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Caring with Compassion, Domain 2: Bio-psychosocial Care
4. Interdisciplinary Team Care
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4. Interdisciplinary Team Care
Knowledge Objectives:
Learners will be able to describe:
1. Training, licensure, and scope of practice of nurse practitioners, physician assistants,
and pharmacists.
2. Training, licensure, and scope of practice of social workers and case managers.
3. Scope of practice of addiction counselors and mental health providers
4. Outreach, team-based health care delivery models of demonstrated effectiveness
among homeless persons.
5. Specific team skills and communication approaches essential to high-functioning,
interdisciplinary care teams.
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Objective 1: Training, licensure, and scope of practice of nurse practitioners, physician
assistants, and pharmacists.
Case 1
A 25 year-old homeless woman has difficulty accessing the nearest primary care
physician’s office for herself and for her 2 children, because the physician’s building is not
on a public bus route. Her case manager provides her with a pamphlet introducing a
nearby clinic run by a collaborative group of volunteer healthcare professionals. The clinic
pamphlet lists the names of the core clinical team members.
Which of the following professionals is most likely to be able to independently function as
her family’s primary care provider?
1.
2.
3.
4.
5.
Sheryl Brown, ANP
Mark Perez, PA
Luanda Smith, LPN
John Rodriguez, PharmD
Holly Chang, RN
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Case 1 Answer
Which of the following professionals is most likely to be able to independently function as
her family’s primary care provider?
1. Sheryl Brown, ANP. Correct. In most states, advanced nurse practitioners may be
recognized as primary care providers, although some states require that they establish
a collaborative agreement with a physician in order to practice.
2. Mark Perez, PA. Incorrect. Physician assistants must practice under the supervision of
a physician.
3. Luanda Smith, LPN. Incorrect. Licensed practical nurses perform clinical support
services under the supervision of a registered nurse (RN) or physician.
4. John Rodriguez, PharmD. Incorrect. Pharmacists do not function as recognized primary
care providers, although they often support provision of preventive services and
chronic care management.
5. Holly Chang, RN. Incorrect. Registered nurses cannot perform independent primary
care practice, although they often provide essential primary services within a primary
care team.
To meet the spectrum of bio-psychosocial needs of homeless and medically underserved
patients, multiple health care providers with complementary skills must work together
effectively and efficiently. A remarkable range of responsibilities and skills are represented in
members of the health care team. The following brief descriptions introduce the scope of
practice for clinical health professionals who commonly care for homeless persons.
Nurses
Licensed Practical Nurse (LPN)

Training: LPNs have completed up to 12 months of basic nursing skills training
from an accredited School of Nursing.

Licensure and Scope of Practice: LPNs must take a national licensing examination
and must obtain a state license to practice nursing. They practice under the
supervision of a registered nurse (RN) or physician. LPNs are limited in scope of
practice (e.g. they may not start blood products on patients or complete admission
assessments in hospitals), but they excel in day to day management of patient
needs.

Clinical Team Roles: LPNs may may function as an office nurse in a primary care
clinic, provide bedside care in a tertiary care center or skilled nursing facility, or fill
the role of case manager. In underserved clinics, LPNs may be essential to provision
of routine direct patient care, such as placement and reading of PPD tests. As
clinical team extenders, they may be essential for routine communication and
patient management needs, including telephone follow up and triage.
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Registered Nurse (RN)

Training: RNs may be educated at the diploma (hospital-based), associate, or
bachelor’s level. Today, most RNs are prepared through associate (2-year) and
baccalaureate (4-year) degree programs.

Licensure and Scope of Practice: RNs must graduate from an accredited school of
nursing and must pass a national licensure exam (NCLEX). Upon successful
completion of the NCLEX, RNs must obtain a license to practice nursing from the
state. State requirements for maintenance of licensure vary; most require that RNs
complete a minimum number of continuing education hours.

Clinical Team Roles: RNs play an integral role in community clinics, ranging from
providing essential services to the provision of home-based services through the
public health department and private agencies.
Nurse Practitioner (NP)

Training: NPs are bachelor’s prepared RNs who have additionally completed two to
four years of graduate degree education in nursing. As part of their education, NPs
complete a minimum number of direct patient care hours. NPs can be trained in
primary care, acute care, midwifery, or anesthesia. Furthermore, NPs may
specialize by population: pediatric, adult/gerontology, women’s health, or family
care.

Licensure and Scope of Practice: After graduation from an accredited school of
nursing, NPs sit for a national certification examination for their population and
setting specialty (eg: Adult-Gerontology Primary Care, Pediatric Acute Care). After
obtaining national certification, NPs must obtain an additional license to practice
advanced nursing in their state. NPs must complete continuing education hours
and direct patient care hours to maintain both licensure and certification. NPs are
trained in health care systems, disease prevention and management (including
mental health), and health promotion. As such, NPs are capable of practicing
independently to diagnose common illnesses and chronic diseases, initiate
treatment plans, and prescribe medications (2). Actual NP scope of practice varies
widely between states, due to legislated restrictions. In some states, NPs may
practice entirely independently, without any collaborative agreement with a
physician, while in other states NPs have limited authority. In nearly all states, NPs
may serve as primary care providers and may bill for services under Medicare and
Medicaid, but are not reimbursed at the full physician rate. In some states, NPs may
prescribe controlled substances, but must have their own DEA registration. One
useful compendium of state-based scopes of practice is available at:
http://www.bartonassociates.com/nurse-practitioners/nurse-practitioner-scopeof-practice-laws/.

Clinical Team Role: In caring for the homeless and medically underserved, NPs most
often act as primary care providers. They may provide care out of a free clinic,
Federally Qualified Health Center, or Nurse Managed Center. NPs can care for
patients’ acute needs, such as cold and flu symptoms and musculoskeletal injuries,
as well as manage chronic illnesses and common mental health problems. NPs
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consult with physician collaborators, mental health workers, and social workers as
needed to provide holistic care to patients. Additionally, in most states NPs can
complete assessments and paperwork for Social Security Disability and
Supplemental Income (SSD and SSI) and insurance claims. NPs can also serve as
caseworkers, often dealing with the most complex or difficult patients.
Physician Assistant (PA)

Training: Several science pre-requisites are required prior to enrolling in a PA
program. For this reason, PAs generally hold a bachelor’s degree, often in science,
earned prior to enrollment in PA training. PA programs vary by institution in
length, but must be at least one year long with at least four months of classroom
instruction. In addition to classroom training, PAs complete rotations through
several medical areas including sub-specialties. On completion of training, PAs have
usually completed the equivalent of a Master’s degree in total instruction.

Licensure and Scope of Practice: Upon graduation, PAs must pass the Physician
Assistant National Certifying Exam. After initial certification, PAs must complete
continuing education requirements to maintain their credentials. PAs are licensed
by states, and must pass recertification exams to maintain licensure. PAs work
under the supervision of a physician. Unlike a NP who may practice independently
in many states, a physician must be on-site for PA practice. PAs must have a
documented collaborative relationship with a physician to obtain prescriptive
authority. Similar to NPs, PAs may bill insurance companies, however they are
reimbursed at a reduced rate to physicians.

Clinical Team Role: PAs may work in acute or primary care. They may care for the
acute needs of patients or manage common chronic illnesses. Because their care is
directly supervised, their team role is primarily determined by the needs and skills
of the supervising physican; they may order and interpret diagnostic tests, provide
treatment, and complete insurance paperwork.
Pharmacists

Training: Pharmacy schools require a broad range of college level science prepharmacy prerequisites, so pharmacists usually possess a bachelor’s degree in
science prior to pharmacy school entrance. The Doctor of Pharmacy degree
(PharmD) requires a four-year program after the pre-pharmacy curriculum. Course
work includes classroom work and supervised clinical work experiences. Further
training – a 1 or 2 year residency program – is available.

Licensure and Scope of Practice: All states require a license to practice pharmacy.
Pharmacists must pass two exams: a general pharmacy exam, and a state-specific
pharmacy law exam. Pharmacists dispense drugs and medications prescribed by
authorized clinicians. While they often make suggestions to prescribing clinicians,
they may not prescribe medications independently.

Clinical Team Roles: Pharmacists are highly valuable team members in the care of
medically underserved patients. Their roles have been expanding, particularly for
care of patients with chronic illnesses. They can assist with identification of
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medication resources, advise clinicians regarding cost-effective regimens, instruct
patients on the use and proper dosage of medications, and monitor medication use
for patients with chronic illnesses. They often serve an essential role in identifying
expected side effects and interactions with other prescription and nonprescription
medicines. These professionals also order and maintain inventories of medications
and medical supplies required for use in the clinical setting.
Clinical teams comprising nurses, physician assistants (under physician supervision) and
pharmacists can provide a broad range of services for patients with complex biospychosocial
care needs. (Figure 1)
Figure 1: Clinical Team Roles: Nursing, Physician Assistant, and Pharmacist
Role
Education
Common Clinical Roles
LPN
1 year
Routine direct patient care, case management, and
patient communications under under RN or
physician
RN
2-year
or 4-year (BSN)
Direct patient care, home care services, and
outreach care, under physician supervision
NP
BSN + Master’s degree
(MS)
Primary care practitioner, advanced office practice,
complex case management; practices independently
or with a physician in a collaborative relationship
PA
Prerequisites and 1+
years (MA equivalent)
Pharmacist
Pharm D
Physician supervision required, and clinical role is
determined by arrangement with the supervising
physician
Independent clinical dispensing practice, or
collaborative clinical team relationship, including
chronic care management
Key Points:
 LPNs have more limited formal training compared with RNs, but serve many
essential roles in responding to routine patient needs and addressing
administrative necessities.
 RNs play an integral role in community clinics, ranging from providing essential
services to the provision of home-based services through the public health
department and private agencies
 Nurse practitioners may have independent practice rights, or may prescribe within
a collaborative physician relationship, depending on state regulations. In many
states, nurse practitioners may function as primary care clinicians, and this role is
particularly common in care of the underserved and homeless population.
 Physician assistants work under the direct supervision of a physician. The
responsible physician determines their scope of practice. Therefore, they have
highly variable roles.
 The role of pharmacists is expanding, with more emphasis on patient assessment,
monitoring and modification of chronic medication regimens, and patient
counseling.
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Objective 2: Training, licensure, and scope of practice of social workers and case managers.
Case 2
You are meeting with a community service group that wishes to set up a free healthcare
clinic for the local underserved population. They ask you to comment on the potential role
of a case manager who has expressed interest in working at the clinic.
Which of the following is a correct statement regarding the field of case management?
1. The prerequisite degree for case management is a nursing degree (RN or higher) with
advanced practice training in case management.
2. The prerequisite degree for case management is a social work master’s degree (MSW)
with advanced practice training in case management.
3. There is no licensure requirement for case management.
4. The focus of case management is on cost reduction through utilization review, hospital
discharge planning, and outpatient utilization management.
5. Case managers are employed by insurance companies, not by health care delivery
systems or by specific clinics.
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Case 2 Answer
Which of the following is a correct statement regarding the field of case management?
1. The prerequisite degree for case management is a nursing degree (RN or higher) with
advanced practice training in case management. Incorrect. There is no prerequisite
degree for case managers, although a degree in social work or nursing is common.
2. The prerequisite degree for case management is a social work master’s degree (MSW)
with advanced practice training in case management. Incorrect. There is no
prerequisite degree for case managers, although a degree in social work or nursing is
common.
3. There is no licensure requirement for case management.
4. The focus of case management is on cost reduction through utilization review, hospital
discharge planning, and outpatient utilization management. Incorrect. Case
management focuses on care planning, facilitation of services, care coordination,
functional evaluation, and social advocacy. Improved care quality and reduced cost can
both be obtained through effective case management, but cost is not the primary focus.
5. Case managers are employed by insurance companies, not by health care delivery
systems or by specific clinics. Incorrect. Case managers may be hired by diverse
organizations to improve the quality, continuity, coordination, and costs of care
Complementing the clinical health care team, social workers and case managers provide
particular expertise in psychosocial and aspects of patient care needs. In settings without
onsite social workers and case managers, such as student-run free clinics, clinicians often
have increased responsibility for triage of patient support needs and identification of
appropriate and available community resources. Engagement of other interdisciplinary team
members, such as LPNs, RNs, and pharmacists, may be possible to assist with some care
needs.
The following brief descriptions introduce the usual scope of practice for social workers
and case managers. Due to institutional variability of job descriptions, clinicians should
additionally learn the scope of practice for these roles as defined within their own institutions.
Social Worker

Training: Professional social workers hold a bachelor’s or a master’s degree in
social work (BSW or MSW). Social workers trained in providing mental health
services and counseling are called Clinical Social Workers.

Licensure and Scope of Practice: Master’s prepared social workers may become
licensed clinical social workers (LCSW) after completing supervised work
experiences, additional coursework, and a licensure exam. Licensure is regulated at
the state level and permits social workers to bill insurance companies for
counseling services.

Clinical Team Roles: All social workers can provide counseling interventions to
address social needs, and licensed clinical social workers (LCSWs) can provide
more extensive mental health counseling and crisis intervention. Team care roles
may include: provision of short term mental health counseling; accessing
community resources such as housing, financial assistance, medication assistance
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programs, insurance application, or transportation; coordination of care with
Community Mental Health agencies; safety and violence interventions; substance
abuse education; and access to substance abuse treatment resources.
Case Manager
Case management involves ongoing, proactive involvement in assessing a patient’s
needs and developing a therapeutic relationship in order to effectively implement plans,
coordinate care, and address care barriers. For high risk and homeless patients, case
managers may be helpful in advocating for safe, permanent housing, access to health care
and medications, income security, and care for psychiatric and behavioral problems. Case
managers strive to meet these clinical and social needs while promoting quality, cost
effective care.
In contrast to a social worker, the case management role tends to be more longitudinal,
with a focus on coordination of care for high risk and high need individuals. Case managers
additionally address appropriate utilization and cost-effectiveness of care; therefore, case
managers often play an essential role in the care of homeless and medically needy
populations. The specific functions of a case manager will vary by the particular setting
and employer: hospital, community, clinic, or government/insurance company.

Training and Licensure: Case managers are most often social workers but may be
nurses or even persons without specific health professions licensure. Certification
in case management is available but not required through the Case Management
Society of America (http://www.cmsa.org/). There is no licensure requirement,
although many case managers are separately licensed through their nursing or
social work professions.

Scope of Practice: Responsibilities can be limited to short-term resource
management (e.g., hospital utilization review) or resource acquisition (e.g.,
transportation, medications) but usually include longer-term or continuity
enhancing activities. Long-term care roles include ongoing coordination of care
among multiple health professionals and healthcare systems. A case manager can
develop a longitudinal and consistent relationship with high risk and high need
patients, facilitate transitions of care, and even accompany patients to care visits to
minimize fragmentation of care. As such, case managers can be uniquely capable
of providing longitudinal, continual assessment of patients’ medical, psychological,
and social needs in order to obtain resources and limit social and medical episodes
of decompensation. They may also provide direct care, such as coaching behavioral
change or supervision of medical adherence.

Clinical Team Roles: The broad skills of a case manager are particularly important
for high risk and high utilization patients. Because of their focus on continuity and
patient coordination, case managers can promote improved care quality [1, 2], with
data suggesting increased cost-effectiveness[2] and improved clinical outcomes,
even for patients with severe mental illness[3]. Engagement of case manger
services may be particularly critical for patients with multiple biomedical,
psychiatric, and social-behavioral comorbidities who need support over time. In
contrast, standard social work services are more appropriate for discreet and time
limited needs. For instance, case management may be particularly helpful for a
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patient treated by Community Mental Health providers, medical providers, and
substance treatment centers who requires support for adherence with a complex
neuropsychiatric treatment plan in order to minimize inappropriate utilization of
emergency or high cost services.
Figure 2: Clinical Team Roles: Social Worker and Case Manager
Role
Education
Common Clinical Roles
Social Worker
Bachelors (BSW) or
Masters (MSW)
Short term counseling, crisis intervention, access to
community resources, and access to substance
abuse treatment
Case Manager
Not specified (often
trained in nursing or
social work)
Longitudinal coordination of care for high risk and
high utilization individuals
Key Points:
 Social workers, while often focusing on helping patients acquire resources or
insurance, are also qualified to perform advanced psychosocial assessment and
counseling.
 Case managers can facilitate care coordination and quality for complex, vulnerable
patients.
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Objective 3: Scope of practice of addiction counselors and mental health providers
Case 3
A 26-year-old man is discharged from an acute care hospital following admission for
alcoholic hepatitis. He reports daily use of oral opioids or heroin in addition to binge
alcohol use. On discharge, his case manager assists him in scheduling a visit with an
addiction counselor.
All of the following services can be provided by an addiction counselor EXCEPT which
one?
1. Cognitive behavioral therapy to identify and alter his negative behaviors.
2. Substance replacement treatment with methadone.
3. Peer substance use counseling to modify his relationships.
4. Examination and modification of his daily environment to reduce substance use
‘triggers’.
5. Identification of childhood experiences leading to substance abuse.
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Case 3 Answer
All of the following services can be provided by an addiction counselor EXCEPT which
one?
1. Cognitive behavioral therapy to identify and alter his negative behaviors. Incorrect.
Many addiction counselors provide psychological counseling including CBT.
2. Substance replacement treatment with methadone. Correct. Addiction
counselors are not licensed to prescribe medications.
3. Peer substance use counseling to modify his relationships. Incorrect. Addiction
counselors often facilitate peer counseling relationships among their clients.
4. Examination and modification of his daily environment to reduce substance use
‘triggers’. Incorrect. Addiction counselors help patients examine and modify social
and environmental triggers, and develop alternatives to limit ‘triggers’ to substance
use.
5. Identification of childhood experiences leading to substance abuse. Addiction
counselors may incorporate psychodynamic counseling as one component of a
treatment program.
Homeless and medically underserved persons often require not only biomedically and
socially supportive care provided by physicians, nurses, case managers, social workers and
pharmacists, but also ongoing, concurrent care provided by addiction counselors and/or
mental health specialists. Although these mental health services usually occur in times and
places separate from other health services, it is important for clinicians to understand the
types of mental health and behavioral services provided.
Addiction counselors

Training and Licensure: Addiction counseling centers and addiction counselors are
regulated by state requirements, so licensure or certification is required by each
state. Certification standards are often broken into achievement levels, (e.g.
Counselors I and II) which are determined by the quantity of hours spent in
classrooms and in supervised clinical training. Minimum degree standards vary
from high school equivalency to masters’ degree; most addiction counselors have
completed significant higher education, such as a MSW (masters in social work.)

Scope of Practice and Team Role: Addiction counseling addresses not only the
identified addiction but also any co-existing psychosocial issues, physical health,
mental health and legal concerns. The counselor and client develop mutually
agreeable treatment goals and determine appropriate strategies for achieving those
goals. Treatment may include individual or group counseling sessions, inpatient
rehabilitation, or outpatient programs. Outpatient sessions generally include assessment
and evaluation of progress, education, planning and coping strategies, supportive
counseling, and targeted treatment recommendations.[4] For reasons of confidentiality,
addiction counselors may not share the details of a client’s care, but team
communications may occur with clinicians, social workers, and case managers in order
to ensure that biomedical complications are stabilized and psychosocial supports are
addressed.
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Mental Health Providers
An array of professionals may provide mental health care: psychiatrists, clinical
psychologists (clinical psychology PhD or PSY.D), licensed clinical social workers,
psychiatric clinical nurse practitioners, licensed counselors with a master’s degree in
counseling, or individuals with no formal training.[4] Selection of a professional will
depend on care needs. Psychiatrists or psychiatric clinical nurse practitioners may be
required for prescription medication management, while clinical psychologists are skilled
in psychotherapy techniques, psychoanalysis, behavioral therapy, family therapy,
cognitive retraining (e.g. cognitive behavioral therapy), biofeedback, and social
learning.[5] As noted previously, licensed clinical social workers can provide general
mental health counseling and crisis intervention, with particular expertise in problem
solving and identification of support services.
Key points
 Addiction counselors address not only the identified addiction(s) but also any coexisting psychosocial issues, physical health, mental health and legal concerns.
 Addiction counseling treatment may include individual or group counseling
sessions, inpatient rehabilitation, or outpatient rehabilitation programs. Outpatient
sessions generally include assessment and evaluation of progress, education,
planning and coping strategies, supportive counseling, and targeted treatment
recommendations.
 Mental health providers include physician psychiatrists, PhD psychologists,
psychiatric clinical nurse practitioners, licensed clinical social workers, and
master’s degree counselors. Clinical psychologists have expertise in formal
psychotherapeutic and cognitive/behavioral retraining techniques, but do not
prescribe medication.
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Objective 4: Outreach, team-based health care delivery models of demonstrated
effectiveness among homeless persons.
Case 4
Which of the following interventions has NOT been demonstrated to improve the
health of homeless persons?
1. Case management
2. Assertive community treatment teams
3. Same-site medical and mental health care
4. Free access to medications
5. Access to ‘dry’ housing
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Case 4 Answer
Which of the following interventions has NOT been demonstrated to improve the
health of homeless persons?
1. Case management
2. Assertive community treatment teams
3. Same-site medical and mental health care
4. Free access to medications
5. Access to ‘dry’ housing
Early studies from the 1970’s and 1980’s demonstrated that outreach-oriented, teambased interventions among homeless persons can improve mental health and substance abuse
outcomes. In systematic reviews of specific interventions to improve the health of homeless
persons published in 2005 [6] and updated in 2011[7], successful interventions included:
 Case management
 Early housing after hospital discharge
 Engagement with mental health care providers (for the mentally ill)
 Engagement with substance abuse services (for substance abusers)
 Health promotion programs
Outcomes included utilization of mental health / substance abuse services, achieving
stable housing, decreasing risk behaviors, and clinical outcomes such as functional
improvement and abstinence. Many studies were of limited methodological quality, and none
addressed physical health.[7]
Multiple studies have demonstrated clinical benefit for co-location of medical services at
the same site where mental health services are provided. Medical services may include
special services for those with substance use disorders, although traditional co-location
models focus on primary medical and mental health care. This supports access to necessary
care for mental health patients with significant co-morbidities, with the goal of increasing
preventive care utilization and improving chronic care management. Co-location reduces
hospitalizations, improves access to care, and improves health status in a cost-neutral
manner.[8]
It is not surprising that programs to provide housing have been associated with improved
housing status. However, controversy remains regarding the best approach for housing
provision that supports health and recovery for homeless individuals with substance
dependence disorders. Recent studies have emphasized the central role of abstinencedependent housing in improving not only housing status but health, especially following acute
medical events.[7] In contrast, “housing first” intervention programs remove barriers such as
sobriety from shelter and housing requirements in order to support subsequent efforts at
behavior change and medical adherence.[9, 10] Therefore, is possible that successful housing
intervention programs depend not simply upon on the sobriety status for individuals, but on
the total care program supporting the housed individual.
“Street Medicine” Outreach Programs
Street medicine programs provide mobile services for “hard sleeper” homeless and others
who are unable to obtain shelter, while also providing services to sheltered persons. These
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programs are particularly prominent in major urban areas, but smaller programs exist in
many non-urban communities. Street medicine outreach teams usually consist of two or more
health care professionals, often including nurses and social workers but sometimes including
physicians. They go to the homeless in the streets, under bridges, and in tent cities. Their
primary goals are to establish relationships, provide contact information, and address
immediate needs when possible. In some models ongoing therapy (e.g., medication
administration) and monitoring (e.g., limited physical examination, blood pressure or blood
sugar monitoring) are performed in the field as well.
Unfortunately, research evidence for morbidity or mortality benefit related to street
medicine outreach for “hard sleepers” is quite limited, despite significant coordinated team
efforts[11], but data has demonstrated improved process quality measures such as flu shots,
Pap tests, and mammograms.[11] Importantly, street medicine teams function out of a deep
desire to directly address the moral frameworks of social justice and altruism/compassion
that are essential to clinical care. In addition, outreach team members have been essential
voices in advocating more globally for compassionate treatment and provision of essential
subsistence services for our most needy and vulnerable populations.
Assertive Community Treatment
Assertive Community Treatment (ACT) is a type of intensive community-based mental
health service provided to individuals with serious mental illness who have high psychiatric
hospital utilization and/or needs for crisis stabilization.[12] ACT was developed in the 1960’s
during the shift of psychiatric care to the outpatient setting, around the time that the
Community Mental Health system was established. Rather than utilizing a case manager who
visits the patient to encourage and facilitate adherence with separate office-based care, ACT
incorporates direct provision of psychiatric care and rehabilitation services in residential and
community settings by ACT team members for a small, defined caseload of individuals.
Therefore, ACT multidisciplinary staff are the direct providers of psychiatric and
rehabilitative treatment.[13]
Elements of the ACT model [14]:
 Services are targeted to persons with serious mental illness
 Services are provided directly by the ACT team
 Team members share responsibility for the individuals served
 Small staff to consumer ratio (1 to 10)
 No time limit on the team’s involvement with an individual
 Services are available 24 hours a day, 7 days a week
 Interventions are provided in the location where the problem occurs rather than
in the clinic or office
 Treatments and services are comprehensive, flexible, and individualized
 Team members are assertive in engaging individuals in treatment
Randomized controlled trials have demonstrated that ACT decreases hospitalizations,
increases housing stability, and increases patient and family satisfaction.[14] In homeless
populations, compared to standard case management, ACT reduces homelessness and
symptom severity among severely mentally ill patients.[15]
ACT is delivered through Community Mental Health (CMH) departments; because CMH
systems often function separately from the rest of the health care system, clinicians caring for
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homeless persons or persons with severe mental illness should ask whether their patients are
also under care of an ACT outreach team.[12]
Key points
 Outreach-oriented, team-based interventions of demonstrated success in
improving the health of homeless persons include:
o Case management
o Engagement with mental health care providers and/or substance abuse
services as necessary
o Co-located medical and mental health care
o Access to housing
o Assertive community treatment
o Health promotion programs
 Street medicine outreach programs have demonstrated improvement in clinical
process measures while addressing principles of social justice and compassionate
care, although research evidence to date for clinical outcome improvement is
limited.
 Assertive Community Treatment (ACT) is team-based, outreach oriented care for
severely mentally ill persons; it emphasizes direct provision of necessary care,
rather than care facilitation or case management.
 ACT has demonstrated effectiveness in decreasing hospitalizations, increasing
housing stability, and increasing patient and family satisfaction.
 For the severely mentally ill homeless population, compared to standard case
management, ACT reduces homelessness and symptom severity.
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Objective 5: Specific team skills and communication approaches essential to high-functioning,
interdisciplinary care teams.
Case 5
A local student-run clinic is seeking to establish an interdisciplinary team care program for
high-risk homeless patients who frequent their clinic. You are asked to provide leadership
in the planning phase of this initiative.
Which of the following is NOT considered to be a key component of high functioning, interdisciplinary, team-based health care?
1. Established systems for shared financial resources and costs between disciplines.
2. Shared goals that are established by the team, patient, and patient’s support persons.
3. Clear expectations for each team member’s functions, responsibilities, and
accountabilities.
4. Specified channels for communication that are used by all members across all settings.
5. Measurable processes and outcomes for feedback on team function.
Caring with Compassion, Domain 2: Bio-psychosocial Care
4. Interdisciplinary Team Care
19
Case 5 Answer
Which of the following is NOT considered to be a key component of high functioning, interdisciplinary, team-based health care?
1. Established systems for shared financial resources and costs between disciplines.
Correct. While financial realities clearly affect teams, the key components of
interdisciplinary team function are generally considered separately from any financial
arrangements between team components.
2. Shared goals that are established by the team, patient, and patient’s support persons.
3. Clear expectations for each team member’s functions, responsibilities, and
accountabilities.
4. Specified channels for communication that are used by all members across all settings.
5. Measurable processes and outcomes for feedback on team function.
When complementary clinical and allied professionals work together as a highly
collaborative team, such care is termed “interdisciplinary team care.” Interdisciplinary teams
comprise expertise across the biopsychosocial spectrum and can be essential to the care of
highly complex patients, including medically complex homeless persons. Yet, the mere
involvement of multidisciplinary providers does not ensure success. Effective teamwork is not
spontaneous; it requires specific skills.
A large body of research exists on the factors constituting and promoting good teamwork.
For healthcare purposes, care teams can be highly variable in composition, size, setting, and
communication methods. Yet, essential team-based care principles can be seen in groups that
embody “teamness.”[16, 17] (Figure 3)
Figure 3: Five Principles of Team-Based Health Care[16]
Shared Goals
Clear Roles
Mutual Trust
Effective
Communication
Measurable
Processes and
Outcomes
Care team, patient, and family/support persons work to
establish shared goals reflecting the patient’s and family’s
priorities. Goals should be clearly articulated, understood,
and supported by all team members.
Clear expectations for each team member’s functions,
responsibilities, and accountabilities, which optimizes the
team’s efficiency and divides labor as possible
Team members earn each others’ trust and create strong
norms of reciprocity
The team prioritizes and continually refines its
communication skills, maintains channels for candid
communication that are used by all members across all
settings.
The team agrees on and implements reliable and timely
feedback on both team functioning and achievement of team
goals, to track and improve performance.
20
Caring with Compassion, Domain 2: Bio-psychosocial Care
4. Interdisciplinary Team Care
In ideal circumstances, teams are proactively designed within a group planning process
that allows for direct and explicit attention to each of the five team-building principles.
Practically speaking, it may be helpful to approach the principles of team-based care from the
point of view of common challenges to team function in less-constructed settings. The
following challenges should be kept in mind[13, 16]:
 Goals. Do patient and team member goals appear to be congruent? Are
family/support members sufficiently engaged in the patient’s goals? Are there
conflicts in goals between care team members that need to be resolved?
 Roles. Are team members aware of potentially overlapping competencies and
responsibilities? Are there professional preconceptions regarding role
competencies that need to be addressed or corrected by clarifying the scope of
practice of team members? Is there inefficiency or conflicting care related to
unnecessary overlap of roles?
 Trust. Do team members express shared values of honesty, discipline, and humility?
Is there a need to clarify scope of practice to improve trust in the division of labor?
Are active and reciprocal communications in place to support reciprocity of trust?
Have providers had honest communication regarding their capacity to complete
necessary tasks?
 Communication. Is there a common language among team members, avoiding
jargon specific to particular professional roles? Is plain language used to engage the
patient and support members? Do communication systems allow free flow of
information across all settings and individuals?
 Measurable Processes and Outcomes. Are problems clearly identified and described,
allowing for effective decision making? Are decision-making and leadership roles
clear when necessary, and flexible when needed? Is a timeline in place if
appropriate? Do team members reflect shared values of creativity and curiosity,
seeking to solve problems and reflect on lessons learned?
Putting it All Together
To conceptualize potential team roles in a clinical setting, consider the team care
necessary to meet the needs of the following patient:
You are providing care at a local homeless shelter’s medical clinic when a case
manager approaches you for assistance in the care of a 75 year-old Japanese man. He
is living in the country as an illegal immigrant, has no health insurance, no job, and no
family. He rotates between living outdoors and living in warming centers. The shelter
administrative staff and caseworkers would like you to evaluate him because many
shelter residents have complained about his smell. They state that while he appears
only slightly dirty, the smell is "like rotting flesh". The patient, who has only
intermittent and scattered contact with the shelter clinic, reluctantly presents for
evaluation.
Your patient’s English is limited, but you determine that he has severe mental
illness as well as bilateral trench foot. He reports that he had trench foot in the past
and that he knows the best way to treat it is to "keep it moist". Despite repeated
education as to the correct treatment for trench foot (drying, not moisture), the
patient refuses to stop "soaking" his shoes in efforts to maintain a moist environment
Caring with Compassion, Domain 2: Bio-psychosocial Care
4. Interdisciplinary Team Care
21
for his feet. In addition, he declines treatment for mental illness. After consultation
with the shelter administrative team, the case manager, the social worker, your
medical director, and the clinical support staff, your team establishes goals of care:
resolution of severe trench foot, necessary treatment of his mental health disorder,
and establishment of hygiene necessary for non-disruptive continued residential care
at the shelter. Your team institutes the following plan:
 He will be presented with a contract for continued care and housing at the
shelter. In partnership with the patient, measurable outcomes are established:
in order to continue care and housing at the shelter, he must present to the
hospital for admission as required for intensive care of his severe trench foot.
 While he is hospitalized, the clinician and social worker will communicate with
an inpatient psychiatry team, who will evaluate him and document their
findings.
 Meanwhile, the patient’s mental health case worker and the shelter social
worker will collaborate with you (the clinician) and start the process to obtain
a court order for the patient’s necessary medical and mental health treatment.
 Once the client is discharged from the hospital, the case manager, social
worker, and clinician will provide documentation and testimony as needed to
obtain the court order and implement care necessary for his mental and
physical health.
 Patient mental health, physical health, housing status and social supports will
be monitored for success.
In this scenario, all members of an interdisclipinary team are integral to the achievement
of the desired measurable outcomes. A collaborative effort, defined goals, ongoing open
communication, effective distribution of roles, and respect for each member’s expertise and
scope of practice is essential to success of the established care plan.
Key Points:
 Interdisciplinary teams comprise expertise across the biopsychosocial spectrum
and can be essential to the care of highly complex patients, including medically
complex homeless persons.
 Five key principles can be seen in groups that embody effective team care:
o Shared goals
o Clear roles
o Mutual trust
o Effective communication
o Measurable processes and outcomes
 Effective team members reflect shared values of honesty, discipline, humility,
creativity and curiosity.
22
Caring with Compassion, Domain 2: Bio-psychosocial Care
4. Interdisciplinary Team Care
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