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Brain injury case management

The importance of interdisciplinary working

Adopting such practices can enable becoming more effective as practitioners and improve client outcomes, says Dr Shabnam Berry-Khan of PsychWorks Associates

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Working in a truly person-centred way can have life-changing results for clients – but while teams aspire to deliver this, how many truly do? 

Dr Shabnam Berry-Khan, clinical psychologist, Advanced BABICM case manager and founding director of PsychWorks Associates, highlights the importance of taking an interdisciplinary approach to client rehabilitation – and how, by thinking about our whole underpinning, we can achieve another score for reflective practice

 

Have you noticed how the language around rehabilitation is changing and how words like holistic, joint working, integrated care, co-created goals, collaboration, shared goals, interdisciplinary working are being used more and more? I’m particularly interested in the addition of the word ‘Interdisciplinary’ into my and others’ rehabilitation vocabulary and the potential to be the next crucial step in advancing rehabilitation case management.

Perhaps you might be working interdisciplinarily already. Perhaps you’re not sure if you are.

If you are unsure, a good way of assessing whether you are working in an interdisciplinary way is to ask yourself and separately those in the team what are the overarching issues and goals for your client.

Ask yourself, and answer honestly. Ask everyone on the team. Ask the client. Ask their family.

You might find that either people won’t be able to answer because they don’t know, or, more likely, you’ll get a series of different answers.

This question forms the litmus test of whether a rehabilitation team is working in an interdisciplinary way or in a more multidisciplinary way.

Back to basics

I realise I’ve jumped ahead into terms that might need defining so I’ll do that briefly now:

I see the process of rehabilitation involving thorough analysis of the problems, covering many different domains, such as behaviours, physical needs, medical/neurological conditions, communication abilities etc. The information to be analysed depends on input from several specialist sources, all of whom know the overall goal they are working towards. The goals are typically about maximising potential and quality of life and they require a sound understanding of the impact challenges have on clients’ lives as a whole person within a particular context. It is restorative as best it can be.

Multidisciplinary team working can be defined as embracing the uniqueness of each discipline involved and defining their roles and responsibilities. There may be involvement  from the client and family, but in the main, the emphasis can be more intraprofessional and with the client.

Contrastingly, interdisciplinary team working can be defined as identifying client-centred goals within a team approach that emphasises an interprofessional, team-based approach characterised by joint work and strong communication with and around the client.

The importance of interdisciplinary working

Relevant research in the rehabilitation field talks about the benefits of moving towards interdisciplinary working and we seem to like what we’re hearing as practitioners. We heard about improved outcomes (Singh et al, 2018), better communication between team members (O’Daniel & Rosenstein, 2008)) and great patient satisfaction (IHT website). But, we also hear it is challenging to implement (Misiewicz, 2016) and there is perhaps some confusion with understanding the difference with more ‘standard’ multidisciplinary approaches.

Given how rehabilitation is defined here, it certainly cues us to work in an interdisciplinary way. Working interdisciplinarily might be seen as the missing piece in a lot of therapy packages.

In a Tedtalk about interdisciplinary healthcare by Dr Peng Du, he spoke about how interdisciplinary working helps us keep up-to-date with advances in the field. He highlighted that the the human body and experience is a network of reactions and connections that results in a complex entity. As such, he purports that the human need is not something that can be well understood by a single specialist who is working from a siloed position. He believes bridges between silos need to be made in order to reflect the joined up nature of the human form. Others like Stephanie Walsh Matthews talk further about the creativity and humility that promotes collaborative, shared skilled people because noone is then an expert on their own because the team’s work is the focus and where the effort lies. Tolerance and empathy is developed around the clinical object – in our case, client – and this is an environment conducive to learning and safety. For me, this is truly what client-centred work is all about!

A lot of problems and challenges faced by teams, who are struggling to find ways to advance a client’s rehabilitation, could well be addressed, and indeed solved, by working together and sharing their knowledge and skills in a package that encourages liaison, collaboration, joint working and respectful, creative working. Indeed, this why in every client case, our PsychWorks Associates clinicians are encouraged to propose recommendations that build in liaison with the other therapists on the team – if you don’t, by the philosophies of Du and Matthews, one is much less likely to be an effective clinician in the holistic rehabilitation programme we’re trying to build, implement and finesse.

Enabling the team to achieve interdisciplinary working

To achieve truly interdisciplinary support – that is effectively the pinnacle of person-centred care – is incredibly complex. Without a mechanism for the whole team to work together, teams can’t and don’t do it.

Looking at case management, interdisciplinary working is an attitude, it’s a philosophy, it’s a method, and it requires the buy-in from everyone concerned. From the client to the therapy and care teams to the wider professional network. But, as a case manager, implementing such a known positive requires quite a lot of thinking and consideration to harness the power of the team and collaboration.

So, let’s break it down: What do we have to draw on currently? Well, CQC would endorse that safe healthcare for any client goes back to the understanding of who a client is ie a good quality and holistic assessment. For us in case management, this means a robust Immediate Needs Assessment (INA). From this initial understanding, we can produce a picture of this client, their background, their values, what their needs currently are, and what their ambitions are.

We can also assume that recruitment for support workers and therapists is made from this pen picture framework. The type of team your client needs to have around them to feel attuned, aligned and like they belong is likely to contribute to better outcomes. By understanding the client, we can then understand their care and therapy needs, and who is best to deliver them. With the recruitment challenges we are hearing so much of at the moment, this is no mean feat for any case manager.

We also know that communication is key to a care and therapy programme because the power of the respectful, open-minded and innovative clinician is evident in their verbal communications and their non-verbal behaviours. Keeping in touch with colleagues, sharing feedback from sessions, thinking about the meaning of certain data within the patchwork of different specialisms are all vital in interdisciplinary clinical practice.

We also know that collaboration underpins the entire professional machine. Meeting regularly – formally and informally – needs to be encouraged and funded to provide the best approach for the client. Without the supported space to promote such collaborations, interdisciplinary working will not be possible.

There is a lot for case managers to think about and coordinate. Coming back to the question posed at the start of this article, without checking in about the goals being worked on, we run the risk of falling back into siloed, multidisciplinary team functions.

Recognising interdisciplinary team working can be difficult to achieve for teams, and in the absence of a model developed specifically for personal injury work, at PsychWorks Associates, I have developed our own case conceptualisation model – a formulation-based approach which supports interdisciplinary working and keeps the client at the centre of rehabilitation at every point. It is preliminarily called the Personal Injury Formulation and Intervention Model (PIFIM).

By having a model to work from, and refer back to, this can be the means for any individual members of the team at any point in the client’s rehabilitation – outside of the usual multidisciplinary team meetings – to facilitate collaborative working.

This way, we are being guided by something that helps us understand how we fit with other people and how what we produce can provide additional insight for others on the team. We can see how everyone is adding their contribution into something that makes perfect sense for the client – because it has been based around the client from the outset and the approach to rehabilitation is shared.

It’s a bit like an orchestra: every musician (team member) has the same score (formulation) to follow which is coordinated by the conductor (case manager), and the outcome is in making music considered beautiful by its audience (the client and family). Of course, this imagery doesn’t quite capture the involvement of the client and their family, but I hope you get the gist!

Without musicians fit for the score, without an audience understanding what they are participating in, and without a skilled conductor to implement the score, the sound is likely to be far from beautiful other than by chance. Rehabilitation becomes a whole, inclusive approach that can be reviewed and improved for those maximised results.

Another point for reflective practice

But, no interdisciplinary model works in isolation of our humanness so we need to ask ourselves some hard questions:

  • Do I know the client well enough?
  • Have I recruited the right team around them?
  • How can I improve communication between team members?
  • Can interventions be more joined up between the disciplines?
  • Do I receive good enough updates?
  • What aspects of the programme are/are not working?
  • Have the client’s needs changed?

And these hard questions cannot be asked superficially. Case managers will require a balanced weekly timetable that allows for processing of the clients’ needs, reflecting on clinical intuition, opportunity to receive robust supervision and attend CPD events, and also to facilitate the all-important communication and processing time between team members.

At PsychWorks Associates, we use a 80:20 model, where 20 per cent of our associates’ weeks are reserved for non-clinical practice such as reflection, supervision and CPD. To take the time to look at the work that is being done and to have the space to take a step back, process and review. This is a very valuable part of being a clinician and indeed being a team player especially in interdisciplinary work.

Evolution or revolution?

I believe it is a very positive thing that we are slowly moving away from multidisciplinary ways of working and towards an interdisciplinary approach. There’s a lot to do to ensure this approach can be embedded in practice, not least because funding needs to reflect the time required, but we also need the tools to be able to shift the culture to implementation. I hope the PIFIM model is seen as a promising start to promote case managers and other rehabilitation colleagues to work more collaboratively with one another.

Ultimately, what we are all trying to achieve is the best possible quality of life for our clients, and we all want to do everything we can to support them in this. By embracing a truly interdisciplinary way of working, we are finding a way forward which will benefit the team, the clinicians within it, and crucially, the client. Perhaps you will join us in this revolution? If so, take a look at www.psychworks.org.uk/jobs/ and be in touch.

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