All for one

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