] formed working relationships that enable progress towards the team’s objectives • Performing: Relationships, team processes, and the team’s effectiveness in working on its objectives are synchronizing in a successfully functioning team • Transforming: The team is performing so well that members believe it is the most successful team they have experienced • Ending / Out-the-door-ming:The team has completed its mission or purpose [or funding has been terminated] and it is time for team members to pursue other goals or projects.

7. Process of Team Development • Know the need: Team must know the needs of the population it is serving and how it can meet those needs (Leader must know the need and communicate it to the team members.) • Secure funding sources. “Buy-in” from management • (The most innovative ideas come from the deck-plates / people actually doing the work.) • Establish roles and responsibilities of team members • Determine competencies required by the team • Establish the who, what, when, and where of the team meetings • Establish team rules and standards of procedure • Provide appropriate ongoing training and support.

8. Ten Characteristics of an Effective Treatment Team • Leadership is defined • Members understand their roles. No “turf wars” • Members understand & respect differences • Members assume mentorship responsibility for all new members • Team schedules the work to be done and commits to their tasks and deadlines • Team develops tangible work results • Team members are mutually accountable for work results • Individuals’ performance is assessed based on achieving team results • Problems are discussed and resolved by the team • The Team incorporates the Patient(s).

9. Characteristics of Effective MDT Members • Respect the leader • Respect others: respect the process and agree to disagree • Meet regularly • Honest • Listen to one another • Open to constructive criticism • Know personal abilities and limitations • Understand respective roles and responsibilities • Keep treatment of individual as the focus.

10. Role of the Supervisor • Teacher • Counselor • Consultant • Monitor of the quality of professional services • Gatekeeper of those who enter the team.

11. Supervisors • Develop program policies and procedures • Manage program referrals • Monitor fidelity of evidence-based treatment • Oversee quality control and financial responsibilities • Provide treatment to patients • Provide weekly group supervision • Provide individual supervision as needed.

12. Tips for Supervisors - 1 • Be an Excellent Team Member – model the process • Motivate your Team • Support your Team • Liaison with Management • Encourage Staff Development and Training • Plan and Meet Targets • Maintain Discipline.

13. Tips for Supervisors -2 • Hone your Skill Set • Build and Sustain a Team Culture • Practice Transparency • Strengthen Team Bonding • Manage Resources Effectively • Criticize Constructively. Praise in public. Reprimand/correct in private

14. Tips for Supervisors - 3 • Adopt Corrective Measures • Be Approachable • Be a Good Listener • Shoulder Responsibility • Take Initiative • Celebrate the Success of your Team.

15. Effective Supervisors5 A’s Available -Open, receptive, trusting, and non-threatening Accessible -Easy to approach and speak with “Able” [capable] -Possess real knowledge and skills to share Affable -Pleasant, friendly, and reassuring Anticipating -Train their relief. • All of us need some time off • No one wants to be indispensible • Train a competent member to cover in your absence • Team members unconsciously need it

16. Managing a Team • Embrace individual differences • Discourage group think • Zombies, 1000-yard stare, no discussion or disagreement, rubber-stamp decisions • Embrace positive conflict • Facilitate open and honest conflict.

17. Length of Stay • Patient turnover How often should the treatment team meet?

18. Team Member Differences • Cultures and backgrounds • Theoretical constructs • Opinions • Expectations and needs • Perceptions and facts • Personalities, egos, and interest • Knowledge and skills • Goals and objectives.

19. Challenges of managing a team • Understanding the differences • Collaborating is not the norm • Everyone has their own view • Trust can be really difficult to earn • People tend to remember the few times you messed up • People have short-term memories • People want to have influence • You rarely get the opportunity to hand pick your own team • You have to be willing to delegate • You are responsible for mediating conflicts of difficult personalities.

20. Team Conflict • Conflict is normal • Conflict can be managed • Conflict can lead to positive results • Conflict can lead to negative results • Conflict can lead to win/win solutions • Conflict can lead to improved communication.

21. Signs of Team Conflict • Name calling • Gossiping • Sarcasm • Airborne furniture • Increased absenteeism • Complaining / critical emails • Anger • Clique formation • Not sharing information • Lack of results • Missed deadlines.

22. Managing Conflict • Acknowledge the conflict - Conflict rarely heals itself. • Make it a team effort to resolve conflict • Have the team define the conflict • Focus on situation, don’t make it personal • Brainstorm solutions • Establish common ground • Agree on plan to resolve conflict • Execute plan.

23. Creating a Safe Environment • Purposeful and goal-directed communication • Clear and well-defined boundaries • Structure that has patient’s needs as the focus.

24. The Setting… • 300 +/- bed tertiary care Medical Center • “Detox ward” 12-bed Psychiatric Ward – part of a 32-bed inpatient adult psychiatric service • ASAM Level 4 care • Average length of stay: 3-5 days • Serving active duty military, military retirees, and their family members NOTE: We did not get to these next slides because of the duration of the Experiential Exercises. These describe the treatment teams I work in at Portsmouth, their evolution, and their outcomes. - Gary

25. Clients served • 65% active duty [USN>USA>USMC>USCG>USAF] • 15% AD Family members • 10% Retired • 10% Retired Family members --------- • 75% from Emergency Room • 20% from other wards [injury, illness, withdrawal] • 5% from Outpatient Psychiatric clinic --------- • 90% admitted with diagnosis suspicious for a SUD • 85% suicidal ideation/behavior • 15% seeking detox services

26. Team Members • Psychiatrist [1] • Psychiatric Resident and/or Intern [1-2] • Registered Nurses [2-4 per shift] • Certified Addiction Counselors [2] • Licensed Clinical Social Worker [1] • Art Therapist [1] • Recreation Therapists [2 + 4] • Chaplain [1] • Psychiatric Technicians [3-5 per shift] • Case Managers [2] • Occupational Therapist [o/c] • Clinical Nutrition [o/c]

27. Mission of our Team • PATIENT/CLIENT FOCUSED - 1 • Patient diagnostic assessment • Diagnostic interviews: • MD, RN, LCSW, CAC • Physical Exam • Laboratory Studies • Radiologic Studies, if indicated • Psychological Testing • Art Therapy Assessment • Patient safety and stabilization • Suicide / assault / elopement precautions • Detox protocol

28. Mission of our Team • PATIENT/CLIENT FOCUSED - 2 • Psychological treatment • Therapeutic milieu • Group therapy • Individual therapy • Family therapy • Recovery workbooks • Medication Assessment and Management • Patient education • Addiction education groups • Twelve-step Meetings • AA & NA from local volunteers • Referral for rehabilitation/after-care

29. Mission of our Team • TRAINING-FOCUSED • Psychiatric Residency Training • PGY-1 and PGY-2 • Medical Student Teaching • USUHS • EVMS • Psychology Interns and Post-doctoral Fellows • Art Therapy Interns • Recreational Therapy Interns • Social Work Students • Pastoral Care Residents

30. Development of our MDT “Old school” [1980’s – early 90’s] • Off-going nurses give report to the “day team” at morning report. • Doctors held their sessions with patients. • Nurses did their nursing assessments. • MDs, RNs, and Techs came together in Group Therapy and post-group processing. • Ancillary staff performed in their roles. • Everybody wrote their own note. Sometimes they were read by others… • Limitations • “Surprise!”

31. Development of our MDT Evolution mid-1990’s – 2000’s • JCAHO - > BPSS added to team. • Department Head with addiction background. AMS / CAC added to team. • ACGME mandated increase in supervision of residents • Mandated increase in staff physician involvement • “Reimbursement” tied to workload calculations based on documentation review.

32. Development of our MDT “TODAY” • Rounds expanded in scope and duration • Interviews by teams, not individuals • Other’s perspectives, wisdom, and experiences were embraced and utilized • Splitting less likely • Staff’s reactions could be processed • Trainees appreciated other discipline’s expertise • Healthy staff interactions were modeled for trainees • Continuity of care enhanced • Fewer “surprises.”

33. Consequences -? • Patients found the team intimidating. • Individual’s process may be slowed. • Distractions from other members

34. Challenges to the Practice Rotating Interns, residents, and students Inexperienced tech staff Staff deployments / transfers Three partially-overlapping electronic medical record systems Sequestration / furlough of staff Ineffective computer hardware

35. Not a Concierge Service • Must have a competent core / corps • MD, RNs, LCSW, CAS • Relatively high staff turnover does not allow us to be selective about our staff: interns, residents, corps staff, spot-fill RN’s • Junior staff members: malleable and mistaken, naïve and novice • Indoctrination and training is critical. • Continuous improvement mentality – identify and learn from your many mistakes • Take nothing for granted • Empower patients to critique us.

36. Outcomes? • 100% receive medical evaluation • 100% receive psychiatric evaluation • 99% receive RN evaluation • 95% receive individual CAS evaluation - all are reviewed by a LIP • 80% receive LCSW evaluation • 100% of diagnosed SUD’s referred for rehabilitation/treatment [ASAM level 0.5 – 3] • 100% referred for SOME outpatient treatment • 10% referred to Psych IOP • 50% placed immediately in ASAM level 3 rehab

37. THE WONDERFULLY ALLITERATED MDT CAN YIELD… C NOT… C ollaboration ollegiality o-operation ompetency onfidence reativity onfusion alamity risis

38. References • Pleszkoch, Elisabeth NCC, CSAC, LPC, No Counselor Left Behind: Challenges of Supervision in Substance Abuse Counseling. University of Virginia (2011) • Rajeev, Loveleena, How to Manage a Team. (2012) • Walker, Diane, Career Training, Bella Online Career Training (2013) • Dallas E.M.A./HSDA, Standards of Care: Substance Abuse Services.Ryan White Planning Council of the Dallas Area (2004) • Segal, Jeanne Ph.D.and Smith, Melinda M.A., Conflict Resolution Skills. (2013) • Schaufeli W, et al. (eds)Professional Burnout, Washington, DC: Taylor & Francis (1993)

39. References - continued • McGovern, Mark, Ph. D., Integrated Services for Substance Use and Mental Health Problems; Clinical Administrator’s Guidebook. (2008) • Jacobson, N. and Curtis, L., Recovery as policy in mental health services: Strategies emerging form the states. Psychiatric Rehabilitation Journal, 23, 333-341 (2000) • Kennedy, Frances A. Ph.D. and Nilson, Linda B., Ph.D., Successful Strategies for a Team (2012) • Avery, C., Teamwork Is an Individual Skill: Getting Your Work Done When Sharing Responsibility. San Francisco: Berrett-Koehler Publishers, Inc. (2001)

40. References - continued • Lencioni, P., The FIVE Dysfunctions of a Team. San Francisco. Jossey- Bass (2002) • Maginn, M. D., Effective Teamwork. Burr Ridge, IL: Irwin Professional Publishing. (1994) • Parker, G. M. Team Players and Teamwork. San Francisco: John Wiley & Sons (1996)

41. Thank you for being with us! Enjoy the rest of your VSIAS Conference 2013 and your stay in the “Colonial Capital!” gary.munn.ctr@med.navy.mil