Arif Nazir, MD currently holds the positions of Assistant Professor of Clinical Medicine, Indiana University School of Medicine, Division of General

 Arif Nazir, MD currently holds the positions of Assistant Professor of Clinical Medicine, Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics; Consultant

Geriatrician, IU Center for Senior Health; Medical Director, Extended Care and Nursing Home Service, IU Geriatrics

 Dr. Nazir did his post graduate training in Lahore, Pakistan and Upland Pennsylvania. He also did fellowships in Geriatric Medicine at the Albert Einstein Medical Center in Philadelphia,

Pennsylvania; as well as Michigan State University in East Lansing, Michigan.

Arif Nazir MD CMD FACP

Assistant Professor, Indiana University School of Medicine Medical Director, OPTIMISTIC

Objectives



By the end of this presentation

the audience will be able to:

1. Differentiate between multidisciplinary and

interdisciplinary (ID) care

2. List the components of true ID Care

3. Discuss provision of ID protocols in the

Mr. Z at Shiny Meadows

 89 yo NH resident with moderate dementia  Lost >15 pounds in 6 months (117 lb)

 2 falls with no serious injuries in 1 month

 PT evals and discharges due to dementia

 Son meets with care plan team and desires therapy but aggressive measures

 Doctor evals 1 week later and orders CT abdomen, lab tests and a swallowing study

Mr. Z’s Care - Is it:



Compliant with regulations?



Patient-centered?



Evidence-based?



High quality?

When disciplines work together

A

• Consultative Care Model

• Recommendations based on consultant expertise

B

• Multidisciplinary Model

• Multiple but differing plans run in parallel

C

• Interdisciplinary Care Model

Interdisciplinary Care

Health care activity which

requires:

collaborative, interdependent

use of shared expertise

directed toward a unified

purpose of delivering

Interdisciplinary Care (ID) in NHs

 Mandated by regulations

 Is NH care truly interdisciplinary ?

 Evidence for true ID care in NHs is limited

 20% physicians fail to review any care plans

 Only 21% docs review parts of Minimum Date Set

 _{Systematic review of ID care in SNFs}

 27 team-based trials, all randomized

 Fall- prevention, med. management, ulcer Rx etc.

 66% trials effective

 Leadership, communication, and coordination of tasks among members key elements for success

 Involvement of facility doctors crucial

Strategies to Promote Team

Work

Clarify Roles

Processes

(Communication, Coordination, tools) Leadership

Conflict management Accountability

Benefits of Interdisciplinary Care

 Aim: Reduce Avoidable Hospitalizations Among Nursing Facility Residents

 Grant Period: 9/2012- 9/2016

 _{Focus on long-stay residents}  At least 15 NHs in project

 Utilize evidence-based

strategies e.g. INTERACT

 Provide resources and train

 7 programs accepted nationally

CMS Innovations Center

Demonstration Projects

 Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care

 A 4 year demonstration project

 Conducted by Indiana University, University of Indianapolis and IU Geriatrics

 Project team partnering with 19 Indianapolis Nursing Homes

 Intervention based on three cores:

 Medical, Transitional and Palliative care

 RNs as the Agent of Change:

 RN at each facility for clinical care, staff training and Quality Improvement processes

 RNs supported by NPs (6 FTE)

 provide urgent, chronic and transitional care

 Facility staff education and training

 Emphasizing interdisciplinary strategies

Promoting Interdisciplinary Care

OPTIMISTIC has several interventions that

utilize and emphasize interdisciplinary

collaborations

 Collaborative care reviews

 Transition visits

 POST forms

 INTERACT program

Geriatric Issues

 Yearly overview (cross section) of care

 RN talks to staff and family to complete “CCR tool” (History, medications, falls, ulcers, mood, cognition, weight and nutrition, goals of care)

 NP and RN attend the CCR “clinic”

 NP completes the CCR Consult with 1-5 recommendations (geriatric circle)

 NP and RN then discuss action plans with the PCP and the family

 Interdisciplinary loop is completed

Collaborative Care Reviews

Medical Issues

Back to Mr. Z

 Assuring interdisciplinary Care for Mr. Z

 Communication between physician, therapy and

care plan team

 Manage conflicts among team to reach

patient-centered care planning

 Clarify roles of various team members, particularly

for:

○ Educating son about futility of physical therapy

○ Formalizing Advance Care Directives (tube feeds, hospitalization etc.)

Summary



Interdisciplinary care is key for

patient-centered care



Nursing homes need to invest in processes to

provide true interdisciplinary care



OPTIMISTIC has implemented protocols to

promote effective interdisciplinary care