Across many projects and partnerships, the Foundation has come to believe that high quality care for complex older adults MUST be team care. Not only is there far too much work for any one provider, but the nature of the work requires a team to implement successfully. Geriatric care is long-term care, not necessarily in the sense that everyone is in an institution, but in the sense that geriatric care is chronic care that needs to be delivered over years of time. Older adults and their family members always need to be on the team. However, teamwork over long periods of time with evolving goals and changing clinical issues is not only very hard and outside most clinicians’ skill set, it is also countercultural.
Even within the professions where the Foundation works to build competence and capacity for teamwork, there is a centrifugal force that tears at the team concept and leads to passionate re-creation of the wheel and destructive struggles for turf. Over the last several months, my colleagues and I have noted with dismay various projects that have been proposed to enable one profession to develop some competence that is already integral in another. Physicians have proposed to become experts in care coordination and discharging planning. Nurses have trained to “master” community care and psychosocial supports.
I don’t see how any of these efforts makes sense. A team where everyone tries do everything is not a team but a mob. Common purpose, specialization of function, excellent communication, defined roles, and processes for coordination of effort are what define a successful team. As we learned years ago in our geriatric interdisciplinary team training program, it takes a fair amount of “special education” just to get over basic issues like lack of trust in other professions and ignorance of their competencies.
However, I think teamwork is also threatened by the ubiquitous drive for non-physician professionals to become autonomous providers. We see this in those disciplines that do not yet have the ability to directly bill Medicare and struggle to get the same payment scheme as physicians currently have. These professionals are fighting to get out of the bundle of services currently reimbursed through an overall payment for hospitalization, home care episode, or nursing home stay. They say that they no longer want to be considered “costs” on a ledger but sources of revenue--and have the autonomy that physicians have.
I can understand that it must be galling to other team members to have one profession, medicine, determine both its own services but also the services of virtually all the others. Unfortunately, what we have seen of physicians, who generally have this kind of autonomy, is that autonomy does not lead to good teamwork, even among themselves. Fragmentation and poor communication among physicians is the rule rather than the exception.
While a level reimbursement playing field among health care professionals is attractive, I think the common standard should be for all providers, including physicians, to be acknowledged to be part of the “cost” structure of health care. All providers should be on salary, including physicians, rather than other professions trying to get onto the piecework payment policies that have done so little good. A team with a common purpose of high quality clinical care should have clear incentives to produce high quality outcomes with shared financial resources.
[Editorial note: This post was included in the September 17, 2009, issue of the Health Wonk Review.]