Dementia care in nursing homes represents care for very frail and disabled residents, suffering from complex problems in various domains, including the physical, psychological and social domain. These problems require an integrated approach, not primarily targeting the disease but focusing on the resident as a human being with a disease and also supporting the family and other informal caregivers (Boyd et al. 2005, Schols et al. 2004). Ideally, this approach gets stature through a coherent and coordinated care supply, which is provided by multiple disciplines within a healthcare facility and/or in alignment with disciplines of other healthcare organizations. To enable an integrated approach, multidisciplinary teamwork is necessary. Offering care from a multidisciplinary approach puts challenges on the organization of care, more specifically on the share each healthcare professional gets in the care process, on the related mutual agreements between different healthcare professionals and on their mutual communication. In the eyes of the residents and their family caregivers, integrated care actually is taken for granted (Institute of Medicine 2001). They do find it most normal that healthcare professionals, who are involved in the care of a particular resident, know each other’s activities, so as to ensure that the care will be offered coherently. In short, in their eyes, this should simply be standard care (Huyse et al. 2010). Nevertheless, daily care practice is often still unbendable, and in many cases care provision occurs rather fragmented, both in and outside healthcare institutions.

In this chapter the following issues will be addressed:

A multidisciplinary approach in fact is relevant for many issues and problems that occur in the nursing home setting and that are discussed in this book. Therefore, this chapter has a more general and descriptive character.

Nursing home residents with dementia are mostly old to very old persons, who seldom suffer from dementia alone. Often they show a complex geriatric profile consisting of considerable comorbidities, disabilities, handicaps and polypharmacy and also challenging care problems such as malnutrition, falls, pressure ulcers, incontinence, use of restraints and not to forget behavioural problems ranging from apathy towards agitation and/or aggression.

Such a profile is challenging to cope with in the traditional healthcare model which is mainly single disease oriented and based on disease-specific guidelines, coming forward from the strongly promoted evidence-based approach that is based upon the paradigm of the randomized controlled trial. In fact, this approach causes fragmentation of care because it asks for homogeneous patient groups and not for multimorbid heterogeneous ones (Boyd et al. 2005).

Nursing home residents suffering from dementia are already far beyond this single disease status. Their complex polyvalent problems require multifaceted activities of multiple care providers and professionals (Hertogh et al. 1996, von Korff et al. 2009). These activities do start already before their admission to the nursing home and have to be aligned directly with the preferences of the person with dementia and his or her family caregivers who also are involved from the beginning of the dementia process. This complex care process puts demands on the collaboration, communication, coordination and continuity of care inside and outside the nursing home and of course in the transitional phase as well; not to forget the difficult cure – care decisions that often have to be made during their total care trajectory (Goodman et al. 2016).

Residents with dementia therefore represent complex patients. Offering tailored care to them in both the home situation and the nursing home, during their total ‘patient journey’, has become increasingly difficult during the years, as healthcare systems of many countries have become rather fragmented and highly differentiated. These difficulties are also experienced by the family caregivers and professional caregivers.

In most countries, nursing home care is basically offered by employed nurses and welfare workers and additionally by regularly or on demand visiting physicians (mostly general practitioners) and paramedical professionals, including physiotherapists, occupational therapists, speech therapists and dieticians. In some countries, including the Netherlands, physicians and paramedical professionals are employed by the nursing home organization itself (Schols et al. 2004). In nursing homes of most Western countries, it is nowadays rather standard to make an integrated care plan for (= together with) every resident and his or her primary family caregivers. This care plan is made after assessing the relevant biopsychosocial factors of the resident and consists of tailored nursing, treatment and welfare activities that have to be executed in a collaborative, multidisciplinary model by different disciplines, of which the outcome and follow-up are monitored regularly (Smith and Clarke 2006). The quality of care related to this institutional care model is not only dependent on the quality of the individual professionals but also on both the effectiveness and embedding of the ‘multidisciplinary care model’ itself. Effectiveness refers to adequate planning of the care and welfare processes and the way these processes are supported by adequate communication and shared decision-making within the team and with the resident and his or her family. Effectiveness also refers to the overall governance of the care processes. Embedding means that the care model must be embedded in an appropriate living environment. Nowadays, most nursing homes want to offer their residents with dementia a rather homelike environment to live in, to enable the residents to live their lives as much as they were used to (Huyse et al. 2010).

This section describes some relevant theoretical aspects of multidisciplinary care provision without aiming to be complete.

Multidisciplinary collaboration is not a new phenomenon in healthcare. In various settings, including nursing homes, collaboration between, for instance, physicians and nurses exists already for a very long time. However, in the past this collaboration was mainly based on hierarchy and differences in power (Fewster-Thuent and Velsor-Friedrich 2008). Throughout the years, one has been looking for new, more egalitarian forms of multidisciplinary collaboration. In these efforts, the main problems of multidisciplinary collaboration involve problems in the relation between disciplines (and persons!), the preservation of professional autonomy and the relation with the own professional background, the different discipline-related languages and jargons and also the issue of team leadership. Moreover, in larger healthcare organizations, different multidisciplinary teams within an organization may sometimes develop towards too autonomous functioning and getting ‘lost’ from the total organization. What remains, however, is the consensus that a multidisciplinary approach is to prefer above a monodisciplinary one for residents with complex problems, meaning problems that show a component complexity, a coordinative complexity and an ambiguity (Stoffels 2008, Jonge et al. 2006, Huyse et al. 2006). Component complexity means that more than one medical or nursing or psychosocial domain is involved. Coordinative complexity involves that there is also a dynamic interaction between these domains and that intervention on one domain can interfere with problems in other domains. Ambiguity (for instance, in ethical dilemmas) means that insufficient or inconsistent evidence-based information is available and that consensus and therefore adequate and rather intense communication are needed to achieve the best possible solution for daily practice. Offering tailored care to residents with such complex problems ultimately is the main goal and common interest of a collaborative approach, which has to lead to a win-win situation for the residents and the professionals (Firth-Gozens 1998).