GERIATRIC HEALTH
CARE TEAM
Prepared by
Level IV Team
OBJECTIVES:
At the end of the lecture, the students will be able to:
A. Identify the specific roles and responsibilities of each member in the
geriatric healthcare team, such as the geriatrician, nurse, occupational
therapist, and case manager.
B. Implement care strategies that integrate recommendations from
multiple team members, ensuring a comprehensive approach to meet
the physical, emotional, and social needs of elderly patients.
C. Demonstrate a collaborative attitude by actively listening to and
respecting the input of various team members involved in elderly
patient care.
D. Value the importance of teamwork by recognizing each team member’s
role and unique contribution to the holistic care of elderly patients.
Geriatric Health Care Team and
Collaboration
•a multidisciplinary group of professionals
dedicated to providing holistic and coordinated
care for elderly patients.
• Collaboration among these team members is
essential for delivering high-quality, comprehensive
care that addresses the diverse physical,
emotional, and social needs of older adults.
Roles and Responsibilities in the Geriatric
Health Care Team
A. Gerontologist/Geriatrician
Role: Collaboration:
1. Gerontologists focus on Geriatricians
the social, psychological, -provide medical oversight and
and biological aspects of consult with other team members
aging to design individualized
treatment plans
2. Geriatricians are medical
- They also coordinate with case
doctors specializing in
managers to monitor medication
diagnosing, treating, and interactions, chronic disease
preventing diseases in older management, and acute issues
adults. specific to elderly patients.
B. Nurse Gerontologists
Role: Collaboration:
- specialize in elder -communicate changes in
care, focusing on the patient’s condition to
assessments, the geriatrician and other
monitoring, and team members, ensuring
patient education that care plans are
- play a critical role in adjusted as needed
- educate the family and
daily care and assist
support caregivers in
with patient needs
implementing day-to-day
aspects of care
C. Occupational Therapists (OT)
Role: Collaboration:
- help elderly patients -collaborate closely with
improve or maintain physical therapists and
their ability to perform gerontologists to create
adaptable environments and
activities of daily recommend modifications or
living (ADLs) and work assistive devices
on enhancing motor - provide essential input to case
skills, cognitive managers and nurses about the
functions, and safety patient’s ability to perform
tasks independently, aiding in
discharge planning and home
safety evaluations
D. Physical Therapists (PT)
Role: Collaboration:
- focus on improving - coordinate with occupational
elderly patients’ therapists to ensure a
strength, mobility, comprehensive rehabilitation
balance, and pain approach
management to help - working with nurse
prevent falls and gerontologists to identify potential
increase physical risks
independence - contribute to team discussions on
a patient’s physical progress, which
informs care planning and
adjustments in mobility support
E. Speech Therapists
Role: Collaboration:
- assist elderly - coordinate with nurses,
patients with speech, geriatricians, and dietitians to
language, ensure nutritional safety,
swallowing, and especially for patients with
cognitive issues, swallowing difficulties
which are common - They work with the OT and PT
due to age-related
on functional communication
conditions like stroke
and cognitive exercises,
or dementia
providing updates on
improvements or challenges
F. Case Managers
Role: Collaboration:
- oversee the coordination - play a central role in
of healthcare services, organizing team meetings,
discharge planning, and coordinating care, and
the implementation of ensuring continuity between
care plans for elderly inpatient and outpatient
patients services
- serve as the link - provide critical updates to
between the healthcare the family, explaining the
team and the patient’s patient’s needs and available
family resources
G. Family/Significant Others
Role: Collaboration:
- act as primary - participate in care discussions,
caregivers, offering provide insights into the
emotional and physical patient’s preferences, and are
instrumental in implementing
support for the elderly
care plans at home
- receive guidance and training
from team members, such as
nurse gerontologists and
occupational therapists, on
effective caregiving strategies
H. Nursing and Interdisciplinary Care Conference Team
Role: Collaboration:
- consists of - holds structured meetings
representatives from where they collaboratively
various disciplines within assess, adjust, and refine care
the healthcare team who plans based on updates from
meet regularly to review each discipline. These
the elderly patient’s meetings enhance
progress, discuss care communication, reduce
plans, and resolve redundancy, and promote
challenges comprehensive, unified care
for elderly patients
Collaboration Mechanisms Among Team
Members
[Link] Team Meetings
[Link] Health Records (EHR)
[Link] Care Plans
[Link] Involvement
[Link]-Up and Case
Management
[Link] Team Meetings
-holds routine meetings to discuss patient
progress, challenges, and goals. This open
forum allows all disciplines to provide
input, ensuring comprehensive decision-
making
2. Electronic Health Records (EHR)
-Using a shared EHR system enables real-
time information sharing across the
team. Each member can update notes,
track interventions, and review the
patient’s progress, minimizing
communication delays
3. Coordinated Care Plans
-Each team member contributes their
expertise to create a cohesive care plan that
addresses the medical, emotional, physical,
and social needs of the elderly patient
4. Family Involvement
-Family members are included in
discussions and training sessions to
support a smooth transition to home
care. They are provided with contacts
and resources for continued support
from the healthcare team
5. Follow-Up and Case Management
-Case managers play a key role in
coordinating follow-up appointments and
ensuring that all healthcare team members
remain updated, even post-discharge. This
ensures continuity of care and prevents
readmission
3. Teamwork and Collaboration Among the
Geriatric Health Care Team
• What is Teamwork?
• Teamwork is the collaborative effort of a group to achieve a common goal or
complete a task efficiently and effectively.
• It involves cooperation, communication, coordination, and the willingness to
contribute individual skills and knowledge toward shared objectives
Core Elements:
•Successful teamwork relies on mutual
respect, trust, defined roles, and open
communication among team members. It is
an approach where diverse individuals work
together, leveraging each other’s strengths to
maximize performance
Key Components of Effective
Teamwork in IPC
• Communication: Clear, open, and respectful communication is essential for sharing
information and ideas.
• Mutual Respect and Trust: Valuing each professional’s contributions encourages a
collaborative environment.
• Shared Goals: A unified goal around patient care ensures all team members work in the
same direction.
• Defined Roles and Responsibilities: Clarity on roles helps in reducing overlap and
optimizing expertise.
• Decision-Making: Teams should involve all members in patient-related decisions,
respecting each profession’s input.
Benefits of Teamwork and Interprofessional
Collaboration in the Geriatric Health Care Team
• Enhanced Patient Outcomes: Collaboration leads to comprehensive care
plans, addressing all aspects of a patient’s needs.
• Efficient Use of Resources: Pooling resources allows for efficient care,
reducing duplication of services.
• Reduction in Workload and Burnout: Shared responsibilities can lighten
individual workloads and reduce burnout.
• Learning and Professional Growth: Team members gain insights into other
fields, which enhances their knowledge and skills.
Challenges in Interprofessional Teamwork
• Role Confusion: Without clear roles, responsibilities may overlap,
leading to conflict.
• Communication Barriers: Differing jargon and communication
styles can lead to misunderstandings.
• Hierarchy and Power Dynamics: Power imbalances can stifle
collaboration, as some voices may be ignored.
• Time Constraints: Coordinating schedules across professions is
challenging and can limit team interaction.
Strategies for Enhancing Teamwork in the geriatric
health care team
• Regular Team Meetings: Scheduled meetings provide structured
opportunities for discussion and planning.
• Use of Communication Tools: Electronic health records and
communication platforms improve information sharing.
• Team Training and Development: Regular training sessions on
team dynamics, communication, and conflict resolution.
• Leadership Support: Leaders play a key role in fostering a
supportive and collaborative culture.
Case Study and Practical Application
• Case Study: A hypothetical case can illustrate how an
interprofessional team manages a complex patient case (e.g.,
post-operative care involving surgeons, physical therapists,
nutritionists, and social workers).
• Group Activity: Role-play exercises to simulate
interprofessional communication and decision-making in
patient care.
Evaluating and Measuring Team Effectiveness
• Feedback Mechanisms: Regular feedback on team
dynamics and individual contributions.
• Outcome Measures: Assessing patient outcomes,
patient satisfaction, and team satisfaction.
• Reflection Sessions: Facilitating reflection on team
experiences to learn and improve.
Conclusion
• Summary: the Geriatric Health care team and Interprofessional
collaboration relies on effective teamwork to enhance healthcare
delivery.
• Future Directions: Emphasis on ongoing education, advanced
technology for communication, and policies supporting IPC among
the Geriatric Health care team .
• These notes highlight key concepts in teamwork for
interprofessional collaboration in healthcare, emphasizing
communication, respect, shared goals, and strategies for effective
teamwork. Implementing these can improve patient outcomes and
enhance the working environment for healthcare professionals.
REFERENCES
• American Geriatrics Society (AGS). Geriatrics Healthcare Professionals &
Patient Care Services. A foundational guide on roles in geriatric care teams and
best practices for coordinated elderly care.
• Meiner, S. E. Gerontologic Nursing (6th Edition, 2018). Elsevier.
• The Hartford Institute for Geriatric Nursing. Best Practices in Nursing Care
to Older Adults.
• National Institute on Aging (NIA). Health and Aging: Multidisciplinary Care
Teams for Older Adults.
• Hoenig, H., & Page, P. Geriatric Rehabilitation and Interdisciplinary Team
Approaches in Physical Medicine and Rehabilitation Clinics of North America
(2019).
• British Geriatrics Society (BGS). Best Practice Guidelines for Multidisciplinary
Team Care.
