Speaker 1: I'm Rinaldi Kulkarnidhate, Medical Director for a clinic that oversees the care of patients with multiple chronic diseases. The purpose of this video is to demonstrate the interprofessional collaborative competencies by visualizing an actual transdisciplinary team in the process of creating a patient's care plan. Our clinic focuses on the care of unfunded patients with multiple chronic diseases who are high utilizers of the hospital or emergency department services. These patients often have difficulty navigating through the healthcare system, which can be quite complex, and also face multiple barriers seeking and obtaining care. Care is delivered through a transdisciplinary team model. Our team consists of a provider, either a physician, a nurse practitioner, or a physician assistant, a nurse navigator, a social worker, and a health promoter, or also known as a community health worker. We also have a dietician who participates on the team. There is a clinical pharmacist available in the clinic who consults on all the teams as well. Together, the team provides not only medical care, but also provides a heavy emphasis on education, health literacy, and addressing socioeconomic barriers to obtaining care. We also seek to connect patients to various resources in the community and subspecialty care. You're going to meet the members of a care team, hear about their roles, experiences working on a team, and observe a typical case conference where they're discussing a patient's care plan.

Speaker 2: I'm a general internist by training. What is unique to the physician role in this team setting versus a more traditional hospital setting or clinic setting is that the hierarchy is removed, and so my voice in an interprofessional team is no more important than any other person's voice at the table, which is very rewarding and a gratifying way to practice because you gain a lot from your other team members, and you're really able to lean on them for things that we can't completely handle as physicians ourselves.

Speaker 3: As the advanced practice registered nurse on our team, I care for our patients in the clinic and in the home setting, and also by phone when necessary. During these visits, I use a holistic approach to evaluate and manage new and ongoing patient conditions. I provide a comprehensive perspective to our patient's healthcare needs. This means that in addition to considering the patient's medical conditions, I also evaluate psychological, financial, social, and family circumstances in order to formulate a realistic care plan. Physical examinations, interpretation of diagnostics, prescribing, patient education, care coordination, and communication with other providers are some of the specific tasks I perform daily. I also act as a team resource to troubleshoot complex issues. In regards to working with a team, we utilize a patient-centered approach to care and consider our patient to be part of our team. As a team, we all contribute unique skills, knowledge, and qualities that allow us to identify strategies that can lead to improved outcomes for our patients. We communicate with each other frequently, both in formal meetings and informally by email and phone calls. At our formal case conferences, we review our patient cases and discuss the care plan and patient needs.

Speaker 4: As a clinical nurse navigator, I serve as the team lead, including facilitating the weekly team meetings. Additionally, I help to develop, revise, and communicate interdisciplinary care plans with the team. My role in patient care involves a combination of home visits, office visits, and telephone conversations with the patient for the purpose of education, assessment, and care coordination. My nursing background includes just over three years of intensive care experience and a Bachelor's of Science in Nursing.

Speaker 5: As a medical social worker on a transdisciplinary team, my role is to assist patients in addressing biosocial concerns and barriers that may hinder them from being as healthy as they can or hinder them from focusing on their health care needs. These barriers often include family relationships, finances, housing, transportation, and mental health concerns. My interactions with patients include biopsychosocial assessment, individualized treatment planning, care coordination, discussion of referral to federal, state, county, and city programs, and education. Within the hospital system for which I work, where I've worked for almost five years, all medical social workers must have earned a Master of Social Work degree prior to hire and hold a Licensed Master of Social Work licensure or Licensed Clinical Social Work licensure.

Speaker 6: As a health promoter, community health worker, I'm a frontline public health worker whom establishes trusting relationships with patients to better serve as a liaison link intermediary between health and social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. I'm also certified as a clinical nurse assistant, having worked in an orthotrauma unit for seven years before certifying as a health promoter and community health worker. In this interprofessional team, I help patients understand and incorporate their care plan into their lives, considering social and cultural context. I also help identify barriers to the team that they were unaware of. In my list of duties, I reinforce education, talk to patients with chronic illnesses, assist patients with preparation for important appointments, visit patients in hospital and or patients preferred locations such as home visits or clinical appointments, help locate patients whom have become inactive or are homeless, accompany patients to primary care, specialty and other health community resource appointments, coach patients in order to promote self-care independence, patient advocacy, resource allocation, liaison for patients between medical community and community resources, help identify safety hazards in patients dwelling, and help manage patient source of transportation and or communication.

Speaker 7: I am a registered dietitian, I have a bachelor's degree in nutrition, and I have been a certified diabetic educator for 11 years and have worked in the outpatient setting for the past 16 years. My role as dietitian within the team is slightly different than the other team members in that the dietitian is not specifically designated to one team but instead is designated to three or four different teams. I try to schedule as many of my appointments as home visits because I find that I have a better chance to obtain an accurate picture of the patient's lifestyle and also that I tend to have much better rapport with the patient when I have home visits. The majority of the patients I see are for diabetes, but in addition to that I also have referrals for hypertension, congestive heart failure, high cholesterol, celiac disease, as well as periodic ventral tube feeding. I rely on communication from my team members for accurate information as to why I've received the referral as well as what the patient is wanting out of the referral. I look to my designated advanced practice nurse when I am confronted with a medical condition outside of my scope of care, for example, a patient with a very high blood sugar during the visit. I also periodically make referrals to my other team members when a patient need arises that is also outside of my scope of care. For example, if a patient needs to be accompanied to a specialty appointment.

Speaker 4: Okay, so in our meeting today I think we're going to talk about Mr. John Smith who has had some recent changes.

Speaker 5: So Megan, do you want to speak a little bit more about the changes? Sure. So, as I mentioned, we visited yesterday to his residence at Front Steps. We learned actually when we got there that he is going to be leaving as of tomorrow and this was brand new information to him yesterday as well. So this has been sort of, I think, a little bit calming. He's living with a few other residents and most of them are pretty independent and it seems as though Mr. Smith has been being watched out for by these roommates, which is very sweet but it's not their responsibility. It's not part of what they're supposed to be there. They're supposed to be there for their own services, but it seems as though separately that they're closing the house, so the last of the roommates actually moves out tomorrow as well, so there'll be no one there. And in addition to that, he's been leaving the stove on, so he's unsafe by himself. And he has also, it seems as though his psychiatric symptoms have been presenting themselves. Maybe his medications aren't working at this point, maybe he's not. So that's something that has recently been visited, but he most recently seemed to be having some visual hallucinations and saw something on the wall that was very upsetting to him. So it actually resulted in him going to the emergency department and so this has all been coming to a head. So Leah, I think most of you know her, she runs the recuperative care program through her front steps, so she had a conversation with him yesterday and we happened to be there. And the plan is for him to move in with his mom and stepdad. I think we've spoken before, he has some anxiety around his stepdad. He used to live with them, there's, stepdad uses alcohol and there's been some verbal abuse in the past. So he's got some, he was pretty anxious about it, recognizes that it's the only other option right now. So where I see us coming in is to really step up our involvement with him, provide some wraparound care, and try to fill in where he's been so dependent on Leah and front steps for so long that we really need to step up our involvement and make sure that he gets the care he needs until he gets, well, continuing on past the time that he gets more housing, different housing situation.

Speaker 4: And I can help to find some programs to help get him out of the house, I know that's going to be a focus for him going forward, at least in the interim, hopefully this is just a temporary situation and we can find him something more sustainable long term. I can help with that and one thing that I did hear about recently that I think would be a perfect fit for him is there's a diabetes education class. It sounds like it's on Tuesdays, I think, once a week for a couple hours and if he goes to seven out of the eight classes, he gets a grocery store gift card for about $200. So I think that would be right up his alley in several ways. So, I think, Kristen, I think you're connected with the dietician that runs that program.

Speaker 7: Right, I know the dietician that facilitates that so I can get him in touch with her.

Speaker 4: Okay, yeah, that would be great. I think that would be a good place to start.

Speaker 6: And relating to his housing, I will be seeing him tomorrow because his funding is about to expire, his MAP card. So as I'm there, while we're waiting for his appointment to start, we can start calling around and seeing if there's any housing opportunities for him since we know his current situation has to be temporary, since he's not comfortable being at home.

Speaker 3: Well, Megan, you had mentioned the hallucinations and some memory and mental health issues and I know he's on many meds for many chronic conditions and I'm kind of concerned that, you know, these meds may be causing some issues for him and it sounds like we may not even know exactly if he's on all of those medications and he's got several specialists so they may not even have the most up-to-date medication list. So I'll work to reconcile his medication list and then, Kristencia, maybe we can coordinate so that we can communicate the most accurate medication list to all of his specialists and his primary care doctor. That sounds good.

Speaker 6: That would be a great idea. I mean, usually, since I accompany him to these appointments to make sure that if there are any changes, I also assist in communicating that to all of his providers.

Speaker 2: Is he being stable with his primary care provider?

Speaker 6: Yes, but, you know, just transportation has been an issue, you know, getting him to his appointments. He always complains about foot pain. He doesn't have the best diabetic shoes so I'm going to try to help him coordinate that, but if he loses front steps, they are the ones that also assisted him when he came to his appointments. So that's going to be another issue that we're going to have to kind of figure out, but he does try to make it to his appointments. They never have the updated med list so that's been an issue. So really communicating to the providers is going to be the key here.

Speaker 5: That's something Ana and I can work on together is reaching out to them. I'm going to update, actually, on a couple of those points. He did earlier, last week, I accompanied him to an appointment with his psychiatrist, ATCIC, and so hopefully we can address those psychiatric concerns that seem to be presenting themselves right now. They did, what sort of brought it on was, of course, the emergency room visit, but also, of course, his Cyprexa, it increases blood sugar as one of the side effects. So they've decided to put him back on Haldol. He's been on it for a few days now, but he does have a history of target dyskinesia as a result of that. He's had some hand tremors, so he's a little bit concerned about that, but the psychiatrist and Mr. Smith decided that they would try that at this point. Also, he had, in regard to the memory that you had addressed, the psychiatrist did do a cognitive test on him, the mini mental status exam, and he actually did pretty well on it. On a scale of 30, he got a 25, which is wonderful because it's demonstrating that he's not, you know, having some cognition issues, of course, but I think... Demonstrating it in day-to-day living. Yeah. We had discussed that there's that memory, the gaps in there, that short-term memory is really troubling from our perspective, so we were hoping that if he scored low enough on this exam, that that would suggest that he would be eligible for disability, and then he could, with that associated funding source of Medicare and Medicaid, depending on his work history, that he would be able to go ahead and get some neuropsych testing, but you can't get the neuropsych testing unless you have a funding source, such as Medicaid or Medicare, and that won't pay for it. So it's kind of, hooray for having a high level, high score on your cognition test, but also what's going on with his memory and getting him some good long-term insurance coverage. So I just wanted to update you guys on that.

Speaker 4: And regarding the memory issues, as well, as you guys know, I had been doing weekly home visits with him to help fill his pillbox and make sure his medications are refilled and that kind of thing. So we can try to move those to the hospital, I guess. If he's open to that, I think he will be, to get out of the house. So when I do those, it's obviously really helpful for me that you have those medication lists and then if you guys could help to reconcile the medication list so that I'll know what needs to go in his pillbox, and I'll help him with that. We'll also try to make as many of the refill calls as we can during those visits, but sometimes I know there's still some follow-up that he needs to do afterwards to get some medication.

Speaker 6: So for the most part, because he does like his independence as much as he can have it, so I will occasionally send him a reminder to just call the pharmacy and do the refills. That's great. It helps him.

Speaker 5: And also, he completed his Seating Behavioral Health IOP program with Julie, and Julie had recommended that he, now that he's completed that, that he continue with an outpatient program where he can actually work and get a meal, he can be there a couple days a week. And he's also expressed some interest in doing some Al-Anon classes to deal with the stress of being at home with his dad and the potential alcohol abuse that could continue to happen there. So there'll be other ways for him to get out of the house, it sounds like. Great. He's expressed interest.

Speaker 6: He has. He actually mentioned an Austin Clubhouse, which I was going to try to get information for. So when I do see him tomorrow at his map renewal appointment, I was going to kind of help him do some research and provide whatever I can find. And if you have any ideas, let me know.

Speaker 8: We'll do.

Speaker 5: So, having him see you, I think we should continue to help him brainstorm some options to help him get out of the house.

Speaker 4: Sounds good. I'll definitely do that on my weekly visits. And additionally, obviously the pillboxes and assessing him for the various concerns that we have. We know he has the memory issues and other clinical things going on. So I can help keep an eye on those and check vitals and things like that as well. And speaking of those weekly visits, I wanted to mention to you, Kristen, the last home visit that we had with him, he mentioned that he was having a low blood sugar whenever he was getting off the bus one day. And so he went to the convenience store to buy a Diet Coke and drink that in hopes of remedying his low blood sugar. So between you and I, maybe we can both give him some education on diabetes and hypoglycemia.

Speaker 5: And that kind of thing.

Speaker 7: So you have your pillbox fill on which day? On Tuesdays. I try to do them usually on Tuesdays. Okay. So how about if I go see him on every Thursday? Sure. That sounds great. So we can just kind of reinforce that. The appropriate treatment for low blood sugar.

Speaker 4: With the memory concerns, I think that's probably going to be our plan is to just continue to reinforce things with him.

Speaker 7: Oh, and he mentioned to me that he's concerned with his living with his mother, that his stepfather is not really giving him access to the food in the house. And also I've heard that the food in general there is very high in fat, which is really bad for his gastroparesis and limited stomach motility. So I was thinking I'm going to connect him with Meals on Wheels. They actually have a low fiber pureed option for people with gastroparesis. Oh, that's great. I didn't know that. Yeah. So he'll get a hot meal every day of the week.

Speaker 8: He does have a snack as well. So hopefully he can supplement that as well. Okay. That'll help. Those two working together will hopefully address his concerns.

Speaker 4: And another thing that you and I could work together on, usually when he comes in for his weekly, or when I see him at home, or now it's probably going to be in the hospital, his weekly visit, we reconcile his calendar. I know he has a lot of specialists and appointments and things like that. So that's one thing maybe you and I can both work on is reinforcing that calendar and just making sure that it's updated with every appointment you go to, that the follow-up appointment is listed on his calendar. And I'll help to reinforce that and get that reconciled every time I see him weekly.

Speaker 6: Maybe we can create a Word document that we can all see. Sure. So whoever sees him can take a recent copy of Office of Planned Parenthood. Absolutely.

Speaker 4: Right. And I know he keeps his own calendar as well. So just making sure that that document is updated with his calendar. Sounds good.

Speaker 2: The one last thing, I would like to bring him up to the office and just evaluate his recent ER visit, his recent psychiatry visit, and sort of consolidate everything, make sure that there's nothing that we're doing that's making him worse or causing the hallucinations. He's definitely got polypharmacy as an issue. And in addition to that, he's medically complex, has multiple comorbidities, which could be causing, there could be metabolic things causing his hallucinations. So we definitely want to rule those things out. Yeah.

Speaker 4: And I'll make sure that my next visit with him for pill box and assessment and everything actually happens at the hospital. I think he'll be fine with that. And then that way we can send him to the lab while he's here. Great. Thanks a lot.

Speaker 5: Great. And by then, if he comes in in a week and a half or something, we should be able to, he should be able to tell you how he's feeling about his symptoms if it is in fact psychiatric as opposed to something else.

Speaker 8: Great. Great.

Speaker 5: Okay.

Speaker 8: Thanks. All right. Thanks. Bye.