Interprofessional practice and education

Introduction

Physician assistant (PA) students who train in the early 21st century are being prepared as never before for interprofessional practice (IPP) via interprofessional education (IPE) ( Box 40.1 ). IPE is a newer concept in medical education; therefore PAs who graduated a decade ago may not have had the same experience in IPE as current students and physicians. Working as part of a team with other professions is so important that the Accreditation Review Commission on Education for the Physician Assistant issued a statement that the PA curriculum must include “instruction to prepare students to work collaboratively in interprofessional patient-centered teams ... [and] include opportunities for students to apply these principles.” Accrediting bodies for other health professions have similar requirements ( Box 40.2 ).

Why does working collaboratively require new advances in medical education? Don’t all medical professionals work in teams? Unfortunately, the concept of teams in the United States has traditionally been limited to the group of providers at a specific location or within a specific specialty practice. The team has not been defined as a group of people who work together across professional boundaries to care for one patient. Although specialists, for example, may send a letter of recommendations for the patient back to a primary care doctor, the concept of truly integrated care for the patient is rarely implemented. This fragmentation of care is potentially dangerous for the patient. As a result, policies have been implemented among some payors to provide incentives for better integration of patient care throughout the system.

This chapter is designed to introduce PA students to IPP and IPE. Because instruction in IPP and IPE is a relatively new approach, do not be surprised if you bring something new to settings that do not currently use interprofessional teams. Feel free to discuss these concepts with preceptors and employers but avoid being judgmental with them. This chapter will provide you with the basic principles of IPE and practical ways to implement the competencies in the clinical environment as a student and ultimately as a PA.

Background and rationale for interprofessional practice and interprofessional education

The population of adults over the age of 65 in the United States is estimated at more than 40 million, and this is expected to double to 83.7 million by the year 2050. Although the rates of alcohol consumption and cigarette smoking are lower in this generation of elders, overweight and obesity rates have increased. This means that PAs will be treating more chronic diseases in this group, such as diabetes, hypertension, arthritis, and impaired mobility. According to the National Institute on Aging’s Health and Retirement Study, in 2008, 41% of the older population had three or more chronic conditions, and 51% had at least one or two chronic conditions.

The traditional model of fee-for-service, referral-based care in the United States has been associated with fragmented care; dangerous outcomes; inefficient use of highly trained health professionals; and frustration among patients, particularly elderly adults. The nation cannot sustain the inefficiency and cost of the traditional fee-for-service system. These realizations spurred the development of the “patient-centered medical home” (PCMH) and other collaborative health care models.

In response to the limitations of the traditional system, the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA), was signed into law by President Obama on March 23, 2010. The ACA provides health care coverage for the poorest Americans by creating a minimum Medicaid income eligibility level across the country and improving the affordability of private insurance with federal subsidies for other uninsured Americans. With more people now insured, there is a significantly increased need for primary care providers. Given the shortage of primary care physicians, pressure is being placed on the system to produce sufficient PAs and nurse practitioners to absorb the newly insured patients under the ACA. The U.S. Department of Health and Human Services reported in 2012 that “the number of PAs in the medical workforce (72,000) will be insufficient to meet the future primary care needs.” Even with the anticipated 72% growth by 2025, they will only be able to provide 16% of the providers needed to address the projected physician shortage in primary care. Similar increases in the number of physicians who are being trained will also not fully meet the need for new primary care providers.

In addition to providing insurance for previously uninsured patients, the ACA also enacted provisions to encourage collaborative care models. The government has provided financial support to PCMHs to allow them to accommodate the staff expansion required to improve health care coordination. Additional funds were provided to expand training for medical providers (e.g., PAs) and to increase financial reimbursement to PCMHs that provide high-quality comprehensive medical care in collaborative models. As Medicare transitioned away from the inefficient fee-for-service model, it encouraged the formation of accountable care organizations (ACOs) and has experimented with paying them a set amount per patient to encourage them to develop a collaborative model that would reduce costs. Under the old fee-for-service approach, doctors and hospitals would receive additional payment when caring for patients with preventable complications of a surgery, for example. Under the ACA, health systems are no longer financially rewarded for taking care of patients with preventable complications. Instead, doctors and health systems are rewarded for providing high-quality preventive care and for improving patient outcomes. Studies show that IPP can address the Triple Aim of increasing the quality of care while reducing costs and increasing patient satisfaction.

In contrast to the referral-based system of the past 60 years, in the team-based IPP model, the primary care provider functions as part of a multidisciplinary team. After each member of the team evaluates the patient, the team members collaborate on developing a patient care plan. When one team member discusses the plan with the patient, it becomes clear that everyone is working together in the patient’s best interest. The patient is clearly at the center of this model and viewed as an integral part of the team ( Fig. 40.1 ).

Although long-term health outcomes for interprofessional teams have not been established, studies demonstrate that interprofessional care improves short-term patient outcomes, cost efficiency, and health professional satisfaction. Quality of care is improved by reducing redundancies of medical care services, duplication of medications, medication errors, and gaps in services.

To be better prepared to function as part of interprofessional teams, students need to learn with and about other health professions during their training instead of waiting until they enter the workforce. Early exposure to IPP enables each student to develop a team mentality and the relationships needed to enact change. Universities that train health professionals use a variety of strategies and instructional methods to introduce their students to IPP.

Many universities teach interprofessional skills through student-run clinics. Student-run free clinics have proliferated in the United States, with more than 75% of accredited medical schools having at least one student-run free clinic. Many of these are run as interdisciplinary clinics for the health profession students at these universities. In some clinics, a representative of each profession sees the patient in turn; then the students huddle to share notes and develop a treatment plan, which is presented to the attending. In other clinics, students from each profession see the patient together at the same time in the same room and decide on a care plan together. Student-run clinics offer unparalleled opportunities for preclinical students to experience working in interprofessional teams with the safety of preceptor supervision.

PA students who are able to work in these clinics are encouraged to take advantage of this opportunity to speak with students from other professions. Students should ask each other about their training, what they are currently able to do, and what their scope of practice will ultimately be when they become licensed. Recognizing the roles of each profession is an important competency to master in school before going out into practice.

The most basic interprofessional team consists of a medical provider and a nurse, but with accreditation requirements in most health care professions, it is common to see teams with any combination of the following: physicians, nurses, PAs, nurse practitioners, pharmacists, occupational therapists, physical therapists, social workers, respiratory therapists, and dieticians. Because of the unique concerns in hospice, geriatrics, and the intensive care unit of a hospital, it is possible to see spiritual care providers or clergy, intensivists, rehabilitation specialists, mental health services, and informal caregivers as well. Regardless of the discipline, the need to become proficient in the core competencies is critical for team-based care.

Barriers to interprofessional education

For the IPP model to succeed, exposure to IPP must begin when practitioners are still students. Each profession must provide opportunities for students to receive joint training. Unfortunately, health profession educators have found it more difficult than expected to provide IPE. Attempting to blend among different professions reveals practical and philosophic barriers that can make IPE challenging to implement. Some of the barriers include:

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  Structure of traditional education: Students from each profession are taught in “silos,” unaware of the content of the education and the role of each health profession. These silos promote isolation and inhibit collaboration among the professions. In clinical practice, siloes can create gaps in communication and compromise patient safety. As the health care needs of the community change, each profession adapts to meet those needs. This results in evolving roles and often an overlap of skills among professions. In many cases, health care professionals are unaware of this “role blurring” until they have the opportunity to work side-by-side with each other. For example, many clinical pharmacists are able to perform a basic physical examination and prescribe under protocol, and many occupational therapists are trained in assessing stages of childhood development, anxiety, and depression.

• The first step to overcoming this barrier is to make the effort to learn about the roles and responsibilities of each profession on the student team. You may learn this as part of your curriculum, but you should take advantage of extracurricular opportunities to volunteer in interprofessional clinical environments and learn directly from other health professionals about their training and scope of practice.

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  Interprofessional accreditation standards: Although the inclusion of IPE standards in accreditation procedures is intended to promote the development of IPE, implementation of IPE training is stifled by the variety of standards among each profession and the lack of guidance from accrediting agencies about what fulfills this requirement. For example, some standards may permit a school to simply provide one lecture on roles and responsibilities of different professions or provide a one-time clinical opportunity for students to interact with another health professional. Other standards may expect clinical training to be conducted interprofessionally, either in special clinics for patients with complex conditions, daily interprofessional interactions, or regular interprofessional case conferences. With each profession trying to meet the standards set for them in the context of already overcrowded curricula, it becomes difficult for different professions to agree on how to implement IPE activities.

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  Complexity of academic scheduling: Arranging time for IPE is an extremely difficult task because of the differences in content, complexity of schedules, and logistics of transportation to a common location. Most students are already in classes 35 to 40 hours per week. Trying to create a common time for a course for students from different professions is extremely difficult. For this reason, programs have to be creative, typically incorporating short IPE activities within existing courses. Some common IPE activities include a panel of speakers from different professions, an IPE day where students from different professions participate in workshops and simulated clinical activities, and student-run clinics, which are often scheduled in the evening hours.

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  Attitudes of faculty and administration: Merging IPE content into existing courses requires time, effort, and changes to the way things have always been done. These changes sometimes meet with resistance from faculty or administrators who do not believe in the viability of IPE or who are simply overwhelmed with the demands of running their existing programs. As IPE becomes an accreditation requirement for each profession, faculty will adjust to the new expectations, and IPE will become an accepted part of the curriculum.

Barriers to interprofessional practice

Even as the barriers to IPE seem difficult to overcome, barriers to true IPP are likely even more substantial:

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  Traditional silo structure of health professionals: The silos that exist in education result in silos in practice. In any given health care environment, doctors talk to doctors, nurses talk to nurses, social workers talk to social workers, and so on. Through experience, they become self-reliant and tend to refer out any questions that they perceive to be beyond their scope of practice. The reality is that even the conditions that they believe are within their scope can be better cared for by an interprofessional team.

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  Fee-for-service reimbursement structure: Fee for service refers to the system whereby a health care provider, after seeing a patient, bills either an insurance carrier or the patient for services rendered. The traditional system is not set up to receive invoices for consultations from multiple providers or a team. The ACA created an infrastructure that made way for a novel reimbursement system that not only reimburses a medical group based on the number of individuals assigned to its site but also provides bonuses based on performance, improving health outcomes. In other words, there can be financial rewards for offering high-quality health care and preventing disease. Team-based care will be one of the keys to success for this new system.

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  Physical space in health care facilities: Medical facilities in the traditional system are designed for optimal patient flow for a health care professional from a single discipline (e.g., a family medicine practice, physical therapy clinic, social work office). This physical setup works well in the “referral system” model but is not conducive to IPP. Many new provider offices are being constructed with a more inclusive design that may include onsite facilities for multiple disciplines at the same time, such as dentistry, physical therapy, occupational therapy, and social work in addition to primary care. How much better might the care that the patient receives be when a health care team is in close proximity to each other, actively informing each other of the patient’s progress and revising patient care plans together? This is the current direction of health care.

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  Lack of training and experience in IPP: To a health care provider who is accustomed to working autonomously and directing care for his or her patients, it can be a large adjustment to work on a team, especially when others now have input into your decisions. Functioning as part of a team does not come naturally for many providers. It requires training and experience. In the IPP model, the team leader role may be given to the one with the most team experience rather than always being assigned to the physician, as has been the tradition. PAs should be prepared to both lead these teams and know how to be a responsible supporting member of a team.

Interprofessional education competencies

Creating health care reform begins at the root, educating students from multiple professions to learn the interprofessional competencies and graduate with experience in interprofessional care. The World Health Organization recommends that health care students and medical providers become proficient at the following interprofessional skills or competencies:

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  Teamwork: Acquisition of the knowledge and skills linked to interprofessional collaboration and networking and building trust

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  Role recognition: Understanding one’s own roles, responsibilities, and boundaries, as well as those of other health and social care professionals

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  Communication: Effective communication, listening, negotiation, and conflict resolution and facilitation

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  Learning and reflection: Transferring interprofessional learning to the clinical setting; learning about team development; and reflecting critically on one’s role in the team

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  The patient: The central focus of the interprofessional team should be the patient and their family; cooperation is in the best interest of the patient; and the patient should be treated as a partner within the team

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  Ethics and attitudes: Ethical issues relating to teamwork; respect; awareness of stereotyping; and tolerating differences and misunderstandings