MDT Guide and Toolkit

1: Introduction to Multidisciplinary Teams

Chapter 1: Summary

The increased attention given to elder abuse has illuminated system failures. MDTs were developed to address many of these system failures. Benefits of an MDT accrue to victims, MDT members, and the community. However, no two MDTs will be alike. The size and structure of an MDT will reflect the needs and resources of the community in which it is developed.

Introduction

Although MDTs have been in existence for decades, they are only recently gaining widespread acceptance and adoption. Most of what we know about MDTs is based on experience rather than research, suggesting MDT practice may change with new knowledge. Elder abuse MDTs will continue to evolve as more communities utilize the model and gain experience with them.

Communities have differing political issues, geographies (rural, urban, suburban), and demographics. Any community can develop an MDT, even communities with limited resources that preclude the development of a complex MDT model, such as an Elder Abuse Forensic Center. The size and structure of an MDT will reflect the needs and resources of the community in which it is developed.

As will be discussed in detail, starting an MDT is challenging. Teamwork does not arise through the simple organization of professionals and calling the group a “team.” Because MDTs are so challenging to develop, it typically takes strong leadership to implement an MDT. There is frequently a charismatic and energetic leader in the community who advocates for a change in the system’s response to elder abuse, and who is politically savvy and has the influence to obtain the cooperation from multiple agency heads. In some cases it takes persuading a strong leader in the community that an MDT is needed.

A word of warning: Be flexible. An MDT may start out doing things one way, but over time may find that the protocol is no longer working for the team. In addition, although it is the responsibility of the MDT Coordinator to bring the team together, there are times when a different structure will perform better. Always obtain feedback from your MDT members.

Finally, many MDTs feel compelled to expand into other arenas. The Toolkit item titled: Additional MDT Activities, details activities that other MDTs have seen fit to undertake. Over time, your MDT may identify needs in the community that the MDT may want to address. For example, in Texas, the MDT assigned a geriatric nurse practitioner for half a day per week to the APS office as a resource for APS caseworkers. Innovative solutions like this are occurring all across the country.

Defining a Multidisciplinary Team

Rooted in the biopsychosocial model, MDTs are defined as a group of people (comprised of representatives from three or more disciplines who work collaboratively), bound by a common purpose (the MDT has a shared goal and shared definition of the problem they are addressing), and is characterized by five elements:

Shared Decision-Making
The entire team participates in the decision making process, sharing information, and sharing successes.
Partnership
MDTs are characterized by a formal Memorandum of Understanding (MOU) or an Interagency Agreement (IAA).
Interdependency
Group and individual outcomes are influenced by the team.
Balanced Power
All members of the MDT have equal input and prohibit a single member from dominating the group.
Process
The development and use of protocols to introduce predictability and accountability into the case review process, including protocols for conflict resolution.

Types of Problems Addressed by Multidisciplinary Teams

MDTs are used in a number of fields (education, medicine, business, social services). There are many different types of MDTs geared towards the needs of older adults specifically. For example:

Elder fatality review teams
Hoarding teams
Mental illness teams
Elder abuse teams
Guardianship teams
Financial abuse specialist teams
Code enforcement teams

This guide focuses on elder abuse case review MDTs. Although the MDT concept is not new, there is growing recognition of the need for an MDT response to elder abuse. An MDT approach is victim-focused and designed to correct for the shortcomings in the system (described below). In addition to system coordination, MDTs should seek to better understand victims’ priorities and needs.

The Need for Multidisciplinary Teams

Elder abuse “includes physical, sexual, or psychological abuse, as well as neglect, abandonment, and financial exploitation of an older person by another person or entity, that occurs in any setting (e.g., home, community, or facility), either in a relationship where there is an expectation of trust and/or when an older person is targeted based on age or disability” (DOJ, 2014).

Elder abuse is receiving increased attention and with it greater societal awareness. Prevalence rates of community-dwelling older adults indicate that 10% of older adults have experienced some form of abuse in the past year provide traction for this increased attention. However, the majority of elder abuse cases do not reach the attention of those charged with responding. Not only is it important to identify and respond to these cases based on honoring human rights, but also because of the consequences associated with elder abuse. For example, older adults have greater difficulty in recovering from physical injuries and financial loss, and have an increased risk for early mortality.

Reports of elder abuse come from a variety of sources, although most victims enter the system through either adult protective services (APS) or law enforcement. Typically, the formal response to elder maltreatment rests with APS, an agency that focuses on protection of the victim.

The increased attention given to elder abuse clearly has indicated that there are typically system-wide failures to detect and care for older victims. Once in the system, victims, who frequently have numerous needs, may be exposed to multiple agencies. The victim initially may be visited by APS or law enforcement. Some victims will require a neuropsychologist to conduct a cognitive assessment, a physician to treat and document physical injuries, interviews with a prosecutor or law enforcement officer, and even a safe place to stay toavoid further abuse. Currently, multiple agencies may simultaneously be working on the same elder abuse case, with each agency working within its own silo unaware of the interventions, strategies, and case planning being attempted by other agencies. This approach is neither victim-centered nor responsive to the myriad of victim’s needs. Furthermore, it does not respond appropriately to the needs of perpetrators, which is increasingly being recognized as an important aspect of a sustainable intervention strategy.

An uncoordinated system is problematic because it frequently results in:

System overload for the family
Victims being jostled from one place to another
Less than optimal outcomes for victims
Duplication of interviews and services
A bureaucratized “one-size-fits-all” adversarial investigation
Lack of communication between systems
Conflicting recommendations
A poor match between the family’s strengths/needs/problems and interventions
Inadequate and fragmented service delivery that fails to address underlying problems
Responding to the presenting problem without exploring other possible victimizations

In the face of these potential system failures, stakeholders instinctively think, “There’s got to be a better way!” And there is: A multidisciplinary team (MDT). The two key assumptions are that:

Complex cases require a complex response
No one agency can address all the needs (physical, emotional, intellectual, familial, interpersonal, financial, social, cultural, and spiritual) of an older victim

Benefits of a Multidisciplinary Team Approach

Working in unison, the strength of each agency can complement the others. Together, the agencies involved in the MDT can ensure that victims do not fall through the cracks while addressing their range of needs. An MDT allows each agency’s strengths to shine, while sharing the burden of investigating and responding to complex elder abuse cases. For example, some older adults are distrustful of law enforcement, but law enforcement may be better able than APS to collect the evidence needed to forward a case to the criminal justice system. APS may be better able to empathize with the victim and ensure needed services are being offered. Furthermore, team members are able to provide support to one another, which may reduce the secondary trauma effects associated with these difficult cases. Ideally, the net result is a better outcome for older victims.

Agencies that work collaboratively can produce better solutions for victims, MDT members, and the community.

Successful partnerships can benefit victims in the following ways:

Conducting various evaluations in-home as a team lessens the burden of multiple interviews for the alleged abuse victims, while simultaneously gathering information on needed services for older victims as well as evidence for possible prosecution.
An MDT enhances the probability that no matter where victims enter the system, they have access to coordinated services.
As victims may receive concurrent services by many disciplines, coordination of these services may reduce the number of systems victims have to navigate.
Collaboration promotes greater awareness of available services, and improves access to and receipt of services for victims.
Coordination creates an integrated array of services tailored to the victim’s multifaceted needs that build upon the family’s strengths.
Collaboration produces creative solutions that no one agency could produce on its own.
Working as an MDT provides informal social support for victims, enhanced monitoring and follow-up beyond the crisis period, potentially reducing the recurrence of elder abuse.
Collaboration facilitates more effective and positive outcomes for clients. For example, if health care professionals need to spend time being social workers, then fewer medical needs may be attended to, but if someone else can do the social work, then health care professionals can focus on the medical needs of the client.

Working collaboratively benefits each agency represented on the MDT. Successful partnerships can benefit MDT members in the following ways:

Responsibility for a case (ensuring safety, permanency, and well-being) is shared among the MDT members. This not only lends greater confidence to team members regarding case planning, but it may reduce liability risks due to the input of high-level agency representatives and qualified medical and legal consultants brought in when appropriate. Decisions regarding the client are better informed and reviewed prior to implementation.
Every agency has legal and policy restrictions on their response to elder abuse that other agencies may be able to fill if the need is known.
MDT members may back each other up, pointing out the importance of various MDT disciplines to victims.
Through exposure to different disciplines, team members:
- Learn each other’s mandates and jargon,
- Broaden and enrich their understanding of elder abuse, and
- Sharpen their professional skills to better manage and build cases.
MDT members can access the pool of experts on the MDT to obtain assistance in resolving difficult cases.
Learning how other professionals in the community handle similar situations can bolster MDT member’s confidence.
MDTs can instill confidence that the case is being handled the best way possible by obtaining validation from other team members.
MDTs can enhance job satisfaction by promoting collegiality and motivation, while supporting one another by providing a safe place to vent frustration, relieve tension, and share feelings of helplessness.
MDTs extend and leverage interagency resources in part by reducing the financial and staff burden on individual agencies.
If one agency does not have the resources a victim needs, someone else on the MDT likely does.
MDTs can identify service gaps and make system changes.
MDTs improve the ability of agencies to share information and track families across agencies.
Through group decision-making, fewer errors are made (potentially reducing legal risk).

Successful partnerships can benefit communities in the following ways:

Providing a forum for balancing the interests and perspectives of professionals from diverse disciplines, clients, and society.
Enhancing relationships among public and private service providers.
Creating community responsibility for victim safety.
Strengthening families, which strengthens communities.
Extending the reach of limited resources within a community.

Toolkit Items

Fill in the Blanks: A Webinar for Elder Abuse Case Review MDTs at Any Stage of Development

Chapter 1 (with Citations)

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