Team Conference Research Articles

Strategies for engaging foster care youth in permanency planning family team conferences

The present study examines strategies conference facilitators used to engage foster care youth in decision-making in the context of permanency planning family team conferences. Data collection included observations of permanency planning family team conferences, followed by interviews with foster care youth and conference facilitators. Data analysis focused on gaining a deeper understanding of how facilitators incorporate youth into decision-making, with a specific focus on the strategies they employed. Four strategies were identified in the analysis: creating a safe space, encouraging the youth voice, re-balancing power, and establishing a personal connection. The study's policy and practice implications, limitations and areas of further research are presented.

Job Satisfaction of Nurses and Associated Factors in Public Hospitals in Tigray Region, Northern Ethiopia

Background: Job satisfaction is an important component of nurses' lives that can impact on patient safety, productivity and performance, quality of care, retention and turnover, commitment to the organization and the profession. One of the primary reasons nurses leave the profession is dissatisfaction with their practice environment. The aim of this study was to assess job satisfaction of nurses and associated factors in public hospitals, Tigray, Northern Ethiopia. Methods: Institutional based cross sectional study was carried out from February to March 2011 using both quantitative and qualitative methods of data collection. A total of 255 nurses were selected using simple random sampling method and key informants for the in-depth interview were selected conveniently from the two-third of the total hospitals in the region. Descriptive statistics, bivariate analysis and multivariable logistic regression analyses were employed to identify factors associated with job satisfaction of nurses. Result: Fifty Eight percent of the participants were satisfied about their relationship with physicians. Greater than half of the nurses were dissatisfied with administrative support in nurse-physician relationships. Age, work experience, staff shortage subscales was found to be positive predicators of the nurses satisfaction with their relation with physicians. Conclusion: Almost half of the participants were dissatisfied with current job. The study reveals that there is poor work relationship between nurses and physicians. Hospital leaders should focus in improving nurse-physician work relationships; team conferences and interdisciplinary round.

Intervention and Documentation Reduce Exposure From Falls

Intervention and Documentation Reduce Exposure From Falls

Effectiveness of multidisciplinary team conference on decision-making surrounding the application of continuous deep sedation for terminally ill cancer patients

Continuous deep sedation (CDS) is a way to reduce conscious experience of symptoms of severe suffering in terminally ill cancer patients. However, there is wide variation in the frequency of its reported. So we conducted a retrospective analysis to assess the prevalence and features of CDS in our palliative care unit (PCU). We performed a systemic retrospective analysis of the medical and nursing records of all 1581 cancer patients who died at the PCU at Higashi Sapporo Hospital between April 2005 and August 2011. Continuous deep sedation can only be administered safely and appropriately when a multidisciplinary team is involved in the decision-making process. Prior to administration of CDS, a multidisciplinary team conference (MDTC) was held with respect to all the patients considered for CDS by an attending physician. The main outcome measures were the frequency and characteristics of CDS (patient background, all target symptoms, medications used for sedation, duration, family's satisfaction, and distress). We mailed anonymous questionnaires to bereaved families in August 2011. Of 1581 deceased patients, 22 (1.39%) had received CDS. Physical exhaustion 8 (36.4%), dyspnea 7 (31.8%), and pain 5 (22.7%) were the most frequently mentioned indications. Continuous deep sedation had a duration of less than 1 week in 17 (77.3%). Six patients (0.38%) did not meet the appropriate criteria for CDS according to the MDTC and so did not receive it. Although bereaved families were generally comfortable with the practice of CDS, some expressed a high level of emotional distress. Our results indicate that the prevalence of CDS will be decreased when it is carried out solely for appropriate indications. Continuity of teamwork, good coordination, exchange of information, and communication between the various care providers are essential. A lack of any of these may lead to inadequate assessment, information discrepancies, and unrest.

APA Supports New Complex Chronic Care Management Codes

Back to table of contents Previous article Next article Government NewsFull AccessAPA Supports New Complex Chronic Care Management CodesMark MoranMark MoranSearch for more papers by this authorPublished Online:30 Oct 2013https://doi.org/10.1176/appi.pn.2013.11a17AbstractA proposed Medicare rule, issued in August, addresses regulatory and payment policy issues but does not include the fee schedule. A final rule with the fee schedule will be issued this month.APA is endorsing the government’s move toward incorporating “complex chronic care management codes” as part of the Medicare fee schedule for 2014.In response to a proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) in August, then-APA Medical Director James H. Scully Jr., M.D., told CMS in a letter that the codes can create a means for compensating physicians for non-face-to-face services they provide to patients with complex chronic conditions.(The proposed rule by CMS was issued in August and addresses a variety of regulatory and payment policy issues, but does not include the 2014 fee schedule; a final rule, with the fee schedule, is expected this month. Look to Psychiatric News for coverage.)“APA strongly favors compensating physicians for the non-face-to-face care management, including, but not limited to, team conferences, telephone calls, and patient education they provide to Medicare beneficiaries suffering from chronic care conditions,” Scully wrote. “We commend CMS for moving in this direction, which we believe is a starting point. These codes cross an important barrier in not requiring face-to-face time. We support CMS’s proposal to utilize the parameters described in the CPT guidelines to identify patients eligible for complex chronic care condition management services. A disproportionate share of Medicare beneficiaries suffering from two or more chronic conditions are suffering from a mental illness as shown in CMS’s analysis of Medicare claims for patients with multiple chronic conditions.”But Scully also said that the conditions currently required for billing the newly proposed complex chronic care management service G codes are unlikely to capture the non-face-to-face care management work many psychiatrists are performing for some of Medicare’s most chronically ill beneficiaries.“Among the population of Medicare beneficiaries who comprise the severely and persistently mentally ill, our members often function additionally as primary care physicians, coordinating all or most of this population’s health care,” he wrote. “We urge Medicare to design complex chronic care management codes that our members can use when coordinating the health care of the chronically mentally ill Medicare population. This necessitates the design of complex chronic care management codes that have broader conditions of use, such as the two existing non-face-to-face CPT codes. We prefer the CPT codes because their use permits use of CPT guidelines and, consequently, other payers’ likely adoption of these codes.”Scully also expressed support for the adoption of the psychiatry CPT values, reviewed and approved earlier this year by the Relative Value Update Committee (RUC) for the 2014 Fee Schedule. “Adoption of the RUC recommended values is necessary to correct the current rank-order anomaly that exists between the psychiatric diagnostic evaluation with medical services (90792) and the psychiatric diagnostic evaluation (90791), which does not include medical services,” Scully wrote in a September 5 letter to CMS. “A disparity in payment was created by the adoption of RUC-recommended reductions in practice expense values for only 90792. The inequitable result of this is that psychiatrists and advance practice nurses have been paid less this year for doing more work with more complex patients. We believe this inequity created inappropriate incentives on the clinical level. This issue will be resolved if CMS adopts the RUC recommended practice expenses for the 90791.”Scully also urged the government to adopt new values for CPT codes for psychiatric services, as recommended by the RUC. Other issues Scully addressed included proposed rules around telehealth, liability for overpayment, quality measures, and the Medicare Physician Quality Reporting System. ■Scully’s letter to CMS is posted at http://www.psychiatry.org/advocacy--newsroom/advocacy/9e9023b8-d3da-4c85-a2a2-c02fa8cbad9a. ISSUES NewArchived

Outcomes of Consecutive Patients Referred for Consideration for Transcatheter Aortic Valve Implantation from an Encompassing Health-Care Region

Procedural outcomes for transcatheter aortic valve implantation (TAVI) are well described. However, limited information exists regarding patient screening and selection. Thus, the purpose of the study was to review consecutive patients referred for TAVI from an inclusive-defined population. The Mazankowski Alberta Heart Institute TAVI program has maintained a prospective database on all referred patients. Patients are reviewed in outpatient clinic attended by a nurse, cardiologist, cardiac surgeon, and administrative assistant. After workup is complete, a TAVI Heart Team conference occurs to accept or reject each patient. Since November 2009, 276 patients (145 men and 131 women) have been referred with a steady increase in the number of referrals annually. Mean age was 82.2 years (men 81.6 and women 82.8), with 13% aged <70 years. Mean EuroSCORE was 13.8 and mean STS score was 5.7. Of the referred patients, 34% received TAVI, 17% were rejected, 12% underwent open AVR, 10% refused TAVI, and 27% are currently being assessed or followed. There were no differences in the mean EuroSCORE (13.4 vs 14.3; p = 0.64) or STS scores (5.2 vs 6.4; p = 0.13) of those accepted for TAVI versus those who were not. In conclusion, a team-based approach to assess this complex patient population is essential to ensure efficient and comprehensive evaluation, in turn determining appropriate care allocation. With expansion of clinical experience and the evidence supporting TAVI, the Heart Teams defined to assess this patient population will be burdened with increased clinical commitment and require appropriate support.

Using a profile of a modified Brief ICF Core Set for chronic widespread musculoskeletal pain with qualifiers for baseline assessment in interdisciplinary pain rehabilitation

AimTo describe the use of a “workable” visual profile of function and disability, based on a modified Brief International Classification of Functioning, Disability and Health (ICF) Core Set for chronic widespread pain, for initial assessments in a clinical setting of interdisciplinary pain rehabilitation teams.MethodThe Brief ICF Core Set was slightly adapted to meet the needs of an interdisciplinary rehabilitation medicine team working in a university outpatient clinic and admitting patients referred from primary care. The Core Set categories were made measurable by means of eg, assessment instruments and clinical investigations. The resulting profile was given a workable shape to facilitate rapid understanding of the initial assessment outcome.ResultsIndividual patients showed different profiles of problems and resources, which facilitated individual rehabilitation planning. At the level of the study group, the profiles for the Core Set component Body Functions showed that most patients had severe impairment in the sensation of pain and exercise tolerance categories of function, but most had resources in the motivation and memory categories of function. Likewise, for the component Activities, most patients had limitations in lifting and carrying objects and remunerative employment, but most had resources in intimate relationships and family relationships. At first, the use of the modified Brief ICF Core Set in the team conference was rather time consuming, but after a couple of months of experience, the team assessment took approximately 30 minutes to complete per patient.ConclusionThe profile of the modified Brief ICF Core Set for chronic widespread pain served as a common platform, facilitating cooperation between the rehabilitation team members and providing a uniform language, which helped in structuring the clinical work. The profile also provided an easily accessible, overall view of the patient’s problems and resources, which helped in understanding the functioning situation of the patient.

Assistive Technology for Cognition Following Brain Injury: A Clinician's Perspective

Whether working in a specialized brain injury program, outpatient clinic, acute care hospital, or private practice, speech-language pathologists serving adults with cognitive impairments due to acquired brain injury (ABI) are faced with many challenges: assessment, treatment planning, client and family education, documentation, team conferences, and billing. The combination of these demands requires a high level of efficiency. Include the rapidly expanding field of assistive technology for cognition (ATC) — cell phones, smart phones, tablets, and apps used to compensate for cognitive impairments — and the most experienced and adept clinician can feel overwhelmed. This article describes the practical application of ATC assessment and training in the brain injury day treatment program at the Brain Injury Rehabilitation Center (BIRC), Portland, OR, across three domains: (a) a clinician’s perceptions of ATC and its integration into clinical practice, (b) selected ATC assessment processes and training techniques, and (c) challenges associated with the implementation of ATC in a clinical setting.

Professional Virtual Worlds Supporting Computer-Mediated Communication, Collaboration, and Learning in Geographically Distributed Contexts

Research problem: Although much research exists on virtual worlds, very few studies focus on professional virtual worlds used for working in a global setting. Research questions: (1) How do global managers currently use and experience professional virtual worlds (Virtual Worlds) as a communication media for global work? and (2) How do these Virtual Worlds support global and professional communication in a geographically distributed context? Literature review: We reviewed Virtual World literature in the area of social sciences, education, and games. Little research has been conducted on Virtual Worlds for workgroups. But those studies support the assumption that Virtual Worlds are suitable for global distributed work as a collaboration and communication medium. Methodology: With an explorative and qualitative interview research approach, we conducted 47 semi-structured interviews with virtual world vendors, researchers, and managers using virtual worlds in their work. Data were analyzed based on Grounded Theory Analysis methods. Results and conclusions: The results show four different use cases applied for professional Virtual Worlds: small team meetings, trainings, community building, and conferences. Furthermore, our findings confirm Virtual World literature that states that the professional Virtual World as a communication and collaboration tool supports geographically distributed work as well as visualization and learning in a global context.

Building a healthy work environment: a nursing resource team perspective.

Leadership and staff from the London Health Sciences Centre (LHSC) Nursing Resource Team (NRT), including members of their Continuous Quality Improvement (CQI) Council, attended the first Southern Ontario Nursing Resource Team Conference (SONRTC), held March 2012 in Toronto. The SONRTC highlighted healthy work environments (HWEs), noting vast differences among the province's various organizations. Conversely, CQI Council members anecdotally acknowledged similar inconsistencies in HWEs across the various inpatient departments at LHSC. In fact, the mobility of the NRT role allows these nurses to make an unbiased observation about the culture, behaviours and practices of specific units as well as cross-reference departments regarding HWEs. Studies have documented that HWEs have a direct impact on the quality of patient care. Furthermore, the literature supports a relationship between HWEs and nurse job satisfaction. Based on this heightened awareness, the NRT CQI Council aimed to investigate HWEs at LHSC. The American Association of Critical Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments was adapted in developing a survey for measuring HWEs based on the perceptions of NRT staff. Each of the departments was evaluated in terms of the following indicators: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership (AACN 2005). Ultimately, the Building a Healthy Work Environment: A Nursing Resource Team Perspective survey was employed with NRT nurses at LHSC, and data was collected for use by leadership and staff for creating HWE strategies aimed at improving the quality of patient care.

The China Syndrome Ails America Too

The China Syndrome Ails America Too

Transatrial Antegrade Approach for Double Mitral and Tricuspid “Valve-in-Ring” Implantation

Within the last 5 years, the number of transcatheter aortic valve implantation (TAVI) procedures has increased continuously and, in parallel, the indications for TAVI have expanded (eg, failing surgical valves and rings). Furthermore, alternative TAVI access routes such as transaxillary and transaortic have been applied successfully. We report on, to our knowledge, the first-in-human case of a combined off-pump antegrade transatrial implantation of a transcatheter valve within a mitral and tricuspid annuloplasty ring through an anterolateral minithoracotomy. The patient showed severe mitral valve and tricuspid valve stenosis and regurgitation 15 years after mitral valve repair and 7 years after aortic valve replacement and tricuspid valve repair.

Interdisciplinary communication in inpatient rehabilitation facility: evidence of under-documentation of spatial neglect after stroke

Purpose: Spatial neglect commonly occurs after stroke and predicts poor rehabilitation outcomes. However, this disorder is under-recognized in clinical practices, which may result from the failure to document its presence. This study aimed to identify the predictors for documentation of spatial neglect in inpatient rehabilitation facilities. Method: We performed a comprehensive chart review to investigate whether the presence of spatial neglect was documented in 74 neglect patients’ clinical notes recorded by physicians, nurses, or occupational therapists (OTs), or in team conference notes. Independent variables included neglect severity, length of stay, Functional Independence Measure at admission and discharge. Results: Of the 74 neglect patients, 75.7% were documented by OTs, 63.5% by physicians, and 17.6% by nurses. Although 93.2% of neglect patients were recognized by at least one clinician group, only 31.1% were discussed in multidisciplinary team conferences. Neglect patients who were documented by physicians were more likely to be documented in team conferences. While no factors predicted whether a neglect patient would be documented by nurses or OTs, we found significant predictors for neglect documentation in physician and team conference notes. The odds of being documented by physicians were increasingly greater with poorer efficiency of cognitive rehabilitation (odds ratio = 0.70). The odds of being discussed in team conferences were increasingly greater with more severe neglect (odds ratio = 0.98), and with longer stay in hospitalization (odds ratio = 1.06). Conclusions: Multidisciplinary care may not involve as much interdisciplinary communication as needed to document important disease states. Stroke rehabilitation professionals should be able to recognize spatial neglect independently and document it consistently.Implications for RehabilitationOccupational therapists detected and documented more neglect cases than physicians or nurses. Nurses’ documentation rate of spatial neglect was much lower than physicians or occupational therapists.Spatial neglect was more likely to be documented by physicians if the patients had poor efficiency in cognitive outcome improvement.Stroke patients with more severe neglect or with longer stay were more likely to be documented in team conference notes.No neglect patient was coded with the ICD-9-CM code (781.8), suggesting that using such code for institutional or nation-wide prevalence research on spatial neglect is likely to be unfruitful.

New Medicare Models of Care and the LTC Physician

New Medicare Models of Care and the LTC Physician

Coding for Anxiety and Bereavement

Commonly used codes to report services provided in the office setting for children experiencing anxiety or bereavement, including evaluation, consultation, prolonged service, team conference, and DSM-PC

Effect of the CPT Definition of Nonphysician Qualified Health Care Professional

Services affected by definition, including prolonged E/M, medical team conference, education and training for patient self-management, and online assessment and management service

Indications and practice for tube feeding in Japanese geriatricians: Implications of multidisciplinary team approach

The aim of this study was to examine how geriatricians decide the indication of tube feeding in the elderly with eating difficulty as a result of several disorders, and to determine the factors associated with their decision making and interventions for dysphagia. The design was a cross-sectional study. All board-certified geriatricians in the Japan Geriatrics Society were recruited to this study in September 2010. We sent questionnaires to 1469 geriatricians. Among them, 629 agreed to participate. The survey consisted of self-administered questionnaires regarding demographic information, indications of tube feeding and interventions for dysphagia before tube feeding. We analyzed the remaining 555 questionnaires after excluding incomplete ones. Over 90% of geriatricians answered that "neurological disorder" and "stroke" are indications, whereas 46.8% of them answered that "dementia" is an indication for tube feeding. Geriatricians who organize a multidisciplinary team conference tended to carry out more "interventions for dysphagia before the prescription of tube feeding" compared with the reference group (odds ratio 2.1-8.7) after multivariate adjustment. The results show that approximately half of the geriatricians prescribe tube feeding when the patient has dementia with loss of appetite or apraxia for eating. There is no consensus among Japanese geriatricians about the indication of tube feeding for demented people. We suggest that guidelines for tube feeding in the elderly should be established. Furthermore, a multidisciplinary approach would be desirable for decision making for tube feeding.

Effects of a unique pediatric hematology–oncology palliative care program on medical decision-making and communication between healthcare providers and families: Results of a supportive care survey

PurposeThe purpose of this study was to evaluate family satisfaction with an embedded pediatric hematology–oncology (Hem-Onc) palliative care program and its decision-making tool (DMT). A secondary aim was to identify factors that play an important role in family medical decision-making.MethodsFamilies were asked to complete a self-administered questionnaire within 4 weeks of participating in a Supportive Care Team (SCT) conference and receiving a DMT.ResultsTwenty parents or guardians of pediatric Hem-Onc patients participated in the study. All of the patients had approached a major treatment-related change; all of the study participants had attended a SCT medical decision-making conference and received a DMT. The most important considerations to the study participants regarding treatment decisions were their child's quality of life, their child's chance of improving, perception of their child's wishes, and the hospital staff's advice. Of the people and services that were most useful in guiding medical decision-making, 100% reported that nurses, 95% reported physicians, and 90% reported the SCT helped guide treatment decisions. Ninety percent of those surveyed remembered receiving the DMT, found it to be clear and straightforward, and thought that it improved communication between the family and the healthcare providers.ConclusionsThese findings suggest an embedded pediatric Hem-Onc supportive care program (SCP) and use of a DMT facilitate effective communication between families and healthcare providers, and provide families with adequate decision-making support.

T3 Subdivision Correlation with Nodal or Distant Metastasis in Colorectal Cancer; Is It Practically Useful?

See Article on Page 160-164 The pathological staging system has been regarded as a guideline for predicting the prognosis of patients and for deciding on the need for further adjuvant treatment. In this issue, the Yoo et al. [1] analyzed 555 colorectal cancer patients who underwent curative surgery, especially for pT3 cancer subdivided according to the depth of tumor infiltration beyond the muscle proper layer: 15 mm. These 4 types of pT3 subdivisions were shown to be deeply correlated to the known prognostic histopathologic factors. One thing they did not analyze was the relation between T3 subdivision and the 5-year disease-free survival rate. They only compared pT3 subdivision with nodal and distant metastasis; furthermore, their multivariate analysis revealed that pT3 subtype might be an independent prognostic factor in colorectal cancer. Some studies regarding the relevant risk factors for regional lymph node metastasis in submucosal adenocarcinomas have been performed, and some of those measured not only the submucosal depth of invasion but also tumor budding, lymphatic invasion, vascular invasion, etc. In rectal cancer, the circumferential resection margin (CRM) and tumor deposit also have been reported as important risk factors for predicting patient prognosis, but none of those are recognized as definite prognostic factors in the current American Joint Committee on Cancer (AJCC) staging system. However, several reports have already demonstrated extramural invasion depth to be related with nodal metastasis and distant metastasis in colorectal cancer. Interestingly, pT3 subdivision has been analyzed and has been reported as a prognostic factor in rectal cancer patients not colon cancer patients. Miyoshi et al. [2] analyzed pT3 rectal cancer patients according to a 6-mm cutoff value for the extent of mesorectal invasion, and there were definite differences in the overall 5-year survival rates between the two groups of patients. Kim et al. [3] reported an interesting study regarding how to select high-risk rectal cancer patients based on preoperative local staging using rectal magnetic resonance imaging (MRI). He compared the extent of mesorectal invasion between whole mounted rectal cancer histopathology and MRI using a 5-mm cutoff value to evaluate its value as a prognostic indicator. The overall accuracy of preoperative MRI was 88%, which means MRI can be used to select patient who show T3 with 5-mm infiltration beyond the muscle layer. Those patients could be candidates for preoperative chemoradiation. Unfortunately, T3 pathological subdivision is not accepted as a prognostic factor in the new AJCC tumor-node-metastasis staging system, Furthermore, cutoff points for the penetration depth of cancer invasion beyond the muscle proper layer have not been determined. Currently, most pathologists do not report T3 subdivision, and as far as I can determine, they seem in Korea to be reluctant to measure the distance of tumor infiltration beyond the muscle proper layer. If pT3 subdivision might be a clinically significant prognostic factor, two issues still remain to be solved. One is the lack of a consensus about cutoff points, which should be studied more based on a large patient cohort; the other involves the support and cooperation of pathologists. Based on personal experiences concerning pathological descriptions of the CRM, we have had long discussions and cooperative conferences with pathologists. Currently, CRM status documentation is mandatory in pathological reports submitted in Korea. I think this study showed us an important message about the heterogeneity of the prognoses for the pT3 group of patients. Conventionally, we have not paid attention to the prognoses of colorectal cancer patients in the same category of pT3 patients. Important feedback to the multidisciplinary team conference can allow patients with high risk of nodal and distant recurrence after curative surgery to be identified. Therefore, the strategy for treating patients with high risk may be changed based on preoperative modern imaging. Currently, some evidence exists that preoperative chemotherapy or chemoradiotherapy may have oncological benefits compared surgery first [4, 5]. A couple of well-known high-risk factors are CRM status, tumor deposit, vascular encasement of nodes, etc., and patients with such factors should be candidates for preoperative treatment. Hopefully, pT3 subdivision may be a candidate for use as another high-risk factor, but it seems to have a long way to go.

A Retrospective Review of TATRC Funding for Medical Modeling and Simulation Technologies

In February 2000, the U.S. Army's Telemedicine and Advanced Technology Research Center (TATRC) and the U.S. Army's Simulation, Training, and Instrumentation Command cohosted an Integrated Research Team conference in Maryland. The goal of the conference was to enable end users, researchers, materiel developers, and other government agencies to present their conceptions of how modeling and simulation could and should be developed to meet military medical needs. During the past 9 years, TATRC has funded more than 175 projects relating to simulation. This study was a retrospective review of TATRC's Modeling and Simulation Training projects (N = 175). Our results show that most (>75%) of the funded projects in this study involved industry. More than 85% of the projects that involved industry focused on technology development. Industry development projects seemed to meet their deliverables in a timely fashion. However, academia projects using industry-developed technologies and prototypes were delayed largely because the technologies did not meet their needs. There seems to be a measurable gap between industry's definition of a completed product technology and academia's ability to implement and use the technology in interactive learning environments. Our findings support the need for a standardized strategic design process that involves a strong industry-academia collaboration and early end-user testing to better facilitate the development of sound requirements that guide technology development.