Interdisciplinary Team Embodies Person-Centered Approach to Care

Independence Care System (ICS) is a managed long-term care plan in New York with a mission to help adults with physical disabilities and chronic conditions to live at home and participate in community life. These adults join ICS as “members,” and their care is coordinated through a range of services, including home care, transportation, wheelchair evaluation and repair, specialized clinical programs, and social programs. With a deep concern for their wellbeing, ICS staff manage the individual care needs of each member.

ICS has refined its model of care over the past 13 years. The new Interdisciplinary Care Management Team embodies their person-centered approach, in which the central focus is the member. Each ICS member is supported by a team that includes nurses, social workers, and a member-services coordinator, along with resource specialists in behavioral health, wound care, and rehabilitation. The team also includes a senior home health aide, who provides guidance in addressing issues with personal care services and supports aides in the field to deal with challenging situations.

In many care settings, the aspiration is to have staff from different disciplines work together. More often than not, however, each discipline contributes from its own vantage point, but remains isolated in their separate silo. Sometimes, their different ways of seeing provoke tension — a classic one being between the nurse’s focus on clinical concerns and the social worker’s focus on the social/emotional. At ICS, there was a strong desire to move to a new norm, one where team members could develop a shared lens, informed by these different but complementary ways of thinking.

Working to Achieve Teamwork

ICS sought PHI’s help to make this happen. In a pilot program, PHI Organizational Change Consultant MariaElena Del Valle worked with senior staff to develop the vision, design, and goals for the Interdisciplinary Care Management Team. Once the group was formed, she helped guide members toward functioning as a team, rather than as discrete individuals representing their respective departments. The team then moved on to interdisciplinary care planning, case conferences, home visits, and other aspects of care coordination. It was sometimes challenging: people had strong and often discordant views about what was in the best interest of ICS members. But over time, they learned that it was OK, even beneficial, to have diverse interests — the key was managing these differences.

I had the remarkable experience of observing this team at a meeting, after they had been working together for about eight months. They were doing case conferences, discussing members in crisis. I didn’t know peoples’ roles on the team, and, based on the discussion, it was difficult to tell. A nurse sounded like she could have been a social worker, given her expressed concern about the isolation and emotional state of a particular member; a social worker indicated strong interest in another member’s health status and disease progression; and the member-services coordinator asked insightful questions about a member’s family situation. At other times, their input was more specific to their disciplines.

The team showed a great deal of fluidity between roles, people listened closely to one another, and everyone in the room contributed. Together they developed strategies for fixing problems that were far more creative and effective than they could have individually.

Lessons Learned

Later, I interviewed team members, as part of a Lessons Learned process, to determine how to roll this team model out to the rest of the organization. All were very positive and enthusiastic, though some admitted they were doubtful at first. All talked about how hard they had to work to hear others’ perspectives, how at first each thought only they knew best what to do, and how they were “fixers,” wanting to jump to an immediate solution. But now they could see how much more insight they had into members’ needs — that the multiple perspectives formed a more complete picture, making it easier to come to a solution that actually addressed the underlying problems.

They were also more easily able to work productively with people in other disciplines. For example, the nurses and social workers better understood all the steps involved in repairing wheelchairs, and the rehab specialist understood more clearly why these repairs should be prioritized.

What made it possible to get to that point, they said, was the relationships and trust developed through the initial team-building exercises (which many resisted), their intentional use of the PHI Coaching skills, and their clear focus on ICS members. And though they were pleased with their process, they were much happier with the results. Without a doubt, they said, the members’ health had improved through the pilot program.

ICS is preparing for significant expansion, developing the infrastructure and partnerships to manage the care of approximately 4,000 people by the end of the year. The Interdisciplinary Team model is a key element of their growth strategy. After seeing the success of the pilot, ICS staff believe that, as they roll this model out, they will be able to continue to provide highly individualized, high-quality person-directed care.

— by Sara Joffe, PHI Organizational and Executive Coach