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Cheshire has made ground-breaking progress in building effective inter-disciplinary teams to provide rehabilitation for older people, write team members Anne Marriott and Hazel Wright.

Integrated care for older people, most agree, offers many benefits. In Cheshire the council and health care providers have established three inter-disciplinary teams, which aim to deliver rehabilitation to older people in more co-ordinated ways. The main emphasis of the work is with older people who are experiencing general frailty and have complex needs normally addressed by a combination of different professionals and agencies.

Each team consists of a social worker, physiotherapist, occupational therapist, district nurse and community psychiatric nurse. Home care staff work closely with team members to support the client during their rehabilitation.

Before setting-up the service older people had told us that they wanted one key person who could understand their needs, who could help navigate them through health and social services and with whom they could establish and sustain a working relationship.

Care management provides a framework to deliver an inter-disciplinary assessment,  define needs, and plan and deliver rehabilitation programmes that integrate health and social services. Along with service users, it also monitors the outcomes of intervention.

Within Cheshire the social worker’s role as care manager was well established within older people’s purchasing teams; in contrast, health care professionals had little experience of care management. The introduction of rehabilitation care managers has  enhanced respect between health and social care staff, and unravelled some of the mysteries of social care commissioning. Health staff have had to learn care management skills, and social workers have had to develop an understanding of therapy and nursing techniques and the language of health professionals. By developing an inter-disciplinary approach to care management, the care manager has become the team member who co-ordinates all aspects of a person’s assessment and physical, mental and social rehabilitation.

So, what does inter-disciplinary working mean? What makes it different from multi-disciplinary working? The two terms are rarely defined adequately and often used as exchangeable words. Ovretveit describes multi-disciplinary teams as: “A group of practitioners with different professional training (multi-disciplinary), employed by more than one agency (multi-agency), who meet regularly to co-ordinate their work providing services to one or more clients in a defined area.”¹

Traditionally, this means that each discipline focuses on their own particular contribution to client care and works in parallel with other disciplines. Very often communication takes place on an informal basis at the discretion of individual practitioners. In an effective multi-disciplinary team the focus of communications is probably on the co-ordination of individual contributions to care rather than integration. For example, the social worker will probably take responsibility for the social aspects of a client’s care plan but does not have the authority to co-ordinate the health aspects. Sometimes there is little awareness of the range of services being provided by different agencies.

Inter-disciplinary working provides a more integrated and shared approach to the delivery of health and social care, which overcomes some of the barriers of professional structures and organisations. It recognises the importance of each professional’s perspective, but: “Seeks to blur the professional boundaries and requires trust, tolerance, and a willingness to share responsibility”.²

This is not the same as generic working as it is rooted in the belief that every discipline’s viewpoint is valid and is part of the whole picture of care for an individual. The social worker, along with other members of the team, has had to identify the unique skills associated with the social work role.

We therefore propose a definition of an inter-disciplinary team as a team of professionals from different disciplines (and possibly different organisations) who integrate their shared skills into a framework of core team skills. The team deliver a co-ordinated, person-centred service by working across traditional professional or organisational boundaries and targeting unique professional skills appropriately. Characteristics of multi and inter-disciplinary working are summarised in the table.

Although all professionals take responsibility for a single assessment process, this is a baseline assessment and it is vital that issues raised in this are checked out with the relevant professionals.

Team training has focused on establishing core values, a team philosophy, common policies and protocols and defining inter-disciplinary working. The teams are about to start an eight-month training programme that will encompass all the key topics of our baseline assessment document. This will be supported by defined competences that will form the basis of each care manager’s development programme. Evidence for each competence will include observation by an appropriate professional, baseline assessment documentation, and use of the “talk aloud” technique to determine the level of insight into the tasks carried out and their inter-relationships.

Allocation and team meetings provide an ideal opportunity for staff to learn from each other and exchange ideas, views and knowledge. This has consolidated skills and provides a testing ground for different ways of working. Teams have also learned to face criticism about their new ways of working from established professional groups. Each team co-ordinator has needed to address these pressures, while maintaining the energy and vision of the teams.

This has been a challenging time. However, we feel the benefits of working as a team and focusing on the person and their rehabilitation needs rather than on professional perspectives are contributing to the success of rehabilitation programmes. The recent National Service Framework (NSF) for Older People³ has stressed the importance of each user having one rather than a whole collection of people taking responsibility for their overall care.

Social workers’ experience in care management means that they are uniquely placed to embrace an inter-disciplinary approach and face the new challenges posed by the NSF.

Characteristics of multi-disciplinary working          

- Reinforces boundaries between professionals.

- Generates multiple assessments and professionally orientated goals.

- Focuses on uni-professional skills.

- Allows only general sharing of information due to uni-professional focus.

- Perpetuates uni-professional models of training.

Characteristics of inter-disciplinary working

- Emphasises the similarities across professional groups.

- Facilitates a single assessment approach and person-centred goal setting.

- Acknowledges areas of shared skills.

- Promotes a shared understanding and viewpoint.

- Relies on shared training, mutual trust and respect.

Anne Marriott is the rehabilitation co-ordinator for East Cheshire. Hazel Wright is the county rehabilitation co-ordinator - Eastern Cheshire Primary Care Trust.

References

¹ John Ovretveit, Co-ordinating Community Care, Multi-disciplinary Teams and Care Management, 1998

² Mike Nolan, “Towards an ethos of interdisciplinary practice,” British Medical Journal, BMJ 995

³ Department of Health, National Service Framework for Older People, March 2001