May 142014

The MediCaring team of healthcare providers must reflect and address the array of medical and social services frail elders need. However one labels the team– multidisciplinary, interdisciplinary or trans-disciplinary—its key focus must be to deliver an integrative approach based on a care plan developed in collaboration and with the elder and her family. Such a team is best equipped to manage the long-term needs that evolve as elders shift across settings and functional status.

The Care team can build upon one another’s expertise to achieve the common, shared goals articulated through a shared decision-making process driven by the elder in the development of the care plan. This approach operationalizes a basic tenet of MediCaring: that each frail elder should have reliable, comprehensive, and continuous medical and supportive services. Such a strategy builds on an ongoing, personal relationship with a primary care provider skilled in geriatric care. The entire structure builds on trust that is established between clinicians and elders, and extends to the entire team of caregivers, from home health aides to occupational therapists to volunteers.

Such a team—which functions well and operates in concert–can then provide the range of skills and services frail elders require, and offer these clients a reliable point of contact and entry to the system. In developing strong, trusting personal relationships among key team members, the elder and the family/friend caregivers, the structure offers the potential for enduring and effective care.

Core tem members should include, at the very least, a physician/nurse practitioner, nurse and social worker. Other direct providers such as physical therapists, respiratory therapists, speech pathologists, physician specialists, nutritionists, pharmacists, dentists, home health aides, lawyers, clergy and others can be included on the team as needed. Depending on the elder’s specific need, any member of this core team can respond to the elder’s needs for care, and coordinate treatment and services.

MediCaring builds on and ensures primary care for elders whose needs are complex and challenging. Such care is not the primary care we hear about in discourse that has become so common: a physician who provides routine prevention and screening, offers education about chronic disease self-care, and coordinates services by specialists. Rather, MediCaring is primary care on steroids – necessitating a high-functioning team that can deal with very complicated puzzles of needs and responses.

Core team members would hold biweekly meetings to discuss elders in their care, and review and update plans of care. Care would be delivered accordingly. During each visit with an elder, the visiting provider would conduct a medication review and pain and symptom assessment, as well as to assure that the full range of biopsychosocial needs specified in the care plan were being met.

MediCaring uses geriatric principles and palliative care standards and approaches, but is not limited to the medical aspects of service to the frail elderly population. Indeed, a major part of the endeavor is to shift resources from wasteful and unnecessary medical care toward greatly needed social supports that are mostly provided outside of the medical profession, and even outside of the nursing profession. MediCaring Community teams aim to be all-inclusive in order to meet the unique care needs of frail elders.

key words: Joanne Lynn, Janice Lynch Schuster, Judy Peres, MediCaring book, interdisiplinary team, multidisciplinary team