8: Case Review

8: Case Review

Chapter 8: Summary

 

Case reviews involves the MDT members gathering to have face-to-face disucssions about particular cases. Many benefits accrue to MDT members who participate in case review. However, working out the myriad logistics and ground rules is important for case review meetings to function smoothly. And bring food.

Defining a Case Review Meeting

Not all MDTs utilize case review, but this guidebook emphasizes and encourages this practice. Case review is a process by which the MDT regularly convenes to:

  • Discuss the family’s well-being

  • To share information efficiently

  • To determine what additional information is needed by various MDT members

  • To assign specific tasks to the appropriate individuals

 

These procedures allow team members to draw on the knowledge, experience, training, and resources of the other professionals attending the case review meeting.

Characteristics of Case Review

• Written documents that include criteria for case review procedures and meetings.

 

• Consensus that case review is a forum for reviewing cases on a regularly scheduled basis.

 

• Consensus that case review is an informed decision making process with input from all necessary MDT members based on the needs of the case.

 

• The presence of a designated individual who coordinates and facilitates the case review process, including notification of cases that will be reviewed.

 

• Routine participation of all MDT members.

 

• The presence of a mechanism for communicating recommendations from case review to appropriate parties for implementation.

 

• Consensus that case review meetings are an opportunity for MDT members to increase their understanding of elder abuse.

Benefits of Case Review to MDT Members

 

There are a number of benefits associated with case review that flow directly to the MDT members. During case review:

  • Additional forms of elder abuse may be uncovered. For example, in discussing a financial exploitation case, an MDT member mentioned that the caregiver/daughter leaves her bedridden mother for days at a time. Another MDT member observes “Isn’t that neglect?”

     

  • MDT members learn from each other. For example, a police officer can bring medical documents and photographs to a meeting and get immediate feedback from a nurse or physician regarding the level of suspicion and concern.

     

  • Work is divided among the members preventing duplication of effort.

     

  • The MDT develops innovative and effective care plans for victims by drawing on the wisdom of multiple agency representatives and enhances feelings of competency.

     

  • MDT members become better acquainted with one another which increases the likelihood that MDT members will contact one another between meetings when needed.

     

  • Information from multiple disciplines can assist in a more comprehensive and wholistic view of the client and the client’s needs. For example, APS caseworkers are guided by the principle of self-determination and have different expertise than health care professionals. Therefore, APS may be persuaded by an articulate and impassioned plea by a client who wishes to remain in a questionable situation. A physician, however, may have assessed the client’s cognitive capacity which will influence the team’s evaluation of the situation.

     

  • Information sharing is not only a teaching strategy, but a way for team members to understand any problems the victim may be facing. For example, a victim may say something to one professional, who can then convey that conversation to the team during case review.

The opportunity to discuss the needs of elderly persons within a group of different professionals is conducive to a greater understanding of and respect for each other’s skills (Johansson, Eklund, & Gosman-Hedström, 2010).

 

How Case Review Can Facilitate Trust among MDT Members

 

As discussed, one of the most important concepts that will facilitate a smooth-functioning MDT is trust. The success of the MDT is dependent upon establishing trust among the MDT members early and throughout the life of the MDT. Ironically, trust can be facilitated through the adoption of formal (and informal) rules and procedures.

If teams cannot critically evaluate their own innovations in a safe, shared, intellectual space, they are doomed (Disis & Slattery, 2010).

There are variations in the degree of formality among MDTs, but it is generally preferable to have formal rules and procedures in place, a factor which also contributes to building trust. Some areas to consider include:

  • A summary of the proceedings (written records of meetings typically in the form of minutes; minutes may or may not be disseminated to MDT members)

 

  • Signed contracts or Memoranda of Understanding (MOU; a signed agreement regarding the terms of membership and an agreement to replace representatives who can no longer serve)

 

  • Case review guidelines (what information to include in case presentations and the order in which to present information; The Toolkit item titled: Discussion of Case Review Logistics, provides an example following the Table)

 

  • Policies and procedures manuals (provided to each MDT members; see the Toolkit item titled: Sample Protocols and Policies, for examples)

 

  • Job descriptions (done less frequently, but outlines specific duties and responsibilities of each representative and requirements for MDT participation)

 

  • MDT new member orientation manuals (general information on elder abuse, pertinent laws, research articles, policies, mission statements, confidentiality agreements, and by-laws)

 

  • Acceptable behavior during case review meetings, always with an eye toward building trust among the MDT members (see Case Review Meeting Ground Rules, below)

Trust…is built on past experiences, understanding the motives of others, and a willingness to believe in others (Levi, 2014).

 

Case Review Meeting Logistics…and Bring Food

 

The Toolkit item titled: Discussion of Case Review Logistics presents a description of a number of issues related to meeting logistics that the MDT may want to discuss. And always bring food. Consistent across MDTs is the finding that providing food increases attendance and likely good will. Food can be as simple as cookies and coffee, but providing some nutritional incentive is highly recommended.

 

Case Review Meeting Ground Rules

The Toolkit item titled: Ground Rules during Case Review Meetings, provides an expansive list of ground rules for the MDT to discuss and consider.

Members should avoid speaking in technical terms or using acronyms or jargon. For example, one MDT “fines” members who use an acronym and when a sufficient amount has accrued, use the funds to buy a special treat for the next case review meeting.

The Case Review Meeting

There are many ways to structure a case review meeting. However, typical steps in the case review meeting (descrirbed in greater detail in Table 2) include:

Case Review Flow Chart

Case Review Flow Chart

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Table 2. Description of Steps in a Multidisicplinary Team Case Review meeting

Meeting launch

Consider beginning the meeting with a presentation of the agenda and a brief reminder of the purpose of case review, any announcements, and short informal exercise to get members talking socially.

Case presentation

A member of the MDT presents a case. Information provided may include the type of abuse, the dynamics involved, victim characteristics, abuser characteristics, the victim’s wishes, any services the victim may have accessed in the past, and identification of the presenting problem (what aspect of the case is the presenter struggling with). Some MDTs require information submitted in advance (to enable the preparation of powerpoints) while others do not. Typically, each case will require 30 minutes of presentation, discussion, and recommendations so be sure to allow sufficient time to review the cases on the agenda in the allotted meeting time.

In addition to reviewing new cases, some MDTs review old cases to provide an opportunity for status updates and to allow for discussion.

Discussion of the case

Next, the case is opened up for discussion among the MDT. Any MDT member may ask questions, request more information, or brainstorm about potential solutions. For example, if there are capacity or mental health issues that warrant emergency removal orders, it may be beneficial to discuss these options with the group to determine if there are less restrictive means of advancing safety.

The team should discuss the case from a variety of perspectives. Reaching a consensus on the underlying cause of the problem will facilitate a unified solution. Framing the problem has tremendous implications for which interventions are selected, with important consequences for the victims.

Is the goal safety? Then nursing home placement may be the preferred outcomes. Is victim’s self-determination paramount? Then providing supports for the victim to remain in their own home is the preferred outcome.

A team member stated “She doesn’t want to change” and another team member amended the statement saying “Maybe she doesn’t want to change, or maybe she doesn’t know how.”

Potential recommendation identified

Based on the discussion, a set of recommendations might be adopted that include a record review, new ideas regarding services in the community, suggestions for the next step an individual should take, or a house call. Any further discussion of the risks and benefits occurs at this point. Any dissenting opinions should be formally recorded. MDT members are given assignments which are recorded to ensure follow through.

Summary and recommendations adopted

The MDT Coordinator will write a formal summary of the recommendations adopted by the MDT. The MDT may want to develop a case review data collection form (or some other method of tracking meeting data). Assignments for follow-up are made this point. The meeting minutes are written and distributed as soon as possible to all MDT members. Consider including in the minutes:

  • A description of the condition of the client
  • Other needed services/testing and who is responsible
  • Diagnosis and prognosis (if applicable)
  • A statement regarding the client’s capacity to consent
  • Recommendations for services
  • Goals, time frames, and follow-up plans

After a thorough discussion, a plan of action should be developed and adopted by the MDT, with MDT members carrying out the recommendations. The information captured in the plan of action will assist the team in measuring the success of each case. Accountability is important for the MDT members and survival of the MDT, therefore, assignments should be made explicit during the meeting. Consider recapping assignments and expectations just before the MDT adjourns.

Follow-up

  1. MDT Coordinator (or whomever the MDT chooses for this role) has responsibility for following up with MDT members who were given particular assignments to enhance accountability. In addition to distributing meeting meetings which contains a summary of assignments, some MDTs use email reminders to ensure the MDT member is aware of their commitment. MDT Coordinator should then hold team members accountable at the following meeting.

Report back to MDT

Finally, during the next case review meeting the original presenter reports back to the MDT as to whether the recommendations and insights of the MDT were helpful. This feedback not only validates the MDT members’ advice, but also builds trust among the MDT members.

Case Example

A case was presented in which the presenter knew the man since 2001. She’s recently learned that he has dementia, is driving, and driving without a license (he lost his license years ago because of a DUI). The car is insured and licensed in someone else’s name. She is concerned about him driving. She had called APS and they said they couldn’t help her. They told her to call the police if she sees him driving knowing he doesn’t have a license. She was very frustrated. Everyone around the table agreed that APS couldn’t do anything, but recommended that she take the situation to the police. She said “Can I do that? Can I contact the police about this situation?” Someone else informed her that health care professionals can confiscate keys. Another asked whether his children could remove the keys. If he had a license, she could call DMV, but because he is driving without a license it is a police matter. Someone then went back to man’s girlfriend when the presenter said the girlfriend comes around when the man gets his check each month. The group discussed whether this was a case of financial exploitation. It was determined that he had enough money to pay his bills, that he paid his bills on time, and has capacity (although they mentioned dementia above) and if he had money left over he could give it to whomever he wanted. The couple has been together for 15 years, but have never lived together. Someone mentioned that he paid some bills early and sometimes paid the same bill twice.

 

Find other case examples in Anetzberger, G. J., Dayton, C., Miller, C. A., McGreevey, J. F., & Schimer, M. (2005). Multidisciplinary teams in the clinical management of elder abuse. Clinical Gerontologist, 28(1-2), 157—171 (p. 163-170).