Interdisciplinary care rises to new level at Honolulu VA

Geriatric specialists show the power of teamwork.

By Scott Sleek
Monitor staff

?Mr. B?* enters the Honolulu veterans clinic and is ushered into a meeting room, where he sits at a table and faces a team of medical doctors, psychologists, nurses and social workers. As part of the intake assessment, the health professionals ask him a variety of questions about his medical condition, emotional or mental state and his social support system.

When the meeting is over, the providers understand not only his medical problem, but also his mental condition?and how that may contribute to his physical ailments. The providers then sit down as a team and design a treatment plan that addresses Mr. B?s psychological, social and medical problems.

The health professionals make up the Geriatric Evaluation Management (GEM) team at the Veterans Affairs Medical and Regional Office Center (VAMROC) in Honolulu. The team members say they?re trying to take interdisciplinary health care to a new level. Since many patients have complex, interwoven problems, they should receive a well-round-ed treatment from a closely fused group of providers, says Cole Lew, PhD, a GEM team member.

One fell swoop

One of the unique aspects of the GEM model is the interdisciplinary nature of the assessment phase. The patient?s condition and needs are ascertained in a single, comprehensive intake interview, Lew explains.

?We?ll interview and assess the patient together, then collaborate on a treatment plan,? Lew says. ?This keeps the treatment from becoming fragmented.?

Such an approach also spurs more accuracy and precision in the diagnoses and treatment, he notes. ?If a patient and his or her family are seeing different professionals at different times and places, they have to tell their story over and over again,? he says. ?And that usually means no one is getting the full story. The patient will get tired of telling it and start leaving out important details. So we do the interview all together. And someone is always thinking of important questions for the patient that the rest of us would not have thought to ask.?

The multidisciplinary teamwork is especially important when treating veterans, the team members say. Hawaii is home to a large number of elderly World War II and Korean War veterans. Many of them struggle with aging-related health setbacks, such as arthritis or osteoporosis. Others become incapacitated from strokes, heart attacks or serious injuries. And some are caring for ailing spouses, a stressor that can easily lead to depression, anxiety and other psychological disorders that compound the medical problems.

The GEM team not only recognizes the complexity of many veterans? problems, but also involves the patients? families in the treatment process, Lew says. Family members often need help from a psychologist or social worker to understand their loved one?s problem.

An example of the GEM team approach is the case of ?Mr. I*?. The veteran came to VAMROC after his release from the hospital following a failed suicide attempt. A year earlier, Mr. I, 79, had suffered a stroke that left him partially paralyzed. Because he could no longer care for his wife, who suffered from Alzheimer?s disease, his daughter took a leave of absence from her job to care for them both. Depressed and wanting to relieve his family of the burden of his care, he decided to kill both his wife and himself. He couldn?t follow through with taking his wife?s life, but he shot himself. After doctors saved his life in emergency surgery, he remained severely depressed. He came to VAMROC for follow-up outpatient care.

?Indeed, he?s got medical problems?the paralysis from the stroke and the injury from the shooting,? says Patricia Blanchette, MD, a geriatrician. ?But if we deal with that exclusively, we?re not dealing with the major problem. He was acutely depressed, so we gave him skilled psychiatric care. He suffered from low self-esteem, and his family feels guilty and sad over what happened to him. So a psychologist needed to be involved. And a social worker came in to help work with the family dynamics.?

The team eventually helped Mr. I become more comfortable accepting help from others?which helped lift him from his depression without using expensive inpatient resources, Lew says.

For patients, the treatment model provides the luxury of ?one-stop shopping?: They can see all their doctors at one site, on one visit, rather than traveling to various offices to see different specialists, notes David Bernstein, MD, director of mental health and geriatric psychiatry at VAMROC.

The GEM team?s egalitarian nature is also a unique feature of the model, Blanchette says. She refers to the approach as a patient-centered model, with the various health disciplines revolving around the patient?s needs.

?We don?t really have an official team leader,? she explains. ?The level of involvement for the various professionals depends on what the patient needs. Sometimes they need more from a social worker, other times from psychiatry or medical [personnel].?

?So for this to work, you have to get away from deciding who?s the boss.?

* Editors note: ?Mr. B? and ?Mr. I? are pseudonyms for VAMROC patients who agreed to be mentioned in this article.