By: Ellen Fink-Samnick, LCSW, CCM, CRC
A 75-year-old woman with multiple medical issues falls at home where she lives alone and is hospitalized. The woman, whom we’ll call Lillian, has a supportive family system, but none of her children live near her. With a change in Lillian’s medications, the treatment team would like to see her transition to a sub-acute facility. The team is also concerned that Lillian has neglected some of her health issues in the past; for example, she has diabetes but has not been monitoring her diet.
Lillian, however, is adamant that she wants to return to her own home. Since Lillian is competent to make her own decisions, the next step must be for a comprehensive plan to help her transition successfully to her home, with the support she needs to improve self-care and avoid future hospitalizations.
As Lillian’s case illustrates, transitions of care, particularly for older individuals who may have multiple or complex medical conditions, are critical phases in the delivery of health and human services. Given the aging of the population—with one in five people in the United States expected to be age 65 and older by 2030—there is an urgent call to action to improve transitions of care, which must be heeded by all health and human services professionals. Meeting the needs of older adults such as Lillian requires a holistic approach that focuses on the entire person, and recognizes and respects individuality.
The Transdisciplinary Approach
Meeting the unique and often complex needs of older individuals requires a transdisciplinary approach. Rather than approaching client situations from the context of a specific discipline or expertise, professionals orient to the needs of the person. The transdisciplinary approach allows workable solutions to be devised by reaching across disciplines to share insight, form partnerships, and identify resources in new ways.
Depending upon the complexity of the case and the unique needs of the individual, the transdisciplinary team will likely include a variety of members, such as physicians, clinicians, nurses, dieticians, pharmacists, occupational and physical therapists, speech and language pathologists, recreational therapists, rehabilitation counselors, pastoral care, home health, and, of course, social workers. Indeed, the social worker—particularly one who functions in a case management role—is an integral part of the transdisciplinary team, advocating for the individual’s clinical, behavioral health, psychosocial, and spiritual needs, while also being attentive to any fiscal implications that may warrant consideration.
The goals of the National Transitions of Care Coalition (NTOCC), which is an important initiative supported by the National Association of Social Workers and the Case Management Society of America, are aligned with the strong patient focus of the transdisciplinary team. Moreover, social workers are bound by ethical standards to be objective and unbiased, recognizing that choices are up to the individual and/or his or her support system. These principles are congruent with the standards for advocacy as stated in the Code of Professional Conduct for Case Managers published by the Commission for Case Manager Certification, which states, “Certified case managers will serve as advocates for their clients and ensure that: (a) a comprehensive assessment will identify the client’s needs; (b) options for necessary services will be provided to the client; (c) clients are provided with access to resources to meet individual needs.”
With an appreciation of individuality, options are identified and pursued. Members of the transdisciplinary team provide information about the options and resources available and then work to facilitate the choices that the person and his or her family or support system make. Whereas health and safety issues play a role, such as whether a person is medically stable to be discharged from a facility or whether a home environment is safe, self determination must be preserved, especially at care transitions.
Professionals are often faced with reconciling situations in which a client’s judgment and/or ability to understand the consequences of his or her actions is questioned. The issue is not whether the choice made is the “right” one as deemed by the social worker or other members of the transdisciplinary team, but rather how to assess a safe or unsafe situation and what resources can be accessed to make a situation safe. In Lillian’s case, a collaborative effort on the part of transdisciplinary team members contributed to a safe and workable solution that included home health visits, meals provided by the community, volunteers to help with transportation to follow-up doctor’s appointments, and other identified issues.
The transdisciplinary approach is only possible when members of the team see the whole person. This is an important perspective to overcome stereotypes that exist in society about aging. “Just because someone is 70 or 80 years old does not mean that person is going to get Alzheimer’s disease. Alzheimer’s disease is a pathology. Heart failure is also a pathology. Someone is not going to develop a physical or mental health illness due to chronological age alone. There are physical and mental health changes that occur due to the normal aging process, but the onset of a disease or chronic condition is not normal aging,” comments Catherine Tompkins, Ph.D., Bachelor of Social Work Program Director at George Mason University.
Seeing older adults as individuals, the transdisciplinary team comes together to ease transitions for patients and promote self determination. The transition may involve transfer from the hospital to the sub-acute environment under Medicare, or from a facility to the person’s home with home health care support. Ultimately, it must be what is best for the patient with respect for who he or she is and that person’s right to self determination.
“What we bring are options for the elderly person and the family regarding the services that they could not access without having an advocate, to make sure they understand that they do have options,” comments Connie O. McKenzie, RN, Director of Firstat RN Care Management Services. A private care management services firm in southeast Florida, Firstat serves a large geriatric patient population, as well as clients of any age with disabilities.
Social workers, including those in case management roles, draw upon evidence-based practice, but they also focus on the individuality of every person. Although the needs of the frail elderly cannot be minimized or overlooked, it must be acknowledged that working with older adults is not limited to dealing with those who are homebound or in nursing homes. There are also cultural differences that play a big part in lifestyle, care-giving, and choices. The population of older adults is diverse in ability, lifestyle, and culture.
In a fragmented healthcare system, in which time is often limited and resources scarce, social workers and those in case manager roles champion the individual and provide leadership to the transdisciplinary team to focus on the “bigger picture” of the individual’s life, culture, beliefs, and desires. Choices emerge from the sum total of all a person is—from health condition and financial resources to family and community support, cultural background, and beliefs.
Self determination is also vitally important as patients transition to end-of-life. At this juncture, as at all transitions, it is ultimately the choice of the person and his or her family, and not that of the professionals who must remain unbiased and objective.
For example, when a person has been diagnosed with a terminal condition, he or she may opt to pursue palliative and hospice care. Palliative care is intended to ease any type of pain and suffering and is available at any time during a patient’s illness. It can be delivered along with life-prolonging and curative treatments. Although not all palliative care is hospice care, all hospice care is palliative, because hospice seeks to bring relief from pain and discomfort to terminally ill patients, explains Susan Dolan, RN, JD, a nationally recognized expert on end-of-life care.
“The transdisciplinary team honors individual choices by taking a holistic approach to end-of-life care because they address the unique physical, emotional, and spiritual needs of patients and their loved ones,” adds Dolan, who is also the co-author of The End of Life Advisor: Personal, Legal, and Medical Considerations for a Peaceful, Dignified Death.
Carrying out the end-of-life wishes of the terminally ill person requires sensitivity and also objectivity, particularly when it comes to respecting the individual’s beliefs. For example, a person may want to receive pastoral care or may be vehemently opposed to it. The social worker who is a member of a transdisciplinary team may be called upon to help other members orient to the wishes of the patient and family at a time of conflicting priorities.
An 80-year-old man, whom we’ll call Marvin, had a long history of a degenerative neurological disorder and serious respiratory needs. While visiting family in New Jersey, he became hospitalized, was placed on a ventilator, and received 24-hour nursing care. When it came time for Marvin to transition from the hospital to the next care setting, the best clinical choice was a nursing home where he would continue to receive 24-hour care. Marvin and his wife, however, were emphatic that he be able to spend the last days of his life at their home in Florida. As this was their wish, a transdisciplinary team got to work to make this happen.
The most pressing need was a 24-hour nurse who could drive with the couple to Florida. Once a qualified nurse was found, she went to the hospital to train with the treatment team; the respiratory team; and the physical, speech, and occupational therapists. Because Marvin had a “do not resuscitate’ order, the nurse’s main responsibility was keeping him comfortable and his lungs free of secretions. In the meantime, doctors in Florida who were taking over Marvin’s care were well-informed by physicians in New Jersey, with full summaries dictated and faxed to them.
The case manager, whose discipline of origin was social work, played a pivotal role in assuring that Marvin and his wife understood their options and that they had the support they needed in New Jersey and in Florida. The entire transdisciplinary team stretched outside the clinical “box” to find an innovative solution that allowed Marvin to be transported back to Florida, where he lived a few more months before he died.
A case manager may also be called upon to help the treatment team honor the wishes of the patient’s family, while dealing with pressing medical issues. Consider the example of a pulmonary patient who died in the hospital after being weaned off a ventilator. The patient’s family, according to their beliefs and customs, wanted to stay with the body for 24 hours—in a private room in a busy hospital with patients in the emergency room who needed to be admitted.
The case manager in this situation was a social worker, who was able to assess the multiple dynamics in this situation through a unique lens. Not only did the concerns of the hospital staff about hygiene issues need to be heard, but also the organizational pressure to make the room available for other patients who were waiting to be admitted. At the same time the desires of the family needed to be respected. Through the power of relationship, the case manager was able to respond to the family’s grief as well as the hospital staff’s concerns. In the end, after a two-hour period, the family was able to release the body.
Excellent and Individualized Care
At every care transition along the continuum, transdisciplinary team members reach beyond their own disciplines to bridge the biological, psychosocial, and spiritual needs of individuals. By supporting self determination at every juncture, they focus on the options that are workable and identify and put in place resources in new and innovative ways. With a strong patient focus, the transdisciplinary team pursues medically viable, safe, and ethical solutions that are also supportive of the wishes of the patient and family.
The transdisciplinary approach does not come together automatically or simply by working together. Rather, it is an intentional collaboration that calls for the best from each member, to focus on what the patient wants and needs in support of self determination and advocacy; delivering excellent and individualized care.
Ellen Fink-Samnick, LCSW, CCM, CRC, is a commissioner of the Commission for Case Manager Certification (CCMC), the first and largest nationally accredited organization that certifies case managers (www.ccmcertification.org). She is also president of EFS Supervision Strategies in Burke, VA, and has 25 years of experience developing innovative case management models for health and mental health care. She serves as an adjunct faculty member for George Mason University and Northern Virginia Community College, is a Clinical Supervision Certification Trainer for the National Association of Social Workers Virginia Chapter, and is an examination item writer for the Association of Social Work Boards.