Clinical and administrative teams need to share a common sense of purpose, framed by their organization's mission and driven by best practices and patient needs. At the same time, a committee cannot provide clinical care. Instead, all team members must have authority to act within the team framework and within professional and regulatory guidelines. Whenever necessary, team members must be able to respond to needs or questions that are not really "`in the job description." A social worker may visit a patient and find that he or she is in severe pain. Although the social worker cannot administer medications or increase dosages, he or she can work with the patient and family to contact clinicians, make the patient comfortable, and stay until the crisis has been resolved. Just knowing what is likely to be done puts the social worker in a good position to increase the family's confidence and to get problems solved effectively. Similarly, physicians may need to know the basics about community services, such as Meals-on-Wheels, and be able to give families this information when necessary. When physicians demonstrate real understanding of a community, patients and families tend to feel that professional caregivers are truly concerned for their well-being and comfort, beyond what basic medicine requires.
Groups can take many approaches to cross-training. For instance, during orientation periods, new staff can be introduced to key personnel who can explain their work and its significance to the patient's care. Staff may ``shadow'' one another for half a day to learn more about hands-on work. Key personnel can hold occasional brown-bag lunches during which they discuss advances in the field, emerging trends in patient care, or systemwide improvements in information systems. By attending team meetings, all staff have an opportunity to learn about each other's work, to ask questions, and to gather information.
The Breakthrough Series has revealed several effective orientation and training programs. Among them, the Palliative Care Center of the North Shore focuses on training members of its interdisciplinary teams on how to provide patient- and family-centered care. All team members are required to understand key elements of end-of-life care, such as pain and symptom assessment and management, family dynamics, pastoral care, and psychosocial concerns. Once new employees have completed orientation and are ready to be in the field, they accompany more experienced staff members on patient visits. This process usually begins during the first week of work.
In Massachusetts, Fallon Healthcare System, the University of Massachusetts, and the Harvard Geriatric Education Center have developed a program to train residents and nurses to provide interdisciplinary care of the elderly in community settings. The month-long program includes day-long sessions in which residents and nurses spend mornings attending team meetings, participating in quality improvement activities, evaluating resource utilization, and participating in ethics committee meetings. Afternoon sessions are spent participating in long-term care and rehabilitation medicine, either during home visits or at the day health centers. Through this process, students learn about administrative aspects of care, participate in patient care in a variety of settings, observe social worker and physical therapist assessments, and make home visits.
In California, On Lok Senior Health Services provides a half-day orientation to all new employees on the role of interdisciplinary teams. Physicians, nurse practitioners, home care and clinic nurses, physical therapists, social workers, occupational therapists, recreation therapists, dietitians, and intake staff participate. The On Lok program features three modules, each lasting approximately 90 minutes.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].