Interprofessional Teaming Symposium on Dementia
Xavier University,
February 27, 2025
Group A
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader:
Time keeper:
Recorder:
Nursing | Hannah Anderson |
Psychology | Annaliet Delgado-Rodriguez |
Social Work | Aj Armstrong |
HSA | Timothy Bamugemereire |
OT | Domi Amato |
OT | Ashley Popp |
PT | Natalie Akers |
PT | Jodie Lewis |
SLP | Al-Akasheh, Loreen |
SLP | Pleiman, Mia |
Faculty | Claire Morress |
Group A (Small Groups) IP Team Report: Strengths & Concerns
Problems or Concerns:
Agitated with ADLs/ Urine incontinence
Cannot enter his home due to steps
Interpersonal and language difficulties and aggression towards his family
Financial difficulties approaching 21 day limit
He refuses to work with female providers
Possible UTI
Strengths & Resources:
Supportive family
Rodrigo has the ability to ambulate 100 feet
Intact motor skills for dressing and ADLs
His BP and Glucose are more stable
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group A (Small Groups), IP Team Report: Goals & Action Plan
Goals | Goal 1 Work on strength and balance. Help him ambulate over 150 feet and able to navigate steps | Goal 2 Meet family and agree on patients careplan. Educate compensatory strategy. Educate family on cognitive impairment. | Goal 3 Encourage Rogdrigo to initiate hygiene and grooming task using compensatory strategies |
Action #1 | Work on his balance and single leg stance | Neuropsychology referral for further testing with specific questions about appropriateness of his medication | Educate family and Rodrigo on bathing and grooming strategies |
Action #2 | Get Rodrigo used to assist device | Have conversation with family about compensatory strategies | Complete bathing tasks with use of compensatory strategies |
Action #3 | Educate family about importance of movement | Identify resources that help with financial burden. Look into community resources. Look into need for home health. . | Discuss with family the need for caregiver assistance with ADLs |
Group A (Team Huddle 4:45pm)
1.What was the best part your teaming experience?
Understanding how inter disciplines teamwork can help
Learning how other disciplines see the case
2.Name one thing that went well today.
Every representative of each discipline was given chance to talk
3.What was your one biggest challenge?
Narrowing down on the key issues facing the patient
Knowing the scope of practice of each discipline
4.Name one thing that you learned about a different professional today.
Learned how the different professions collaborated together and how much more cohesive a careplan can be when there is collaboration
Don't overlook other disciplines
Group B
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Hanne Driscoll
Time keeper: Jenna Beatty
Recorder: Pushkar S. Bhatia
Nursing | Liz Boehringer |
Psychology | Hanne Driscoll |
Social Work | Emily Breen |
HSA | Pushkar Shekhar Bhatia |
OT | Jenna Beatty |
OT | Kirsten Pride |
PT | Alex Andros |
PT | Annie Lohmeier |
SLP | Aloboody, Mariam |
SLP | Reynolds, Haley |
Faculty | Kristen Blackham |
Group B (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group B (Small Groups), IP Team Report: Goals & Action Plan
Goals | Goal 1 Safety | Goal 2 Going home
| Goal 3 Increasing independence |
Action #1 | Home assessment (looking at the structure of the home and making sure everything is safe which will result in modifications). | Caregiver training (making sure that his family members know how to take care of Rodrigo, especially his ADL’s). | General ongoing OT/PT therapy for daily tasks. |
Action #2 | Establish connection with a new Primary Care Physician and re-evaluate his medications. The PCP should preferably be male and Spanish speaking. | Provide family with resources for Medicaid eligibility screening, long-term care planning, or financial assistance programs. | Visual scheduling (pictures, written, phone)-as he knows “how” to perform tasks but needs to be directed to do so. |
Action #3 | Fall risk assessment to assess his personal risk of falling. | Mental health, family therapy (making sure that his wife and kids are well), psycho-education (what to expect following a TBI and progressive neurocognitive disorders), neuro-cognitive evaluation. | Increasing his connection to his culture, which mainly includes getting him back involved with the church as he is very religious, and his friends. Connecting him to day programs would be helpful as well. |
Group B (Team Huddle 4:45mp):
1.What was the best part your teaming experience?
Listening to the different professional fields and their perspectives towards the issue and that we are all working towards a single goal. Application of class material in this case was great. The collaborative nature of the different healthcare professionals in one room was incredible to be a part of.
2.Name one thing that went well today.
Building off of what each profession said in a respectful way.
3.What was your one biggest challenge?
Our team had so many ideas so it was challenging to narrow down our priority goals and solutions.
4.Name one thing that you learned about a different professional today.
We all learned a lot of meaningful insights from all the different professions. We all had an idea of each of us did but hearing the different perspectives and ideas from the different healthcare professionals gave us more detailed insights into what each profession does. For example, the HSA student learned a lot about what a Speech Language Therapist does.
Group C
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Ella
Time keeper: Olivia
Recorder: Olivia
Nursing | Ella Bovender |
Psychology | Nora Edelen |
Social Work | Autumn Clifton |
HSA | Olivia Kaye Brockman |
OT | Maria Brophy |
OT | Lindsey Schmidt |
PT | Beth Bergdolt |
PT | Andrew Luxeder |
SLP | Apgar, Emily |
SLP | Reynolds, Taylour |
Faculty | Lisa Jutte |
Group C (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:�- Frustrated with a lot of the tasks – poor memory contributes �- Aggression he shows to caretakers (female specifically) -Concerned with sending home since there are women in the home and his aggression with females. �Aggression: change from baseline since his medication dosage was increased � - Bladder and bowel movements �- Forgetting to use his walker�- Left sided neglect – contributes to falls �- cognitive and perceptual impairments – safety concerns whether it be at home and forgetting to turn off stove;�- functional mobility, bumped into a lot of things that were low to the ground.�- Frustrated with participating in speech therapy.�- A lot of comorbidities to take into consideration �- Mild cognitive impairments�- Language barrier to take into consideration �- ability to pay for care in full even at 209.50 with copay�aggression, temper, and connection with peer�Family dynamic: Estranged with family a bit
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group C, IP Team Report: Goals & Action Plan
Goals | Goal 1 Use his assistive device with no more than one verbal cue from a caretaker | Goal 2 Decrease agitation (interactions with people) - keep family aware | Goal 3 Increase executive functioning and visuospatial |
Action #1 | Keep in mind where we are keeping the assistive device - always keep in his field on view | Start with a male therapist in the room along with a female therapist | Making visual schedules for him of things he will have to do throughout his day (dressing, bathing, etc.). + toileting schedule in Spanish and/or English |
Action #2 | Family education on the assistive device and how to educate the patient on how to use it at all times | Teaching coping skills; distress tolerance skills to help manage emotions. | Choose one ADL skills and provide visuals on how to complete that skill to increase independence. |
Action #3 | Putting a visual on the assistive device (bright tape) | Minimize any external stimuli that are triggering or that are a lot to be taking in (keep environment as calm as possible). | Educate family on how to incorporate these visual at home. |
Group C (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
Getting to hear all of the different perspectives from different disciplines - haven’t worked with some of the other professions before. See the overlap between some professions (OT and PT, SW and PSYC).
2.Name one thing that went well today.
All communicated and got to share our ideas and each person was heard and respected.
3.What was your one biggest challenge?
Not having any videos or visuals of the patients - had to make assumptions, everyone still had questions. Written information doesn’t match seeing someone in person and seeing first hand.
4.Name one thing that you learned about a different professional today.
Learned the most about OT and PT - haven’t had the chance to work with this profession as much and what aspects of the case they pulled and was most important. Learned a lot more about health insurance.
Group D
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Megan Brown
Time keeper: Megan Brown
Recorder: Megan Brown
Nursing | Mia Bressanelli |
Psychology | Pooja Heragu |
Psychology | Stephanie Langlais |
Social Work | Ben Dickison |
HSA | Megan Schuler Brown |
OT | Kathleen Cagle |
PT | Emily Brewer |
PT | Owen Martin |
SLP | Bayless, Ellie |
SLP | Rutherford, Ryelee |
Faculty | Michelle Hinderer |
Group D (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group D, IP Team Report: Goals & Action Plan
Goals | Goal 1 Rodrigo will participate in 60% of therapeutic tasks when cued by clinician. | Goal 2 Promote an organizational culture that is inclusive and comforting to all. | Goal 3 Evaluate and assess current financial situations once Medicare coverage expires. |
Action #1 | Further evaluate and educate different caregivers and family on patients history. Brainstorm strategies to improve patients quality of life. | Collect data and understand the culture of the environment while possibly relocating patient to more sufficient environment. Assess whether patient is distressed in environment. | Conduct a Medicare/ Medicaid meeting with family to discuss options for patient coverage once stay is 21 days. Ensure the increase in copay is understood by the family in preparation for discharge. |
Action #2 | Have a checklist of different ADL’s patient has to make progress on as the prognosis continues. Encourage patient to get involved in organizations pastoral care | Collaboration of pastoral care, all caregivers and patients family to reveal patient goals; Introduce new hobbies/ jobs to patient tailored to an improved lifestyle. | Balance and fall rate patient education to family and other supportive individuals, importance of using assisted living devices. |
Action #3 | Expose patient to female providers when comfortable and inform families of process. Introduction of female providers as participation of therapeutic tasks improve. | Encourage patient to explore other areas to recognize patient depression. Incorporate previous enjoyable/ independent activities. Ponder reward and feedback | Ensure home health care is more affordable than expired Medicare coverage, plus comfortable and safe living conditions to honor patient autonomy and mental health. |
Group D (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
Hearing one another's perspective and differences in disciplines that contribute to overall patient safety.
2.Name one thing that went well today.
Communication and collaboration of aligning personal goals with team goals.
3.What was your one biggest challenge?
Competing priorities between professions (what needs to happen now, what can wait).
4.Name one thing that you learned about a different professional today.
Speech pathology incorporates swallowing and speech.
Group E
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Isobel Brown
Time keeper: Abigail Campbell
Recorder: Aiden Bush
Nursing | Abigail Campbell |
Psychology | Natalie Larkman |
Social Work | Denise Domingo Paz |
HSA | Aiden Michael Bush |
OT | Abigail Childress |
Exercise Science | Gianna Maria Cua |
PT | Isobel Brown |
PT | Jack May |
SLP | Beaulieu, Lucy |
SLP | Shields, Hannah |
Faculty | Marnie Renda |
Group E (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group E, IP Team Report: Goals & Action Plan
Goals | Goal 1 Implementing strategies that increase/promote Executive Functioning, ADLs, and Cognitive ability | Goal 2 Reduce Financial Challenges | Goal 3 Behavioral Therapy: Reduce resistance to working with specific caregivers |
Action #1 | Introduce Memory Aids: Putting him on daily routine (daily calendar, visual schedule), develop organization strategies, diet/exercise) | Collaborate with the family to to develop a payment plan and provide cost estimation tools | Starting with male team members, and slowly introducing females into plan of care |
Action #2 | Educating staff on patient characteristics (e.g. what aggravates him, how to regulate it, language preference, de-escalation strategies) Educate family and collaborate with them to determine motivational/reward system for receiving care | Enroll him in discount program or charity care program, given his current finances meet the criteria Connect with copay assistance programs | Creating a calm environment with low stimulation (e.g. appropriate lighting, music, adjusting staff interaction, promoting doing things he likes) |
Action #3 | Implementing strategies for safety, balance, transfers and tolerance | Provide assistance with insurance alternatives, set him up with case manager or financial advisors | Reevaluation of formal behavioral health tests, comprehensive psych evaluation |
Group E (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
Learning the different roles, collaborating, and understanding unique perspectives and how they contribute towards creating a comprehensive care plan.
2.Name one thing that went well today.
3.What was your one biggest challenge?
4.Name one thing that you learned about a different professional today.
Group F
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader:
Time keeper:
Recorder:
Nursing | Addison Colvin |
Psychology | Megan Mathur |
Social Work | Olivia Grammel |
HSA | Jack Dee |
OT | Hannah Clemmons |
Exercise Science | Criselle Lindsay Culhi |
PT | Nick Brunsman |
PT | Morgan Mayleben |
SLP | Bolander, Megan |
SLP | Silbernagel, Lauren |
Faculty | Kara Farris |
Group (Small Groups)F, IP Team Report: Strengths & Concerns
Problems or Concerns:
- Safety with unknown transition of caregiving looming
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group F, IP Team Report: Goals & Action Plan
Goals | Goal 1 Create a long-term solution that meets Rodrigo’s financial constraints with medical needs | Goal 2 Getting him to engage in therapy. Participate in one leisure or social activity when prompted | Goal 3 Decrease frustration and aggression |
Action #1 | Social work resources (Medicaid, Church) | Family Education | Finish cognitive workup |
Action #2 | Look into home healthcare to lower cost. | Meaningful activities, playing radio during | Medication reconciliation |
Action #3 | Provide caregiver support (ex. family therapy, meals on weals) | Work with male or same staff, educate staff on cultural differences | De-escalation techniques (consistency) |
Group F (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
2.Name one thing that went well today.
3.What was your one biggest challenge?
4.Name one thing that you learned about a different professional today.
Group G
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Cody
Time keeper: Nick
Recorder: Adam
Nursing | Myrita Craig |
Psychology | Anton Mays |
Social Work | Natalie Hoffman |
HSA | Adam Christopher Deitsch |
OT | Al Maria Henry |
Exercise Science | Ashley Elizabeth Elma |
PT | Nick Burch |
PT | Cody McJunkins |
SLP | Brosnahan, Victoria |
SLP | Tackett, Baileigh |
Faculty | Ashley White |
Group G (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group G, IP Team Report: Goals & Action Plan
Goals | Goal 1 Agreeance and expectations between patient and family members on plan of care. | Goal 2 In 3 days, PT will be able to ambulate 200ft with quad cane and SUP assist in order to maintain and improve safety and functional mobility during ADLs at home. | Goal 3 Structured therapeutic support for both cognitive function and psychological wellbeing. Connecting family and patient with services that will continue his care upon discharge. |
Action #1 | Meeting and laying out all options for family and patient. | Education on how to properly use assist device. Education to family on how to assist patient using these devices. Education and reasoning with patient to show benefits of proper use and compliance. | Connect to his own bilingual individual case worker to aid patient/family in obtaining available resources through proper channels. |
Action #2 | Education about what to expect for both the patient and family. | Visual aids for ADL’s around the house. | Setting him up with therapist and working out logistics before he leaves. |
Action #3 | Choose a plan. | Actual result of his 200ft test. | Giving family/patient list/document of community resources for his needs. |
Group G (Team Huddle 4:45mp)
Group H
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader:
Time keeper:
Recorder: Chad F.
Nursing | Tori Johnston |
Psychology | Cameron Mills |
Social Work | Molly Kantz |
HSA | Chad Franzer |
OT | Madison Illing |
Exercise Science | Carly Jo Fulmer |
PT | Michael Centa |
PT | Ally Muench |
SLP | Carden, Amanda |
SLP | Vest, Miyanna |
Faculty | Emily Buckley |
Group H (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
-motivation
-problem with eating/Monitor Diates
-Continuing managing T2 Diabetes
-Memory Tasks/Disoriented
-aggression with staffing (especially woman).
-payment for services
-decreased education
-family dynamics
-Potentially returning home to previous environment.
Strengths & Resources:
- ability to have rehab, he is making process just has behaviors.
-family is able to translate
-Resiliency
-Catholic/faith strong
-previous lifestyle
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group H, IP Team Report: Goals & Action Plan
Goals | Goal 1 Return Home with Utilization of family support | Goal 2 Implement patient independence/improve cognitive function. | Goal 3 Sustainable Lifestyle |
Action #1 | Speech- Therapeutic tasks- will participate in 60% of therapeutic tasks when cued by the clinician Complete cognitive flexibility for functional tasks with 80% accuracy. | Speech- Therapeutic tasks- will participate in 60% of therapeutic tasks when cued by the clinician Complete cognitive flexibility for functional tasks with 80% accuracy. | Make caregivers away of available resources/coordinated schedule/routine. |
Action #2 | PT/OT- Home visits, functional strengthening, social activity on own weekly/group activity. Functional transfers/family education session. Daily logs. Nursing-medication management/organize consistent schedule to decrease risk of agitation. | PT/OT- Home visits, functional strengthening, social activity on own weekly/group activity. Home exercise program. Nursing-medication management/organize consistent schedule to decrease risk of agitation. Social Work- find resources that can support the family at home (potential in home care/assistance). | Home Health- OT/PT visits for a couple of weeks when patient return home as well as nursing. Demonstrate competency to ensure medication taking compliance. Get follow up appointments scheduled prior to discharge. |
Action #3 | Psychology - Understand the agitation (culture/depression potential). | Psychology - Understand the agitation (culture/depression potential). Continuous monitoring of risk of depression. | Administrator - call family about current status to maintain relationship. |
Group H (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
Open communication/teamwork/feedback
2.Name one thing that went well today.
Utilizing each others strengths, everyone reviewed the case prior to this event. Everyone had different ideas and fresh perspective.
3.What was your one biggest challenge?
Too many people and guided talking points. Scenario challenge that this input was too late in the process.
4.Name one thing that you learned about a different professional today.
Collaboration is key. Communication and realistic expectations.
Group J
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Sophia Leto
Time keeper: Abigail Westerfield
Recorder: Dawit Gebreab
Nursing | Sophia Leto |
Psychology | Jennifer Pasternak |
Social Work | Kane May |
HSA | Dawit H Gebreab |
OT | Caroline Kane |
Exercise Science | Alex Michael Hall |
PT | Lizzy Conway |
PT | Jakob Myers |
SLP | Diana, Madeline |
SLP | Westerfeld, Abigail |
Faculty | Lauren Burke |
Group J (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
PT: Safety, shortness of breath
OT: Troubles with ADLs, behavioral issues
SLP: Cultural views towards women, lack of decision making skills, communication issues
Psych: cognitive impairment, educational issues, depression
Exercise science: financial issues, lack of social support, balance & strength
Nursing: medication issues, cognition & depression
MHSA: financial issues - limited medicare benefits
Strengths & Resources:
PT: Able to walk with assistance, regain use of arm and leg after stroke, supportive family
OT: Able to dress and feed himself, bilingual, supportive family, faith
SLP: family support, faith,
Psych: resilient
Exercise science: medicare, compliant with pt, managing diabetes, prior experience (working in a farm)
Nurse: blood pressure and glucose levels, quit smoking
MHSA: possible faith-based services or medicaid services
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group J, IP Team Report: Goals & Action Plan
Goals | Goal 1 Educate and support the family in the next 3 days. Ex: detailed instructions for care, routine schedule tailored to Rodrigo, transfer training, triggers | Goal 2 Physical aspect Training on balance to prevent falls, Problem solving, cognitive ability | Goal 3 Discharge (Finding financial assistance) Follow-up care |
Action #1 | Working with a cultural competent male psychologist and Implementing activities that are culturally tailored to him | Training on how to use his walker the proper way, practicing on variety of terrains to simulate walking on the farm. | Apply for medicaid long term services and faith based financial assistance, other government assistance services |
Action #2 | Determining who in the family would be caring for him at home. Educating family about care. | Mindfulness exercises, focus more on “right now”, body awareness | Neuropsychology assessment to determine cognition vs depression |
Action #3 | Giving him meaningful daily tasks | Incorporate dual-tasking, safety awareness, and executive function into therapy. | Arrange transportation services and appointments to continue follow up care |
Group J (Team Huddle 4:45pm)
1.What was the best part your teaming experience?
Hearing everyone's perspectives/ideas. We all had somewhat the same goal, but a unique way of attaining it. The learning experience and being willing to listen, communicate and work together as a team.
2.Name one thing that went well today.
Everyone being able to talk and share their perspective.
3.What was your one biggest challenge?
Everyone had different goals that they prioritized based on their background and experience.
4.Name one thing that you learned about a different professional today.
The overlap between all professions.
Group K
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Jose Polanco
Time keeper: Tanner Perry
Recorder: Chloe Hamm
Nursing | Brianna Norwood |
Psychology | Jose Polanco |
Social Work | Lauren Ross |
HSA | Chloe Michelle Hamm |
OT | Tori Kucler |
Exercise Science | Nate Patrick Jeffery |
PT | Sam Crew |
PT | Tanner Perry |
SLP | Downard, Kayla |
SLP | Zeh, Zoey |
Faculty | Erin Hofmeyer |
Group K (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
-He can be aggressive/compulsive to family member and female staff. Culture views toward womens especially toward slp’s.
-Executive functioning/dysfunction (needs to function independently) (ADL’s) (Bio, Social, Psychology).
-Financial concerns related to the cost of continued care beyond 21-day Medicare coverage.
-Look into medicines and make sure he is appropriate with them.
Strengths & Resources:
-Very active lifestyle prior, can bring satisfaction, independence within feeding, dressing and auditory comprehension seems entact.
-Family is center is really good, and religious/faith base foundation.
- Access to Medicare and financial stability from owning a farm.
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group K, IP Team Report: Goals & Action Plan
Goals | Goal 1 Increase activity tolerance and build a routine to complete daily activities. | Goal 2 Emotional regulation, and awareness to his aggression (self-awareness). | Goal 3 Find financial resources. |
Action #1 | Get the best clientele (female+male). | Help him understand societal roles (where everyone fits). | Pro Bono clinics. |
Action #2 | Collaborate with him on what activities he wants to get done and how can we help him do that. | Brief intervention but digestible. | Explore financial assistance programs/other facilities. |
Action #3 | Positive reinforcement. | Family education on caretaking (educating on how to deal with his aggression). | Explore different insurance options to cover the cost of care. |
Group K (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
We all connected and got to meet some really fun people.
2.Name one thing that went well today.
We did really well at collaborating, following the team ideals, giving everyone input and being concise.
3.What was your one biggest challenge?
There was too much time and it was hard to pick the most important aspect.
4.Name one thing that you learned about a different professional today.
There are a lot of subspecialties within specialties.
Group L
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader:
Time keeper:
Recorder:
Nursing | Ricolette Patterson |
Psychology | Caitlin Tycz |
Psychology | Giovanna Marin |
Social Work | Jalynn Sears |
HSA | Drew Bryan Kirby |
OT | Taylor Linkous |
Exercise Science | Natalie Klei |
PT | Liz Duvic |
PT | Jake Phillips |
SLP | Gilmour, Haley |
Faculty | Lisa Dehner |
Group L (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group L, IP Team Report: Goals & Action Plan
Goals | Goal 1 Fix the family’s financial constraints so he can continue to get care | Goal 2 Fix his behavioral outburst at staff and family | Goal 3 Improve his ability to do ADLs |
Action #1 | Explore alternate funding with a social worker (medicaid) | Add things to his care to help him feel at ease (Attend mass, prayer time, play latino music, etc.) | Interprofessional meeting with the family. Find motivators to make him care about PT |
Action #2 | Review with the family the possibility of selling the farm or find a payment plan | Use a male team, with spanish speakers to communicate more effectively | Positive reinforcement and visual schedules/charts |
Action #3 | Connect with community resources (church) | Review his medication and if it affects his mood and have a neurology consult | Enhance home safety with modifications to prevent future falls. |
Group L (Team Huddle 4:45pm)
1.What was the best part your teaming experience?
Getting to hear every professions different perspective that they have on what the biggest issue Rodrigo is having
2.Name one thing that went well today.
Everybody was very respectful to all group members and everyone got a chance to share their ideas and input
3.What was your one biggest challenge?
Agreeing on what the biggest goal should be for Rodrigo and his family
4.Name one thing that you learned about a different professional today.
How disconnected psychology typically is from usual interprofessional health teams.
That their are different types of social workers, not just the one that helps with finding resources.
Group M
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Maia Lynch
Time keeper: Ellie Pritchard
Recorder: Megan Lapensee
Nursing | Ellie Pritchard |
Psychology | Victoria White |
Psychology | Natalie Miselem |
Social Work | Lily Shepherd |
HSA | Megan Alexandra Lapensee |
OT | Maia Lynch |
Exercise Science | Nicole Genevieve McLaughlin |
PT | Erik Edwards |
PT | Katie Rice |
SLP | Gross, Daphne |
Faculty | Shelagh Larkin |
Group M (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
1) Problems
- Want to establish a PCP
- Family relationship is strained
- Struggles with female caregivers (A lot of speech, nurses are female)
- Mental capacity to do ADLs
- TBI
- Neglect of being social at the nursing home
- Doesn’t contribute conversations
- Can’t complete ADLs
- Behavioral issues
- Sequencing issues
- Cognitive and memory decline
- Motor issues (not doing tasks without prompting)
- CDA could’ve caused issues
- Falls
- Copays can cause stress
- Ongoing TBI injury
- Nicotine addiction/withdrawal
- Impaired balance issues (bumping into things repeatedly)
- Getting into the home would be difficult (doesn’t want to use the one step entry, would prefer the back entrance which is three steps)
- Not oriented to location (cognitive issues)
- Aricept and Namenda were both increased which caused anger issues
- 7/30 Montreal Cognitive Assessment
- Does not sleep well
- Feelings of isolation
- Language barrier
- Low frustration tolerance
Group M, IP Team Report: Goals & Action Plan
Goals | Goal 1 Reduce score on the GDS scale (to 15 or lower) and reduce number of outbursts by a month after discharge. | Goal 2 By discharge Rodrigo will be able to complete 3 out 4 ADL tasks with cueing as needed on 2 out of 3 trials.
| Goal 3 By discharge, patient will be able to complete 1 step Min A x 1 with proper caregiver training in order to ensure safe entry and exit into home of patient and caregiver |
Action #1 | Neurocognitive assessment and medication evaluation | Educate the caregiver and patient on individual schedules, ensure family knows about medication | Caregiver training |
Action #2 | Speaking with family members more often and getting on board with therapy (family therapy) | Increase frequency PT and OT sessions while he is still in facility | Functional lower extremity strengthening |
Action #3 | Connect with a counselor or therapist that has a more diverse background 30 minutes per week. | OT/PT co treatments | DME recommendation |
Group M (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
2.Name one thing that went well today.
3.What was your one biggest challenge?
4.Name one thing that you learned about a different professional today.
Group N
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Khalid Yusuf
Time keeper: Emma Hennigan
Recorder: Evan McDonald
Nursing | Stacey Ramirez |
Psychology | Khalid Yusuf |
Social Work | Ryan Sully |
HSA | Evan Matthew McDonald |
OT | Kennedy Marler |
Exercise Science | Nic Andrew Ochoa |
PT | Sam Grantz |
PT | Ben Routhier |
SLP | Hennigan, Emma |
Faculty | Carl Antenucci Natalie Balen |
Group N (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns: Cognitive decline and behavioral disturbances, socially withdrawn, functional limitations (falls, frail, incontinence, mobility issues), poor executive functioning, is hostile toward female specialists, financial constraints, copay pending after day 21, declining sensory functioning (neuro assessment), safety concerns (on blood thinners), left sided neglect, poor medication management (and med increase causing anxiety), poor insulin management, lack of independence, functional and motor concerns.
Psycho social barriers:Financial issues, family concerns/involvement, religious concerns, language barrier (SDOH)
motor /functional barriers: Falls, frail, incontinence, mobility issues
Neurological/psychological: executive functioning, emotional behavioral dysfunction, dementia
Strengths & Resources:
Resources: MOCA (7/30), Depression screen (19), Anxiety (7)
Family support
Values autonomy and dignity
Establish PCP, family/religious support
Auditory is intact
Works well with males
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group N, IP Team Report: Goals & Action Plan
Goals | Goal 1 Enhance cognitive and emotional functioning (safety, mobility, strength, cognitive functioning) | Goal 2 Optimized patient and caregiver education | Goal 3 Safety and discharge planning |
Action #1 | Culturally competent mental health treatment, executive functioning improvements | huddle with caregiver to collaborate on patient care/discharge planning | Medication management in the SNF and home |
Action #2 | Improvement of safe ambulation and decision making | inform of dementia risk factors/course of illness/problem solving issues | Making home adaptations and coordinating home health |
Action #3 | Improvement of ADLs and environment with adaptations | Family support groups | Implement family plan/give discharge recommendations |
Group N (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
Hearing about everyone's expertise, respect for each other, patient always the center, everyone supported each other.
2.Name one thing that went well today.
Understanding of patient priority using biopsychosocial model, being able to describe roles, effective communication, and consolidation of different goals.
3.What was your one biggest challenge?
Narrowing down specific goals, wording of different goals in each others professional language, and not having the patient in front of us.
4.Name one thing that you learned about a different professional today.
How much PT and OT are in discharge planning, learning about what each professional does, and social worker involvement.
Group P
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader:
Time keeper:
Recorder:
Nursing | Danielle Rucker |
Psychology | Kyra Bevenour |
Social Work | Ashley Watts |
HSA | Collin Chan McInelly |
OT | Quincy McElhaney |
Exercise Science | Annika Kimberly Paskiewicz |
PT | Keagen Haffele |
PT | Alivia Smith |
SLP | Howard, Hannah |
Faculty | Jen Phillips |
Group (Small Groups)P, IP Team Report: Strengths & Concerns
Problems or Concerns:
Increase mental health issues with anxiety and depression
He's getting frustrated with current services (Female)
Not interacting much with the other residents
Struggle to listen to the female staff
Tempor and inappropriate behavior
History of falls
Nightwalker: his circadian rhythm is off
Strengths & Resources:
PT and OT sessions
Good social environment with religion and family
Independent with dressing and feeding
Can do a lot of things independently
Having Medicare as a resource
Controlling his medications
Walking/hygiene ability
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group P, IP Team Report: Goals & Action Plan
Goals | Goal 1 Improve safety and mobility. | Goal 2 Increase social activity | Goal 3 Find an independent living plan that is financially sustainable |
Action #1 | A walking program. (PT program) | Increase value-driven activity (Church) | Look into financial assistance like Medicaid and Medigap, community resources |
Action #2 | Have a male staff present when working with female staff | Group activities (Music therapy) | Find an appropriate facility for long term care |
Action #3 | Make sure he is an active participant with treatment. Effective communication with providers (ADLs) | Referral to mental health help (CBT) | Assess whether home health services are a viable alternative. |
Group P (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
The people!
Learning about other disciplines and different types of interventions
Collaborations with different perspectives
2.Name one thing that went well today.
Everyone shared their perspective
Everyone was respectful
3.What was your one biggest challenge?
Where individual goals rank from each profession to the overall care of the patient
Different language
4.Name one thing that you learned about a different professional today.
Learned the different acronyms for different professions
Group Q
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Jena Thayer
Time keeper: Jacob Weyler
Recorder: Mallorie Reimer
Nursing | Chinaza Sam-Okomgboeso |
Psychology | Ellie Borders |
Psychology | Maanasa Nandula |
HSA | Mallorie Ann Reimer |
HSA | Jacob Parker Weyler |
OT | Phoebe Noes |
Exercise Science | Nicholas George Resca |
PT | Ryan Hummel |
PT | Jena Thayer |
SLP | Kash, Macey |
Faculty | Janie Taylor |
Group Q (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
Only cooperating with male providers, female safety with patients
Many comorbidities will influence recovery
Medicated for HTN, could affect cardiovascular recovery and exercise
Refuses to work with SLP, and he is frustrated
Not oriented to location, negative response to medicine
Emotional dysregulation + interpersonal conflict
Struggling to use walkers, elevated risk of falls
Incontinence
Strengths & Resources:
Historically active
Basic medical needs are stable
Cooperation with PT
Resilient and still fighting
Independent with feeding and comprehension is intact
Ambulate on feet, bilingual
Strong family support
Employed and has steady finances
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group Q, IP Team Report: Goals & Action Plan
Goals | Goal 1 Enhance Rodrigo’s interpersonal relationships at the facility | Goal 2 Help Rodrigo regain his independence and to not further his decline. | Goal 3 Addressing patient safety and addressing aggression. All the safeties |
Action #1 | Frequent care team meetings to discuss his care. | Incorporate activities that he likes when doing therapies. | Co-treating Rodrigo with a male PT and the female clinician. |
Action #2 | Involving family as much as possible, incorporate religion. Discussions on the families role. | Involve cognitive tasks when trying to regain ADLs. | Debriefing and supporting caregivers who experience aggressive behavior. |
Action #3 | Caregiver support meetings, finding how to support then to provide the best care to Rodrigo. | When discharged, has support at home to assist with daily living. Social work involvement and home health aids. | Evaluate medications and conduct psych evaluations frequently. BCSE evaluation implementation. Assess at home environment before discharge to ensure safety. |
Group Q (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
Willingness to collaborate, well prepared, everyone was kind, refreshing to see other departments who all strive to enhance healthcare quality.
2.Name one thing that went well today.
Overall collaboration, open to new ideas.
3.What was your one biggest challenge?
All departments viewed the #1 goal for Rodrigo differently.
4.Name one thing that you learned about a different professional today.
Group R
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Evan Rudek
Time keeper: Olivia Borglin
Recorder: MArie M. Reinert
Nursing | Moriyah Skinner |
Psychology | Olivia Borglin |
Psychology | Katie Saba |
HSA | Marie Reinert |
OT | Cora Pack |
Exercise Science | Evan G Rudek |
PT | Marisa Kenyon |
PT | Alyssa Witmer |
SLP | Knight, Eve |
Faculty | Cindy Foreman |
Group R (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
Strengths & Resources:
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group R, IP Team Report: Goals & Action Plan
Goals | Goal 1 Psychosocial | Goal 2 Physical | Goal 3 Placement/Payment |
Action #1 | Referral to Therapist/ Baseline Assessment | Nursing: Assessment of daily activity and medication review with doctor, bowel and bladder evaluation, nutrition | Keep patient for additional 1 week of care by applying Medicare Advantage |
Action #2 | Produce motivational System to build into confidence / dignity | Physical therapy/ Occupational: Strategic plan of care to achieve activities like dressing, hygiene, toileting, and balance, (walking), steps | Referral to home to have home health care and education to family and safety check of home. |
Action #3 | Building into family about education of dementia and therapy to help build skills and have a (POC) | Exercise Science: getting him daily activity (every 2 hours), exercise, and daily walk | In SNIF continue to work on activities to work on bridging care home and re- assessment before going home |
Group R (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
Everyone was confident to talk and energetic to engage.
2.Name one thing that went well today.
We had great team collaboration and built into each other’s ideas and perspectives.
3.What was your one biggest challenge?
Due to little information we had to make a lot assumptions with social needs, feasibility, and complete picture.
4.Name one thing that you learned about a different professional today.
For all the clinical care professionals it was interesting to learn about the administration of healthcare. For the administrator it foundational to learn how to support the clinical side of healthcare.
Group S
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Jaclyn Schutzbach
Time keeper: Carrie White
Recorder: Karsten Titze
Nursing | Elizabeth Acuff |
Psychology | Hannah Geiger |
Psychology | Jaclyn Schutzbach |
HSA | Karsten Gunner Titze |
OT | Mallory Paris |
OT | Carrie White |
Exercise Science | Sara Elizabeth Street |
PT | Cierra Kolar |
PT | Willie Wolfe |
SLP | Marazita, Carrie |
Faculty | Jeremy Steeves |
Group S (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
-Helping the patient perform ADLs/medication
-Patient’s strength, balance and mobility
-Executive functioning
-Patient and caregiver education
-Mental health and mental cognition
-Language barrier
-Nearing the 21 day mark, at which time a copay of $209.50/day begins
Strengths & Resources:
-Support system/strong faith
-Compliant with medications
-Fluent in english and spanish
-Compliant with male workers
-Hard worker
-Motivated, Resilient and disciplined
-Improving functioning after stroke
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Goals | Goal 1 Improve overall cognitive stability. | Goal 2 Improve physical strength & function to help patient with ADLs and reduce his risk of falls. | Goal 3 Improve the patient’s social and emotional well being. |
Action #1 | Educating patient on executive function skills through the use of a routine or schedule. | Rediscover patient’s interest and motivation for recreational activities | Psychoeducation on Dementia to the patient’s family to address symptoms and strategies to provide support. |
Action #2 | Reconcile medications to ensure the patients symptoms are not caused by the medications he is currently on. | Continue PT & OT services to increase independence | Individual therapy to the patient to address anxiety, depression and lack of social motivation |
Action #3 | Minimizing stressors by improving coping skills | Educating family on skills to assist the patient and to monitor his improvement | Educating the staff and family on ways to de-escalate aggressiveness to increase social interaction |
Group S (Team Huddle 4:45mp)
1.What was the best part your teaming experience?
Learning & seeing how different specialities approached reaching the set goals we wanted to achieve.
2.Name one thing that went well today.
No field overpowered another field. We were all able to hear each other out and collaborate efficiently and effectively to achieve a common goal.
3.What was your one biggest challenge?
Narrowing down the various issues and agreeing on the goals we wanted to achieve for the patient. The complexity of the patient played a big role into deciding goals for the patient and how to achieve favorable outcomes.
4.Name one thing that you learned about a different professional today.
Every profession takes a different approach to achieve a goal. We learned about different medications, evaluations and different aspects of care we wouldn't have initially thought of.
Group T
CLIENT: _Rodrigo Perez_______
Date: 02-27-2025
Leader: Dave Lecount
Time keeper: Connor Hamilton
Recorder: Jacob Walker
Nursing | Aimee Gauger |
Psychology | Connor Hamilton |
Psychology | Margaret Wolfson |
Social Work | Sydney Wymbs |
HSA | Jacob Thomas Walker |
OT | Casey Peter |
OT | Bailey Winner |
Exercise Science | Paul Michael Yadgar |
PT | Dave LeCount |
SLP | Mullen, Caroline |
Faculty | Debbie VanKuiken |
Group T (Small Groups), IP Team Report: Strengths & Concerns
Problems or Concerns:
-Cognitive Decline & Orientation
-Nutrition
-Potential history of TBI’s
-Diabetes
-High Copay
-ADL’s
-Aggression/Frustration (Interpersonal Relationships)
-Visual/Spatial Neglect
-SOB
-Financial Strain
-Education
-Socioeconomic Status
-New Medication
Strengths & Resources:
-Bilingual
-Family Support
-Religious Background
-Music Lover
-Ambulate w/ walker
-Farm Financially Stable
-Feed himself
-Compliance w/ medication
-Work ethic
After identifying strengths & problems: * and Bold 2 or 3 top strengths & 2 or 3 top concerns
Group T, IP Team Report: Goals & Action Plan
Goals | Goal 1 Improve daily functioning by reducing the impact of mood & anxiety symptoms | Goal 2 Address functional mobility deficits in order to increase independence and improve ability to perform ADL’s | Goal 3 Find ways to reduce Financial Strain |
Action #1 | Environmental Modifications + Staff Education | Implement HEP | Reducing Speech Therapy Sessions |
Action #2 | Value-based Intervention | Visual Schedule- (Cues/Reminders) | Seeing if he’s eligible for Financial Assistance Programs (Community Resources) |
Action #3 | Culturally informed Family Therapy | Caregiver + Family Education/Involvement | Screening of Medications (Potential for elimination/Holistic Options) |
Group T (Team Huddle 4:45pm)
1.What was the best part your teaming experience?
-Seeing how the different disciplines would address the problem and seeing the overlap between them.
2.Name one thing that went well today.
-Mutual respect among everyone and what they had to say.
3.What was your one biggest challenge?
-Taking a step back to look at the patient as a person. Using the different disciplines to develop one holistic answer to address an issue.
4.Name one thing that you learned about a different professional today.
-How the different disciplines intertwined and how they can all collaborate to make a comprehensive care plan. Different ways to address similar issues that a patient faces.