Chapter 9

Education of the interdisciplinary team

Emma Barker, Patricia J. Volland, and Mary E. Wright

Introduction

As the nation’s population continues to age at a rapid pace, multiple public and private initiatives are targeting geriatric care by focusing on the education and training of the health care workforce. Many of the educational programs designed to enhance geriatric training for the different health professions use competency-based and interdisciplinary approaches to prepare future clinicians (Mezey et al. 2008; Harahan et al. 2009; The American Geriatrics Society 2010). By their nature, these educational efforts are meant to reach providers prior to their entry into the “real world” of the health care system and equip these newly minted health care professionals with a grounding in geriatric principles of care and the abilities to function effectively in a team environment. On another front, in the “trenches” of the health care, new models of care coordination are continually being developed and implemented in an effort to overcome the fragmentation and poor quality of care resulting from a system that is currently ill-equipped to serve the chronic care needs of older adults (The New York Academy of Medicine 2008). As efforts to reform the health care system are set in motion, education and training initiatives can and should complement the development of new models of care, because any meaningful progress will not be possible unless these new models are staffed with professionals who have both the training and the spirit of cooperation that fundamental change requires.

The importance of pursuing efforts on both fronts is reflected in the Institute of Medicine’s (IOM) seminal report “Retooling for an Aging America,” which calls for the enhancement of competence of all members of the health care workforce through changes to educational curricula and training programs, as well as the redesign of models of care to address health care needs both comprehensively and efficiently (IOM 2008). This report underlines that simply expanding the capacity of the current system would be insufficient to meet the needs of older adults; instead health care professionals must be trained to provide care more efficiently, with an associated improvement to quality, by putting their skills to work within a more intelligent, rational approach to care. Ultimately, improving care for older adults through educational programs and care coordination initiatives are the same: bringing together multiple providers through interdisciplinary collaboration, establishing and implementing geriatric competencies, and integrating medical and long-term care needs.

If educating future professionals in geriatric care and implementing new models of care are necessary steps in responding to the needs of a growing population of older adults with multiple chronic conditions and long-term care needs, then it is also necessary to have a care coordinator to bring all the moving parts together within the care coordination framework. The latter means identifying a specific individual to fulfill the care coordination function, or for the team itself to have designated roles that allow for a genuinely collaborative approach to the development and execution of an ongoing care plan. As care coordination continues its path toward fuller implementation within the context of health care reform, developing a more concrete and detailed understanding of the function of care coordinators themselves, as well as their training and qualifications, will further the goal of attaining quality care.

The aim of this chapter is to provide an overview of the current state of competency-based and interdisciplinary training for the health care professions and its role in the evolution of geriatric care, how these educational movements relate to emerging and established models of care coordination, and the steps currently being taken to develop training and qualification standards for care coordinators. We will also outline what is meant by comprehensive care coordination, which takes into account the broad array of services that may be required by the older adult in addition to medical care, such as long-term care needs, mental health needs, and community-based services. Finally, we will present recommendations on how to best move these initiatives ahead, with a specific focus on the role of the care coordinator and issues pertaining to training, competencies, and licensing or credentialing.

Care coordination, as well as the role of care coordinator, is still coming into its own as a model of care and a professional designation. To date, models of care coordination have come in many shapes and sizes, as they have developed in response to the needs of specific populations in particular settings. In order to single out the most successful programs, experts in the field continue to evaluate the achievements of different models based on clearly defined objectives (Boult et al. 2009; Brown 2009). Establishing an evidence base for care coordination helps to identify best practices and find common ground among discrete approaches, while determining which professionals have the basic expertise for performing this role and how they should be further trained. As programs are evaluated and the commonalities are identified, it is anticipated that more clarity will be achieved over time. This will take a concerted effort, but as with the development of any profession or system, it is certainly achievable.

Competency-based educational initiatives and interdisciplinary training

By definition, comprehensive care coordination, which seeks to integrate a full array of health, social support and long-term care services for older adults, requires the involvement of a host of “players,” including doctors, dentists, pharmacists, social workers, therapists, direct care workers, caregivers, and, of course, the older adult being cared for. Comprehensive care coordination may be defined as a “client-centered, assessment-based, interdisciplinary approach to integrating health care and psychosocial support services in which a care coordinator develops and implements a comprehensive care plan that addresses the client’s needs, strengths, and goals” (National Association of Social Workers 2009). These services are provided by individuals with different levels of training, varying degrees of geriatric competency, and across multiple settings. Given the fiefdoms of different areas of practice, the historical separation of hospital-based acute care from long-term care, and the overall fragmentation of medical care, genuine collaboration can be difficult to achieve (Leipzig et al. 2002; Reuben et al. 2004). Nevertheless, competency-based training in geriatrics can assist with both the recognition of core competencies across professions and an interdisciplinary approach to providing quality care.

Competencies are measurable professional behaviors composed of knowledge, values, and skills that can be integrated into practice (Council on Social Work Education 2008). Educational models based in competencies that are defined by evidence-based practice with measurable outcomes have been developed by numerous professional organizations. The disciplines of nursing and social work have been particularly active in establishing competencies and guidelines for educational programs (Damron-Rodriguez 2008). Overall, a survey of the literature shows that over the last decade there has been a significant expansion of geriatric competency development in a discipline specific manner for almost all of the professions involved in providing care to older adults.

While it is not our intention to provide a comprehensive analysis of all competency-based training initiatives here, some are worth singling out as representative of the general trend toward reaching consensus on the core elements of knowledge and skills defined as competencies. One of the most recent developments in this area has been the development of a set of competencies for medical school residents that resulted from a systematic, multi-method process to identify and define the minimum geriatrics-specific competencies needed by a new intern to adequately care for older adults (Leipzig et al. 2009).

These competencies were finalized during 2007, and part of this process took place at the July 2007 Association of American Medical Colleges (AAMC)/John A. Hartford Foundation (JAHF) Consensus Conference on Competencies in Geriatric Education. The final competencies span across eight domains and are 26 in total, with each domain identifying observable behaviors that medical students must demonstrate to prove competency in the area of geriatric care. The organizers of this project were able to obtain the participation of 450 experts in geriatric medicine, 44% of U.S. medical schools, and several major medical education organizations (Eleazer & Brummel-Smith 2009). Some of this response may stem from the recognition that the woeful lack of geriatric specialization across professions may require the integration of geriatric competencies into academic curricula for all comers, specialists or generalists.

At an earlier point in time, leaders in the field of social work engaged in an iterative process comparable to that described for medical residents, with the development of competencies for both specialists in aging at the graduate level and generalists at the baccalaureate level. The Council on Social Work Education (CSWE) Strengthening Aging in Social Work Education (SAGE-SW), the Geriatric Enrichment in Social Work Education (GeroRich) Project, the Social Work Leadership Institute and the CSWE National Center for Gerontological Social Work Education (Gero-Ed Center) were all engaged at different points in time in the development of these geriatric competencies (Hooyman 2009). The CSWE curriculum development projects worked to embed gerontological competencies in the foundation curriculum and overall organizational structure of social work programs, where competencies are stated as educational outcomes for students completing required coursework. The Social Work Leadership Institute, through its Hartford Partnership Program in Aging (HPPAE), focused on tailoring competency-based education to prepare MSW students to become specialists in aging, using a rotational model of field education integrated with advanced classroom learning.

Nursing has been singled out as one of the most important professions in geriatric competency development, and as with other fields, a number of organizations have played a role in this process. Of particular note has been the work of the American Association of Colleges of Nursing (AACN) with the Hartford Foundation Institute for Geriatric Nursing to develop competencies as stated in “Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for Geriatric Nursing Care” (AACN 2000). These 30 competencies and curricular guidelines are designed to help educators incorporate geriatric content into nursing programs, and have provided a foundation for further efforts to develop competencies for further initiatives, among these the AACN and Hartford Foundation initiative to develop national, consensus-based competencies for advanced practice nurses. Many other professions have followed suit to develop geriatric competencies, as seen with the medical school community most recently. A more comprehensive treatment of this subject can be found in “Examining Competencies for the Long-Term Care Workforce: A Status Report and Next Steps” (Harahan et al. 2009).

The development of geriatric competencies has been accompanied by the continued interest in the contributions of interdisciplinary teams that provide quality geriatric care. The benefits of interdisciplinary practice have been recognized and recommended by a number of leading organizations that set standards for the provision of health care services. The Health Resources and Services Administration (HRSA) recommended that competencies for interdisciplinary health care teams cover the areas such as the ability to share knowledge and decision making that transcend individual professional methods and provide client-centered and/or community-based health care needs (U.S. Department of Health and Human Services 2005). The IOM echoed this call for competencies noting that interdisciplinary team training requires competencies founded in evidence-based practice with measurable outcomes and a process of evaluation (IOM 2008), and the American Geriatrics Society has issued a position statement on the importance of interdisciplinary care (American Geriatrics Society 2006).

A comparative study of the competencies developed by five health care professions that include dentistry, medicine, advance practice nursing, social work and pharmacy has documented a high degree of similarity across these competencies (Mezey et al. 2008). This study further found that certain competencies were essential to interdisciplinary team work, for example comprehensive assessment, measurable objectives, and communication and collaboration. As such, interdisciplinary collaboration is a lynchpin in the ability of a team to coordinate care, since key elements for the success of an interdisciplinary approach are having a shared purpose and goals, clear roles and responsibilities, coordination of activity, and trust. Not surprising, the competencies developed by individual professions vary in balancing competencies with an interdisciplinary focus versus discipline specific knowledge and skills. At present, none of these competencies explicitly states coordination of care, although many of its elements are included, such as assessment, development and implementation of a care plan, and interdisciplinary collaboration.

With the release in 2010 of a report entitled Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Entry-level Health Professional Degree, the Partnership for Health in Aging (PHA) identified “care planning and coordination across the care spectrum” as one of the six competency domains that are relevant to ten different health care disciplines (The American Geriatrics Society 2010). This paper also identifies a domain for “interdisciplinary and team care,” or competencies required for collaboration and consultation among health care professionals providing services for the older adult population. Through an iterative process looking at the competencies in the professions of dentistry, medicine, nursing, nutrition, occupational therapy, pharmacy, physical therapy, physician assistants, psychology, and social work, core competencies were defined and endorsed by 28 national organizations. PHA describes the essential skills and approaches these professions should master in order to provide quality care for older adults. The PHA statement of competencies received backing from organizations representing nurses, pharmacists, social workers, occupational therapists, psychiatrists, physicians, physical therapists, national geriatric organizations, and others.

In addition to competency-based training, the movement toward trained interdisciplinary teams providing care coordination for vulnerable populations of older adults has gained momentum and reaches back to initiatives pioneered in the 1970s by the Department of Veteran Affairs (VA). At that time the VA established an educational interdisciplinary team training model for staff and trainees; the Interdisciplinary Team Training Program in Geriatrics (ITTG). In addition the VA funds the Geriatric Research, Education, and Clinical Centers (GRECC) a team-based educational program including social work, nursing, pharmacy, and audiology. The geriatric focused programs (such as the Geriatric Education Centers (GEC), the Geriatric Training Program for Physicians, Dentists, and Behavioral/Mental Health Professions, and the Geriatric Academic Career Award [GACA]), train health care professionals from multiple disciplines. GECs are currently in over 48 states training health care professionals and students in hospitals and university settings from over 35 disciplines.

With funding from the JAHF the Geriatric Interdisciplinary Team Training Program (GITT) has fostered collaboration among medical residents, advanced-practice nursing students, and master’s students in social work. The goals of GITT included teaching trainees respect for other disciplines and imparting the skills to work effectively with other health professionals in providing interdisciplinary team care (Reuben 2004). GITT was a substantial program financing eight projects over three years; each program took the form of a partnership between an academic setting and at least one clinical agency (Fulmer et al. 2005).

Competencies for care coordinators

Limited information was found from a literature search performed to identify competencies for care coordinators working with the older adult population. However, in work performed for the New York State (NYS) Department of Health in the 2008, The Social Work Leadership Institute prepared a report entitled “Who is Qualified to Coordinate Care,” which identified the knowledge, skills, and attitudes/values needed to perform the essential functions of a care coordinator (The New York Academy of Medicine 2009). In order to distill this information, research was compiled from three major sources: (1) research and analysis of state programs, (2) research and analysis of nationally recognized guidelines, and (3) New York stakeholder perspectives. The methodological approach included information collated from focus groups and stakeholder discussions, surveys of New York State (NYS) care coordination programs, an analysis of the suggested qualifications delineated by national and state programs, and guidelines from prominent national organizations.

Table 9.1 Recommendations for Essential Functions of a Care Coordinator

As defined by The Social Work Leadership Institute, the essential functions of the care coordinator include seven domains: (1) develop and maintain relationships; (2) train and educate patients, families, and medical and social service providers; (3) goal setting; (4) care planning; (5) coordination of services; (6) ensure cost effectiveness while maintaining quality; and (7) ongoing quality improvement (see Table 9.1). These domains were presented to the NYS Department of Health as recommendations and represent a first step toward delineating the qualifications that might be expected of and individual functioning within an interdisciplinary team of health and social service professionals. This work may provide a starting point for a the development of competencies for care coordinators focused on the older adult population, if organizations representing care coordinators, case managers, and care managers come together to perform a consensus building process as has been seen for nurses, social workers, doctors and others.

Care coordinator qualifications

Care coordination for vulnerable older adults, sometimes referred to as geriatric care management, has evolved as an area of practice within several professions, including social work, nursing, and counseling. There are several types of degrees and licensure within these professions which a geriatric care manager may hold. In social work the most commonly held degrees are LCSW, MSW, and BSW; whereas in nursing the most common are BSN, MSN, and APN. A 2002 AARP survey of members of the National Association of Geriatric Care Managers indicates that more than two-thirds of geriatric care managers are licensed professionals, approximately one-third hold a social work license, and another one-third hold a license in nursing (Stone 2002). In addition, many practitioners also have experience in family work, client advocacy, long-term care and/or psychotherapy. Making the transition from social work or nursing to geriatric care management can be a logical step, particularly if the individual has a background in case management. Many of the credentials offered to geriatric care managers, while they do not always require licensing in another professional domain, in general certainly encourage this.

The practice of care coordination (again, often interchangeably referred to as care or case management) has taken a self-managed approach to regulation that currently substitutes for formal, legal regulation on the state or national level. Through the efforts of voluntary associations that represent geriatric care managers/care coordinators, action has been taken to define and uphold standards of practice, ensure the competency and training of the professionals who practice it through credentialing programs, and enhance consumer protection. However, as noted above, there has not as yet been a movement to identify a set of specific geriatric competencies for this emerging area of practice. Perhaps this is an idea whose time has come, given the increased prevalence of care coordination models as a paradigm of health care delivery for older adults and the increasing number of individuals assigned the role of care coordinator within the context of an interdisciplinary team.

To date, self-regulation has developed in the form of credentialing, which technically is an umbrella term used for licensure, certification, and accreditation, although in the case of geriatric care management it is often used interchangeably with certification. Certification, as part of the self-regulatory process, is distinguishable from licensing, which is typically granted at the state level and provides the state with the legal authority to control various aspects of the practice of a given profession (Rops 2002). Geriatric care management is an unusual case in that it is evolving as a stand-alone area of practice, and yet many who perform this role are already licensed in other professions, primarily social work and nursing. While there is often some degree of indirect oversight via the care manager’s primary licensed profession, this does not extend to all practitioners of GCM (Morano & Morano 2006).

In light of the lack of clarity and uniformity surrounding care coordinator qualifications the report prepared for the NYS Department of Health by The Social Work Leadership Institute provided an analysis and recommendations on care coordinator certification, work experience, and continuing education issues, using the research methodology described above to analyze state programs and national guidelines.

Certification and licensure

In 2006, the National Association of Professional Geriatric Care Managers designated four approved certifications for geriatric care managers: Care Manager Certified, offered by the National Academy of Certified Care Managers; Certified Case Manager, offered by the Commission for Case Manager Certification; and Certified Social Worker Case Manager and Certified Advanced Social Worker in Case Management, both offered by the National Association of Social Workers. These programs for certification demonstrate a national movement to professionalize case managers/care coordinators and foster a commitment to work toward uniform standards of eligibility, training, and standards of care coordination/case management practice.

Just over one-third of the care coordination/case management programs researched required certification; of those, most tied this certification to a state-sponsored training program. Of those requiring certification, about half required case managers to pass an exam. Only one program required that professional licensure be maintained (for example, social work) while the person serves in the role of care coordinator. At this time, none of the programs researched required a nationally recognized certification from one of the entities named above.

Work experience

Experience in the field and the community is an important determinant of high-quality care coordination. Many assert that success in care coordination is often based on knowledge, networking, and relationships within the community, all of which take time to build. However, a strict requirement for extensive experience can be a deterrent to filling positions for care coordinators. This problem may be met by embracing a certain amount of flexibility in terms of educational and experience requirements, where strength in one area may compensate for weakness in the other. Experience is always measured in years; and is almost always tied to an educational degree. The eligibility requirements for each of the four accepted certifications by the National Association of Professional Geriatric Case Managers referenced above is instructive in this regard: in general where the candidate for certification has a more general degree at a bachelor’s or associate’s level, more direct experience is required in terms of supervised experience or working with persons with chronic disabilities.

In-service training and continuing education requirements

An analysis across states showed that pre-service (orientation) and in-service training are both very common practices in state-based care coordination programs. Most programs established set guidelines related to the number of in-service training hours required and the timeframes in which training should occur. Of the programs surveyed, six hours of in-service training per year was the lowest common denominator for ongoing training; at the other end, one program requires eight days of pre-service training with 20 hours of additional in-service training (over a two-year period). It was not uncommon for states to establish guidelines related to the content areas of the training.

It is clear that there is currently no uniform approach to designating care coordinator qualifications and training. However, certain trends have emerged, such as the widespread employment of nurses and social workers as care coordinators, and it has been possible by analyzing different models of care coordination – especially where the evidence supports their efficacy – to determine some of the essential tasks performed by the care coordinator and what knowledge and skills are required to facilitate integrated care across services and settings. The existing situation, namely the practice of self-regulation, the multiplicity of credentials currently offered, different education/training options and the high number of practitioners already licensed in another professional domain, raises important questions regarding the best approach to regulation of this emerging discipline in the future. The larger issues that frame this subject will continue to be the need for consumer protection, universal standards of care, scope of practice, and legislative and regulatory measures that have the potential to impact who can and will provide these services in the future.

Conclusion

Currently our health care system is dominated by a fee-for- service structure that runs contrary to the goal of providing quality care that is integrated across services and settings. The educational initiatives that provide geriatric training based in interdisciplinary, competency-based approaches are needed to equip health and social service professionals with the skills to serve an aging population, but these initiatives will not take root unless there is fundamental reform to the way care is delivered. To date, care coordination programs have been developed and implemented in an episodic fashion, with no significant overhaul of reimbursement structures that support the delivery of acute care services rather than the coordinated treatment of chronic illness. The moderate growth of care coordination initiatives that serve older adults, many of which are targeted toward dual-eligibles, has been primarily achieved through demonstrations and state waiver programs, while the problem of bringing these types of programs to a meaningful scale has yet to be addressed.

The passage of health care reform contains measures that support both workforce development and care coordination initiatives to better serve the needs of an aging population (Patient Protection and Affordable Care Act 2010). Whether these measures will be sufficient to significantly alter our current system remains to be seen, although these measures represent a step in the right direction, for both workforce preparation and the delivery of care to older adults. In order to overcome the fragmentation of care created by gaps in service and poor communication among providers, the ultimate goal will be to have both specialists and generalists from all health and social service disciplines properly trained in geriatric care and the basic precepts of care coordination, with interdisciplinary models of care in place that will support these objectives.

Competency-based training has an important role to play in efforts to improve geriatric care, and it is interesting to note the extent to which geriatric-specific competency development has blossomed over the last decade. The competencies that are focused on interdisciplinary approaches to care are the most closely related to care coordination, while the competencies developed by the Partnership for Health in Aging are the first to explicitly single out coordination across the care spectrum as a competency domain. For those professionals who currently function as care coordinators, there has not yet been a collaborative effort to define the relevant competencies, although there are a number of certification and training programs that have added both legitimacy and an educational/ training basis for this role.

The time may be ripe for the development of a set of competencies for individuals or teams who are designated to fulfill the care coordination role. To our knowledge the Social Work Leadership Institute’s comprehensive analysis of the skills, knowledge, and attitudes/values of the care coordinator is the first of its type, although as noted there are a number of national certification programs for geriatric care managers. This work could potentially provide a starting point to bring certification and credentialing organizations together in order to identify care coordination competencies and incorporate these at the foundation of their certification programs, as well as continuing education initiatives. The certification process has helped bring an increased number of licensed professionals from areas such as social work and nursing into the care coordination arena. This process has also played an essential role in the education and training of competent, qualified geriatric care coordinators and should continue to evolve toward consumer protection, universal standards of care, and a well-defined scope of practice based in knowledge and skills that are identified as core competencies.

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