Interdisciplinary Teams Connect the Dots in Home Health Care

Between physical therapy, medication administration, assistance with activities of daily life and more, a home health patient’s care needs can be quite complex and at times prove difficult to manage.

That’s why once patients move from an acute setting back to their homes, care coordination and collaboration become more important than ever, according to experts at the 2016 Illinois HomeCare & Hospice Council Annual Conference and Expedition in Lombard, Illinois. Enter interdisciplinary teams, where various professionals come together to organize care and communicate throughout the process.

“We have a lot of great individual performers, but we’re not worth a dime if we can’t get on the same page,” said Cindy Kraft, CEO of Kornetti & Kraft Health Care Solutions, a health care consulting company that focuses on interdisciplinary, patient-centered care management primarily for home health agencies. “[Patients] are responding to multiple programs trying to exist simultaneously.”


Panelists expressed the importance of several disciplines working together to make decisions and set goals for patients receiving in-home care during last week’s session, titled “Interdisciplinary Approaches: What Home Health Providers Can Learn from Hospice IDTs about Patient Care and Cross Continuum Transitions.” They also outlined care models they’re employing at their respective companies and explained how they can be employed in different settings.

Take Western Illinois Home Health Care, for example, which implemented a behavioral health program called Restoring Wholeness at Home involving multiple disciplines. With a focus on anxiety and depression and the incorporation of behavioral health into the management of the agency’s home care patients, the program seeks not only to return a certain quality of life to those it serves, but also to prevent readmissions.

Interdisciplinary care is an integral part of the program, said Barb Byers, the agency’s CEO and president, and it requires that the entire staff meet monthly to collaborate on projects, interventions and goal-setting.


“When depression is not controlled, there is rehospitalization,” she said.

Another example presented was a complex care management program through Riverside Medical Center in Kankakee, Illinois, which provides nursing and other services in chronic disease management through all transitions of care in a patent’s journey. Someone first meets eligible patients while they’re in the hospital to see what concerns them most about going home, and from there, a team keeps in touch with the patient and other providers involved to monitor health status and assess early signs of problems, program coordinator Beth Ludwig said.

“I think we all know the reality of transitional care—it’s a mess,” she said. “We need to work together.”

Even pharmacists have their role in ensuring that a patient continues to receive care at home, said Jason Williamson, a registered pharmacist at McDonough District Hospital located in Macomb, Illinois. When it comes to interdisciplinary measures, pharmacists can serve as a drug information resource, as well as to prevent adverse drug events, inappropriate medication use and regulatory issues.

“Home health and hospice try to go it alone when it comes to medication problems, but they can reach out to us and utilize us as a resource—especially when it comes to reaching out to prescribers,” Williamson said.

Overall, the purpose of interdisciplinary teams is simple—allowing people to remain at home.

“We need to break down those walls and take care of it in the best place possible, and that’s in a patient’s home,” Ludwig said.

Written by Kourtney Liepelt

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