Interprofessional Healthcare Team Collaboration: Choose Your Own Adventure Activity

Instructions

Interprofessional healthcare teams are comprised of many different people, each with unique professional duties and perspectives.

Explore the dynamics of interprofessional healthcare teams by stepping into the shoes of a specific team member. Your choices will influence how you perceive the case, how the team collaborates, and the quality of care provided.

Background

Older adults face an increased risk of age-associated diseases such as osteoarthritis, macular degeneration, and Alzheimer’s disease. When these conditions limit the ability to carry out personal, household, or other everyday tasks, an individual may require long-term care. Frequently, the caregiver will be a family member or friend.

When home care is interrupted by a serious injury, such as a fall leading to hospitalization, a reassessment of the caregiving situation is often triggered. The resources, requirements, and desires of both the caregiver and care receiver must be taken into account.

Meet the Coopers

Mrs. Cooper, 87 years old, is nearing being discharged from a skilled nursing facility after her hip fracture resulting from a fall. She wants to go home.

Mr. Cooper, 90 years old, has been her primary caregiver. He is in good health for his age. His older brother lives in a nursing home, and Mr. Cooper has vowed he “will never go down that road.” He would prefer his wife to come home but wants to evaluate other options.

They have lived in their two-story home for 53 years.

Choose a Team Member

Dietitian

Pharmacist

Physical Therapist

Physician

Physician Assistant

Registered Nurse

Rehabilitation Counselor

Social Worker

Roles and Responsibilities

Question 1

Question 1: Dietitian

Based on the responsibilities of a dietitian, what information would be most appropriate to share with the team? Click your answer to proceed.

• A detailed physical rehabilitation plan for Mrs. Cooper.
• Mrs. Cooper’s medication management and potential drug interactions.

• Mrs. Cooper’s nutritional requirements.

• An assessment of Mrs. Cooper’s mental health status.

Question 1: Pharmacist

Based on the responsibilities of a pharmacist, what information would be most appropriate to share with the team? Click your answer to proceed.

• Information on Mrs. Cooper’s medications and potential interactions.

• Nutritional plans and dietary changes for Mrs. Cooper.
• Specific physical therapy exercises.
• Mrs. Cooper’s social support needs.

Question 1: Physical Therapist

Based on the responsibilities of a physical therapist, what information would be most appropriate to share with the team? Click your answer to proceed.

• Advice on adjusting Mrs. Cooper’s medication regimen.

• Mrs. Cooper’s current physical capabilities and recommendations for physical therapy.

• A mental health treatment plan.
• Recommended changes to Mrs. Cooper’s social environment.

Question 1: Physician

Based on the responsibilities of a physician, what information would be most appropriate to share with the team? Click your answer to proceed.

• Detailed dietary requirements.
• A plan for social work intervention.
• Specific rehabilitation counseling strategies.

• A comprehensive overview of Mrs. Cooper’s medical condition and results from recent examinations.

Question 1: Physician Assistant

Based on the responsibilities of a physician assistant, what information would be most appropriate to share with the team? Click your answer to proceed.

• Observations relevant to her ongoing treatment.

• A detailed nutritional assessment.
• Suggested social support structures.
• Recommended long-term physical therapy goals.

Question 1: Registered Nurse

Based on the responsibilities of a registered nurse, what information would be most appropriate to share with the team? Click your answer to proceed.

• Advice on Mrs. Cooper’s long-term medication management.
• A comprehensive rehabilitation plan.

• Observations on Mrs. Cooper’s current symptoms and any nursing care insights.

• Mrs. Cooper’s dietary needs.

Question 1: Rehabilitation Counselor

Based on the responsibilities of a rehabilitation counselor, what information would be most appropriate to share with the team? Click your answer to proceed.

• Mrs. Cooper’s rehabilitation needs and any barriers to her treatment plan.

• The specific medications Mrs. Cooper is currently taking and their potential interactions.
• Details about Mrs. Cooper’s nutritional requirements.
• Specific physical therapy exercises for Mrs. Cooper.

Question 1: Social Worker

Based on the responsibilities of a social worker, what information would be most appropriate to share with the team? Click your answer to proceed.

• Specific physical therapy interventions.
• Advice on adjustments to her medications.
• Findings from Mrs. Cooper’s physical assessment.

• Mrs. Cooper’s social support requirements and the need for community resources or support systems.

Question 1 Incorrect Answers

Question 1: Dietitian – Incorrect

Question 1: Pharmacist – Incorrect

Question 1: Physical Therapist – Incorrect

Question 1: Physician – Incorrect

Question 1: Physician Assistant – Incorrect

Question 1: Registered Nurse – Incorrect

Question 1: Rehabilitation Counselor – Incorrect

Question 1: Social Worker – Incorrect

Question 1 Correct Answer

Question 1: Dietitian – Correct!

Question 1: Pharmacist – Correct!

Question 1: Physical Therapist – Correct!

Question 1: Physician – Correct!

Question 1: Physician Assistant – Correct!

Question 1: Registered Nurse – Correct!

Question 1: Rehabilitation Counselor – Correct!

Question 1: Social Worker – Correct!

Member’s Findings

The Dietitian’s Observations and Recommendations

Observations:

• Mrs. Cooper initially had poor intake when she came to rehabilitation.
• This was due to a combination of lingering delirium from the hospitalization leading to poor attention to eating and also possible side effects of the medications (pain medications causing constipation and decreased appetite).
• From her weight of 130 lbs before her injury, her weight has declined to 124 lbs.

Recommendations:

• Mrs. Cooper was offered simple finger foods that were easier for her to eat. Wherever she goes, caregivers should change her diet to more of these types of foods, especially as the dementia progresses.
• Her caregivers should also monitor her intake and weight.
• She should continue her daily calcium and Vitamin D supplements to reduce the risk of bone fractures in the presence of her osteoporosis.

Review the following chart to understand Mrs. Cooper’s long-term care options.

The Pharmacist’s Observations

The pharmacist reviewed Mrs. Cooper’s list of medications and found nothing of concern (i.e., medications inappropriate for people over 65 or medications that, when taken together, may interact). However, she will need assistance with her medications due to her declining cognition.

Review the following chart to understand Mrs. Cooper’s long-term care options.

The Physical Therapist’s Observations and Recommendations

Observations:

• Mrs. Cooper fell at home at least twice. The last time, she fractured her hip. The cause of the falls isn’t known. It could be a side effect of one or more of the medications Mrs. Cooper takes or other risk factors, such as muscle weakness or a visual deficit.
• To make recommendations, it is important to determine the cause(s) of these falls.

Findings:

• The physical therapist saw Mrs. Cooper at the inpatient rehabilitation hospital to determine fall risk. The physical therapist also tested Mrs. Cooper’s strength, sensation, range of motion, and flexibility. Testing revealed a moderate level of fall risk.
• At a follow-up appointment, Mrs. Cooper completed a test to determine whether her falls were due to an inability to divide attention between two tasks, such as walking and carrying a cup of water. Mrs. Cooper scored very poorly on the task, indicating she is unable to walk safely when performing even a simple secondary task.

Review the following chart to understand Mrs. Cooper’s long-term care options.

The Physician’s Findings

Mrs. Cooper’s recent hip fracture has taken a lot out of her, and she has declined quite a bit. It is the physician’s opinion that Mrs. Cooper has now progressed to early-stage Alzheimer’s disease, which may include:

• frequent recent memory loss, particularly of recent conversations and events
• some problems expressing and understanding language
• mild coordination problems
• the need for reminders for daily activities, such as dressing and using the bathroom
• depression and apathy, accompanied by mood swings

Review the following chart to understand Mrs. Cooper’s long-term care options.

The Physician Assistant’s Observations

Mrs. Cooper did well in rehab. She progressed well without any complications except for one urinary tract infection that was caught and treated early. She has not been delirious but often gets confused about the date and needs to be reminded where she is.

Review the following chart to understand Mrs. Cooper’s long-term care options.

The Registered Nurse’s Observations

Mrs. Cooper did well during her rehabilitation stay. She did require two nurse’s aides or nurses to help her in the beginning, but then she gradually got stronger. The main issue was Mrs. Cooper getting up by herself in the middle of the night to go to the bathroom. She would not remember to ask for help and twice had close calls where she almost fell. Luckily, the fall alarm she was wearing alerted that she had gotten out of bed.

The registered nurse is worried that she will fall at home without such care.

Review the following chart to understand Mrs. Cooper’s long-term care options.

The Rehabilitation Counselor’s Findings

The rehabilitation counselor has read the social worker and PT reports and knows that returning home would require the Coopers to make expensive home modifications to accommodate Mrs. Cooper’s physical limitations.

The Coopers shared that they receive $2,400 per month from Social Security and have $100,000 in savings. The Coopers own their home, which is currently valued at $340,000. They have Medicare coverage but do not have long-term care insurance.

Review the following chart to understand Mrs. Cooper’s long-term care options.

The Social Worker’s Findings

The social worker visited the Cooper’s home to carry out a home safety assessment. The social worker found that they had already fitted the rear entry with a ramp for wheeling items in and out of the house. However, the doorways are too narrow to accommodate a wheelchair.

The only bathroom on the first floor is a half bath that is too small to renovate, but the utility room could potentially be fitted with a shower.

There are 16 steps leading from the first to the second floor, which presents a significant safety risk to Mrs. Cooper.

Review the following chart to understand Mrs. Cooper’s long-term care options.

Tables

Long-Term Care Options

Question 2

Question 2 – Dietitian

Based on the dietitian’s findings, which long-term care option do you think is best for Mrs. Cooper?

• Nursing home
• Assisted living facility
• Continuing care retirement center
• Aging in place

Question 2 – Pharmacist

Based on the pharmacist’s findings, which long-term care option do you think is best for Mrs. Cooper?

• Nursing home
• Assisted living facility
• Continuing care retirement center
• Aging in place

Question 2 – Physical Therapist

Based on the physical therapist’s findings, which long-term care option do you think is best for Mrs. Cooper?

• Nursing home
• Assisted living facility
• Continuing care retirement center
• Aging in place

Question 2 – Physician

Based on the physician’s findings, which long-term care option do you think is best for Mrs. Cooper?

• Nursing home
• Assisted living facility
• Continuing care retirement center
• Aging in place

Question 2 – Physician Assistant

Based on the physician assistant’s findings, which long-term care option do you think is best for Mrs. Cooper?

• Nursing home
• Assisted living facility
• Continuing care retirement center
• Aging in place

Question 2 – Registered Nurse

Based on the registered nurse’s findings, which long-term care option do you think is best for Mrs. Cooper?

• Nursing home
• Assisted living facility
• Continuing care retirement center
• Aging in place

Question 2 – Rehabilitation Counselor

Based on the rehabilitation counselor’s findings, which long-term care option do you think is best for Mrs. Cooper?

• Nursing home
• Assisted living facility
• Continuing care retirement center
• Aging in place

Question 2 – Social Worker

Based on the social worker’s findings, which long-term care option do you think is best for Mrs. Cooper?

• Nursing home
• Assisted living facility
• Continuing care retirement center
• Aging in place

Team Meeting

The team holds a video conference to discuss each professional’s findings.

Summary of the team’s findings:

• Mrs. Cooper experienced weight loss during rehabilitation, requiring dietary adjustments and continuous monitoring.
• A moderate fall risk was identified, and Mrs. Cooper struggles with tasks requiring divided attention.
• A diagnosis of early-stage Alzheimer’s was made and is expected to progress within two years, raising concerns about home safety.

The physician’s recommendations:

• Given the progressive nature of Alzheimer’s and the frail condition of her husband and primary caregiver Mr. Cooper, the physician recommends assisted living.
• A facility that has multiple “levels of care” (e.g. a Continuing Care Retirement Community) might be a good option for the couple as she is likely to be more impaired and need more help than he will. Such a facility might allow them not to be separated in the years to come.

The physical therapist’s recommendations:

• Given the findings of the examination and home safety assessment, the physical therapist recommends that the Coopers modify their home to reduce Mrs. Cooper’s fall risk.
• It would also be a good idea to hire a home health aide to assist Mrs. Cooper with her daily tasks.

The rehabilitation counselor’s recommendations:

• The Coopers need to plan for their money to last for some time.
• The cost of a full-time in-home caregiver or for Mr. Cooper and Mrs. Cooper to enter a care facility may not be affordable for the number of years they might need it (without selling their home).

Click to proceed.

Team Meeting

The team holds a video conference to discuss each professional’s findings.

Summary of the team’s findings:

• Mrs. Cooper experienced weight loss during rehabilitation, requiring dietary adjustments and continuous monitoring.
• A moderate fall risk was identified, and Mrs. Cooper struggles with tasks requiring divided attention.
• A diagnosis of early-stage Alzheimer’s was made and is expected to progress within two years, raising concerns about home safety.

The physician’s recommendations:

• Given the progressive nature of Alzheimer’s and the frail condition of her husband and primary caregiver Mr. Cooper, the physician recommends assisted living.
• A facility that has multiple “levels of care” (e.g. a Continuing Care Retirement Community) might be a good option for the couple as she is likely to be more impaired and need more help than he will. Such a facility might allow them not to be separated in the years to come.

The rehabilitation counselor’s recommendations:

• The Coopers need to plan for their money to last for some time.
• The cost of a full-time in-home caregiver or for Mr. Cooper and Mrs. Cooper to enter a care facility may not be affordable for the number of years they might need it (without selling their home).

Click to proceed.

Team Meeting

The team holds a video conference to discuss each professional’s findings.

Summary of the team’s findings:

• Mrs. Cooper experienced weight loss during rehabilitation, requiring dietary adjustments and continuous monitoring.
• A moderate fall risk was identified, and Mrs. Cooper struggles with tasks requiring divided attention.
• A diagnosis of early-stage Alzheimer’s was made and is expected to progress within two years, raising concerns about home safety.

The physical therapist’s recommendations:

• Given the findings of the examination and home safety assessment, the physical therapist recommends that the Coopers modify their home to reduce Mrs. Cooper’s fall risk.
• It would also be a good idea to hire a home health aide to assist Mrs. Cooper with her daily tasks.

The rehabilitation counselor’s recommendations:

• The Coopers need to plan for their money to last for some time.
• The cost of a full-time in-home caregiver or for Mr. Cooper and Mrs. Cooper to enter a care facility may not be affordable for the number of years they might need it (without selling their home).

Click to proceed.

Team Meeting

The team holds a video conference to discuss each professional’s findings.

Summary of the team’s findings:

• Mrs. Cooper experienced weight loss during rehabilitation, requiring dietary adjustments and continuous monitoring.
• A moderate fall risk was identified, and Mrs. Cooper struggles with tasks requiring divided attention.
• A diagnosis of early-stage Alzheimer’s was made and is expected to progress within two years, raising concerns about home safety.

The physician’s recommendations:

• Given the progressive nature of Alzheimer’s and the frail condition of her husband and primary caregiver Mr. Cooper, the physician recommends assisted living.
• A facility that has multiple “levels of care” (e.g. a Continuing Care Retirement Community) might be a good option for the couple as she is likely to be more impaired and need more help than he will. Such a facility might allow them not to be separated in the years to come.

The physical therapist’s recommendations:

• Given the findings of the examination and home safety assessment, the physical therapist recommends that the Coopers modify their home to reduce Mrs. Cooper’s fall risk.
• It would also be a good idea to hire a home health aide to assist Mrs. Cooper with her daily tasks.

Click to proceed.

Question 3

Members disagree about the best long-term care option for Mrs. Cooper. What should the team do?

• Consider what is best for Mrs. Cooper.
• Listen to the person with the most seniority.
• Ignore that any conflict has happened.
• Delay finding a resolution until the team can meet again.

Question 3 Incorrect Answer

Try again. This option may not be best for the team or Mrs. Cooper.

Accommodating one opinion without allowing others to share their perspective may resolve the disagreement but is unlikely to enhance interprofessional collaboration.

Avoiding a conflict is unlikely to resolve the disagreement and may create additional conflicts within the team.

Interprofessional collaborative practice should be timely. Delaying a resolution may negatively impact Mrs. Cooper’s care.

Click here to try again.

Question 3 Correct Answer

The team recognizes the importance of understanding the Coopers’ perspectives and preferences.

Person-centered care enables interprofessional collaboration. Asking “What is best for this patient?” is an equalizer across care team members, administrators, and board members alike.

In this way, the patient’s interests drive decision-making, versus the particular interests of any given team member.

It also allows patients to make informed decisions about their treatment and well-being.

Click here to proceed.

Conclusion

The team holds a meeting with the Coopers.

Each member shares their perspective and answers the couple’s questions. The Coopers explain their long-term care preferences.

By the end of the meeting, the Coopers end up with a prioritized list of long-term care options.

Click here to proceed.

Question 4

Understanding each team member’s role is an important step towards establishing interprofessional collaboration. Would you like to go back and complete this activity from a different member’s point of view?

• Yes
• No

End

Thank you for completing this activity.

References and attributions

Activity

Acknowledging Roles and Abilities of Team Members: A Simulated Geriatric Care Team Meeting With the Coopers by Kristine Kamm, Susan Simpkins, Amit Shah, Mary Quiceno, Roopali Gupta, and Kim Hoggatt Krumwiede. Published in MedEdPortal by the Association of American Medical Colleges under a CC BY-NC-SA license. Material was adapted to the H5P format. Content was edited for brevity and tone. Descriptions of role responsibilities were replaced to remain consistent with the textbook content. Branching questions, images, and videos were added.

Roles and Responsibilities

Occupation descriptions from the Occupational Outlook Handbook. Published by the U.S. Bureau of Labor under a public domain license. Lightly edited for clarity.

Images

Copyrighted images used with permission through a TechSmith Snagit license.

Beginning slide. Copyright (c) 2019 adriaticfoto/Shutterstock. No use without permission.

Background. Copyright (c) 2019 pikselstock/Shutterstock. No use without permission.

Meet the Coopers. Copyright (c) 2016 XiXinXing/Shutterstock. No use without permission.

Dietitian. “A Woman in White Coat Sitting at the Table” by beyzahzah is licensed under the Pexels license.

Pharmacist. Copyright (c) 2018 V_L/Shutterstock. No use without permission.

Physical therapist. “Woman in Blue Scrub Suit Using Macbook Pro” by Karolina Grabowska is licensed under the Pexels license.

Physician. “A Woman Looking at the Screen” by Tima Miroshnichenko is licensed under the Pexels license.

Physician assistant. “Person Holding Pen Writing on Paper” by Ivan Samkov is licensed under the Pexels license.

Registered nurse. Copyright (c) 2019 Rocketclips, Inc./Shutterstock. No use without permission.

Rehabilitation counselor. “A Man Working in an Office” by Diva Plavalaguna is licensed under the Pexels license.

Social worker. Copyright (c) 2018 oekka.k/Shutterstock. No use without permission.

Physician conference call. “Woman in White Scrub Suit Wearing Black and Gray Stethoscope” by Tima Miroshnichenko is licensed under the Pexels license.

Physical therapist conference call. “A Female Doctor Having a Video Call” by Karolina Grabowska is licensed under the Pexels license.

Rehabilitation counselor conference call. “Man in Blue Turtleneck Long Sleeve Shirt Doing Video Call” by Diva Plavalaguna is licensed under the Pexels license.

Conclusion. Copyright (c) 2021 Ground Picture/Shutterstock. No use without permission.

Long-Term Care Table Footnotes

1. National Institute on Aging. (n.d.). Long-term care facilities: Assisted living, nursing homes, and other residential care. U.S. Department of Health and Human Services. https://www.nia.nih.gov/health/assisted-living-and-nursing-homes/long-term-care-facilities-assisted-living-nursing-homes

2. Genworth. (2022). Genworth cost of care survey: Median cost data tables. [Annual median costs in Florida]. https://pro.genworth.com/riiproweb/productinfo/pdf/282102.pdf

3. AARP. (2022, January 27). How continuing care retirement communities work [National averages. Annual cost based on monthly average ($3,555) multiplied by 12]. https://www.aarp.org/caregiving/basics/info-2017/continuing-care-retirement-communities.html

4. National Institute on Aging. (n.d.). Aging in place: Growing older at home. U.S. Department of Health and Human Services. https://www.nia.nih.gov/health/aging-place/aging-place-growing-older-home

Conflict Resolution

“Lessons from the Field: Promising Interprofessional Collaboration Practices.” 2015. White Paper, The Robert Wood Johnson Foundation, rwjf.org

“Person-Centered Care” by the Centers for Medicare and Medicaid Services. Published under public domain.

“Conflict Management” by Ronquillo, Y, Ellis, V. L., & Toney-Butler, T. J. Published by StatsPearls Publishing under a CC BY 4.0 license. Edited for brevity and consistency with its new context.