Interdisciplinary Team

The programs at NeuroPsychiatric Hospital (NPH) facilities maintain an interdisciplinary focus. Using a multi-specialty approach for neuropsychiatric and medical care fosters team problem solving, better morale, and coordination among team members. We strive to demonstrate appreciation, respect, and understanding of other allied professionals, the patient, and caregiver as they are integral parts of our team as well.

The patient and caregiver’s perspective helps direct the overall care and is fully represented in the intervention process. Having their participation and input are essential to assure follow through of the treatment process and rehabilitation strategies, especially once the individual is discharged.

An interdisciplinary team approach necessitates understanding and knowledge of each team member’s role and responsibilities. The table below highlights the unique roles and responsibilities of each NPH interdisciplinary team member.

Patient – Provides insights on his/her daily routines, needs, abilities, interests, and preferences

Caregiver/Family Member – Provides nuances of behavior and physical states of their loved one. Helps the team define realistic goals, and shares effective strategies for interacting with patients upon discharge.

Nurse – Provides direct care to patient. Serves as an integral member of the interdisciplinary team to develop a specialized care plan for each patient.

Nurse Liaison – Provides immediate assistance to the referring facility or family in assessing the needs of the individual and providing ease of access for admission to the acute care setting.

Nurse Practitioner – Provides ongoing healthcare and collaborates with physicians and other disciplines to develop a plan of care. Provides educational sessions to staff about caring for patients with dementia and other disorders. Provides counseling sessions and facilitates support groups for family members.

Primary Care Physician – Recognizes change in cognitive function, conducts routine diagnostic evaluation, provides counseling to patient and family, initiates and/or monitors medical therapy. Refers to specialized medical health professions and community resources and provide longitudinal support for patient and family.

Hospitalist – Provides expert evaluation, diagnosis, and management of unusual or complex dementia presentations; special expertise in managing behavioral symptoms and comorbid illnesses; expert in community resources, home care, and residential care settings. Ongoing support for the patient and family.

Psychiatrist – Expert in evaluation and diagnosis of the full spectrum of cognitive disorders and behavioral manifestations of dementia and related psychiatric disorders. Recommends and monitors medication therapy. Provides counseling for patient and family in coordination with other providers involved in the plan of care.

Social Worker – Conducts comprehensive, strengths-based assessment of individual and caregiver to develop care plan. Facilitates link to community resources to address unmet needs. Coordinates community care with hospital and nursing facility discharge planners. Educates and counsels throughout the disease process. Conducts advocacy activities per patient’s need. Establishes and facilitates client and caregiver support groups.

Case Manager/Utilization/Review – Reviews patients’ records and evaluates progress. Performs continuing review of medical records and identifies the need for on-going hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct review. Reviews and validates physician’s orders, reports progress and unusual occurrences with patients. Consults with Social Services Department regarding the level of nursing care and collaborates with other departments in evaluation of issues affecting discharge plans. Analyzes patient records, and participates in interdisciplinary collaboration with professional staff and supports clinical improvement activities.

Psychologist – Performs neuropsychological assessments for cognitive impairment or dementia and outcomes measurement. Provides psychotherapy and group therapy. Provides end-of-life counseling and family support services.

Pharmacist – Optimizes pharmacotherapeutic regimen to reduce or eliminate dementia-causing drugs. Recommends therapeutic options and monitors for adverse effects. Provides medication-related information to patient and caregiver. Provides assistance for improving medical adherence.

Physical Therapist – Provides interventions such as education and training to both the person with dementia and caregivers to maximize ADLs, function and mobility, promote a safe environment, and to reduce risk of injuries and falls. Works effectively with the interdisciplinary team to support the highest attainable quality of life both for the person with dementia and the caregivers.

Dietitian – Encourages independent eating, educates on the importance of fluid intake, and provides foods that are ethnically and culturally appropriate. Designs specialized dietary plans (e.g. malnourished or diabetic patients)