Interdisciplinary Geriatric Difficult Case Conference: Innovative Education Across the Continuum

Background

The IGDCC was created by four members of 3 health systems in Wisconsin: Wheaton Franciscan Healthcare, Aspirus, and Aurora Health Care. The health systems serve and partially overlap on a broad geographic and demographic area of Wisconsin. The 4 members collaborated on numerous projects in the past, including Nurses Improving Case for Health System Elders (NICHE) implementation [3]. A common concern among the team is the management of challenging geriatric clinical patients and having a prepared workforce to meet those challenges.

Problem/Issue

As mentioned above, the older adult population is increasing, and these statistics are reflected in our service area [4]. Exacerbating these demographic changes is a shortage of health care workers in all disciplines, inadequate geriatric training, and the increased prevalence of multiple chronic conditions. Older adults also have higher rates of 30-day readmissions as well as higher rates of functional decline and medical errors during hospital stays [5,6]. Effective interprofessional teamwork is essential for the delivery of high-quality patient care in an increasingly complex health environment [7]. The IOM’s Future of Nursing report recommends that nurses, who represent the largest segment of the US health workforce, should achieve higher levels of training and be full partners in redesigning health care [8]. Unfortunately, effective care is hampered by poor coordination, limited communication, boundary infringement, and lack of understanding of roles [9]. Meta-analyses have demonstrated that there is a positive relationship between team training interventions and outcomes [10,11].

Objectives

The objective of the IGDCC is to elevate the level of geriatric care in the region by providing an accessible and affordable forum for the education of health care workers involved in the care of our most vulnerable population. To meet this challenge, the 4 founding members of IGDCC utilized the Aurora Health Care Geriatric Fellow’s Most Difficult Case (GFMCC) conference format as a model [12,13]. All disciplines are encouraged to participate, with announcements sent out via the leadership at the participating hospital systems. Participants have the option to call into the conference and teleconference via their own personal telephone and computer; in addition, each participating hospital system frequently hosts an open forum teleconference room where participants also may join a group.

Conference Components

The team uses the Wisconsin Star Method framework for presentation and discussion of the case. The Star Method, developed by Timothy Howell, enables clinical data about a person to be mapped out onto a single field with 5 domains: medications, medical, behavioral, personal, and social [14], creating a visual representation of the complicated and interacting physical, emotional, and social issues of older adults (Figure). By becoming comfortable using this method, the learner can use a similar approach in their clinical practice to address the needs of the patient in a holistic manner.

The case call concludes with expert teaching points from both a geriatric expert and a member of the interdisciplinary team. The interdisciplinary team member is chosen based on the key issues raised by the case. For example, cases that are made complex due to polypharmacy and adverse drug reactions might have a pharmacist presenting pertinent take-home message for the learner. In addition, geriatric teaching experts (ie, a geriatrician or advanced practice geriatric nursing specialist) provide the learner with insights that they can apply to their future practice. Often times the teaching points consist of an analysis of the various geriatric syndromes and how they can be managed in the complex older adult.

Implementation

Implementation of the IGDCC is coordinated by an oversight team with representation from each of the 3 sponsoring health systems. The oversight team currently includes 4 members: 3 geriatric clinical nurse specialists and a geriatric service line administrator. The team is responsible for:

• Planning the conference call schedule
• Making arrangements for case presenters and experts to contribute teaching points
• Registering participants and sharing written materials with participants
• Publicizing and encouraging attendance
• Soliciting feedback for continual improvement
• Exploring and implementing new ways to maximize learning.

Team members share duties and rotate case presentations. The Aurora and Wheaton Franciscan systems provide the geriatric specialists who provide the expert teaching points. The Aspirus system provides the conference line and webinar application and supports publicity and evaluations. All 3 systems are supported by a geriatric clinical nurse specialist who identifies and helps prepare presenters, case presentations, and call participants. Over time, the conference call format has evolved into a webinar format, allowing participants to either phone into the call for audio only or participate via both audio and visual. The visual allows participants to watch on their computer screens while the case is presented using the Star Method. During the call, a member of the oversight team adds clinical details by typing into a Word template of a blank star, adding information for each of the 5 domains in real-time as the case is discussed. Another member of the team facilitates the call, introducing presenters and experts, describing the Star Method, and offering “housekeeping” announcements. The facilitator also watches the timing to make certain the agenda is followed and the call begins and ends on time. During the call, another member of the team updates the attendance spreadsheet and makes a recording of each session.

Some participating facilities reserve a meeting room and project the webinar onto a screen for shared viewing. One of the participating sites has done this quite successfully with a growing group of participants coming together to watch the case during their lunch hour. This allows an opportunity for group discussion—when the conference call is on “mute” so as not to disrupt learners at other locations.

Measurement/Analysis

Attendance has steadily increased. In CY2015 from January to September, the mean attendance per month was 29.1 (mode, 17). The maximum per month was 62 (September 2015). The program enjoyed a boost in attendance beginning in July 2015 when Nurses Improving Care of Healthsystem Elders (NICHE) [3] began promoting the call-in opportunity to its NICHE Coordinators at member health systems. In June 2015, the technology was improved to allow for recorded sessions, and the recordings are growing in popularity from 2 listeners per month in July 2014 to 23 listeners per month in September 2015.