Interprofessional Practice & Education: What is the Evidence? Memorial Interprofessional Education Faculty Development Workshop May 19, 2009

Interprofessional Practice & Education: Overview Interprofessional Practice:CHSRF 2007 Interprofessional Education:CIHC’s Literature Review Interprofessional Education:CIHC’s Competencies Health Council Canada 2009:PHC teams Definitions Conclusions/ Questions

Interprofessional Practice & Education: What is the Evidence? CHSRF Synthesis 2007

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Purpose To assess & synthesize Canadian & international experiences (and literature) in relation to effects of inter- professional collaboration & inter-professional teams in primary healthcare context relating to: Health system outcomes Patient/ client outcomes Provider outcomes

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Methodology Systematic search & analysis of Canadian & international primarily grey and peer-reviewed literature (incl. PHCTF reports and evaluation studies) Key Informant Environmental Survey (on-line survey) Framework for analyzing & categorizing outcomes (Joint Evaluation Team classification) Definitions and Tools for review quality Inclusion/ exclusion criteria

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Inclusion Criteria Relevance (key terms) Reference list detailed & included information from reliable sources (i.e. not letter/ responses from readers) Outcome/ output in at least one of 5 categories of Joint Evaluation Team Classification of inter-professional education outcomes as follows: Benefits to patients/ clients Change in organizational practice Behavioral change Modification of attitudes or opinions Simple reaction to team process

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Outcome/ Review Questions Level 1 (Reaction): How do inter-professional teams affect providers? How do inter-professional teams affect patients/ clients? Level 2a (Modification of attitudes or opinions): How do inter-professional teams affect providers? How do inter-professional teams affect patients/ clients? Level 2b (Acquisition skills/ knowledge): How do inter-professional teams affect providers? How do inter-professional teams affect patients/ clients? Joint Evaluation Team Classification of IP Education Outcomes

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Outcome/ Review Questions Level 3 (Behavioral change): How do inter-professional teams affect providers? How do inter-professional teams affect patients/ clients? Level 4a (Change in organizational practice): How do inter-professional teams affect health system? How do variations among teams affect outcomes? Level 4b (Benefits to patients/ clients): How do inter-professional teams affect patients/ clients? How do variations among teams affect outcomes? Joint Evaluation Team Classification of IP Education Outcomes

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Quality/ Grading High: Intervention study with random allocation to groups, systematic reviews with meta-analysis, & strong methodology (if well done, increased to very high) Moderate: Intervention study with poor methodology or bias/ confounding/ contamination etc. occurred in study, or if there are questions about data management Observational study with strong methodology, & outcomes show large differences between groups with no apparent bias or confounders affecting results GRADE Working Group

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Quality/ Grading Low: Observational studies start here Intervention studies with poor methodology or bias/confounding/contamination etc. occurred in study, or if there are questions about data management Very Low: Observational study with weak methodology (no control group, open to bias or confounding, & weak assessment of outcomes) GRADE Working Group

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Highlights Environmental survey (51/ 124 potential respondents) Modification of attitudes & perceptions (Level 2a) Behavioural change (Level 3) Change organizational practice (Level 4a) Patient/ client benefits (Level 4b)

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Documents Review Results (Grey Literature) 21 documents included (based on criteria) High quality:0 Moderate quality:1 (Mod. attitudes/opinions, Change org. practice; & benefits pts./ clients) Low quality:6 (all levels) Very low quality:14 (all levels except behavioural)

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Peer-Reviewed Literature Review Results Highlights (63/164 meeting inclusion criteria) High quality:13 12 with change organizational practice & pts/ client benefits Moderate quality:14 3 with reaction; 3 with change in organizational practice; 9 with benefits to pts/ clients

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Literature Review Results Highlights (63/164 meeting inclusion criteria) Low quality:23 4 with reaction; 3 with modification attitudes/ opinions & acquisition skills/ knowledge; 3 with behaviour change; 6 with organizational practice change; most with benefits to pts./ clients Very low quality:15 6 with reaction; 2 with modification attitudes/ opinions; 5 with organizational practice change; 11 with pts./ clients benefits

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Overall Key Findings Level 2a & 2b (Modification attitudes/ perceptions & Acquisition knowledge/ skills) Some modification in attitude/perception, at all levels of quality of evidence, for included document and literature reviews Scan confirmed changes in provider perception or attitude toward value &/or use of teams

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Overall Key Findings Level 4a (Change in Organizational Practice) Change in organizational practice, across all included document & literature review areas (except for high quality evidence in document review) Scan confirmed such things as large increases in use of team approach in caring for patients/clients

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Overall Key Findings Level 4b (Benefits to patients/ clients) Identified across all (except for high quality evidence in documents) review area Scan confirmed such things as large increases in client satisfaction with care/service, & increase in access to service

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Overall Key Messages High quality evidence supporting positive outcomes for patients/clients, providers & system in specialized areas (e.g. diabetes, mental health, hypertension) with interprofessional collaboration e.g. Physician/ pharmacist mgmt. hypertension with significant B/P reduction Diabetes shared care very positive feedback re service & increased confidence providing routine diabetes care in practice Case manager & PC physician collaboration for depression significant positive effects in standardized depression outcomes

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Overall Key Messages Positive outcomes for patients/clients, providers & system when interprofessional collaboration fostered & supported on basis of servicing geographic populations or population health models (environmental scan/ some of literature reviews) e.g. FP physicians & clinical dieticians resulted in significant decrease in weight (50% with intense follow-up & personal diet) Some correlation (statistically significant) in team effectiveness & lower wait time appts./fewer ER visits/ higher access PHC Interprofessional services to population 15,000 with improvement satisfaction professional practice, reduction in ER use, healthier lifestyles

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Overall Key Messages Interprofessional collaboration cost benefits in some primary health care settings e.g. lower average provider & patients costs in physician-pharmacist co- management hypertension; lowering cost per prescription with clinical pharmacist in multisite PHC medical group; 38% decrease in in-patient bed usage in PHC mental health project

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Overall Key Messages Variety processes & tools developed to support planning, implementation & evaluation of interprofessional collaboration No identification or clarification of how variations among interprofessional collaborative models affect outcomes Regulatory & legislative support not readily evident to foster & promote consistency & clarity of interprofessional collaborative partnerships & scope of practice, nor availability of physician (& other professional) remuneration models

Interprofessional Collaborative Practice: The Evidence CHSRF Synthesis 2007: Overall Key Messages Limited clarity of definitions for interprofessional collaboration (especially re patient/ client & family roles), teams, & shared care Limited quality evidence regarding interprofessional collaboration & outcomes for servicing geographic populations/ population health models Need for more rigorous research

Interprofessional Practice & Education: What is the Evidence? CIHC: Literature Review (2007) & Competencies ( )

Interprofessional Collaborative Education: The Evidence CIHC IP Education & Core Competencies Literature Review (2007): Highlights Overview IP education around the world There is lack of uniformity of definitions for IP education & competencies; Intended audiences (educators, learners, & professionals) have differing interpretations of what both are.

Interprofessional Collaborative Education: The Evidence CIHC IP Education & Core Competencies Literature Review: Recommendations in Literature to support development of national interprofessional competency framework Global definitions of IPE & competency Common set of goals for all disciplines One set of core competencies regardless of discipline or geographic location

Interprofessional Collaborative Education: The Evidence Preliminary Work re National Interprofessional Competency Framework ( ): Competency Literature Did not yield any research that looks at competency based education in interprofessional programs of study Found little evidence in literature indicating that competency based education for interprofessional programs of study significantly more effective than other models

Interprofessional Collaborative Education: The Evidence Preliminary Work re National Interprofessional Competency Framework: Competency Literature However: Support for CBE model as valuable & relevant curricular design CBE utilized in numerous programs of study & in many disciplines Perception that graduates better equipped to apply their knowledge in variety of professional situations

Interprofessional Collaborative Education: The Evidence Preliminary Work re National Interprofessional Competency Framework: Competency Literature However (cont’d): Seen to address growing emphasis on accountability within professions. Support for notion that successful CBE curriculums must follow closely with constructivist learning theory that obtaining competencies is part of a continuous process on which new knowledge/skills build upon prior knowledge/skills.

Interprofessional Collaborative Education: The Evidence Preliminary Work re National Interprofessional Competency Framework: Competency Literature However (cont’d): Students require on-the-job experience, training, & continuous education Extent to which health professionals able to acquire or improve professional competence depends largely on level & type of competencies acquired in initial education.

Interprofessional Practice & Education: What is the Evidence? Health Council of Canada 2009

Interprofessional Collaborative Practice: The Evidence Health Council of Canada: Teams in Action 2009 Evidence for interprofessional practice Creative mosaic of teams Used in rural & remote regions many jurisdictions Management chronic disease Provide overall PHC to specific communities Community based teams At least 1 in 3 Canadian adults has 1 or more chronic conditions Adults with 1 chronic condition 41% more likely to report access to > 1 primary health care professional

Interprofessional Collaborative Practice: The Evidence Health Council of Canada: Teams in Action 2009 Evidence for interprofessional practice Canadians who have additional access to either nurse &/or other professional were: > 2.5 times more likely to report range of services that met needs 42% more likely to rate quality health care as good, very good, or excellent 46% more likely to have more knowledge of conditions 67% more likely to report know-how re preventing future problems

Interprofessional Collaborative Practice: The Evidence Health Council of Canada: Teams in Action 2009 Further evidence re interprofessional practice required Differences teams making to general population Whether have right mix professionals How much/ well professionals truly collaborate How teams ultimately benefit patients

Interprofessional Practice & Education: What is the Evidence? Definitions

Definition: Interprofessional The relationship between various professions as they purposely interact to work and learn together to achieve a common goal. For example, if a patient has trouble swallowing, nurses, speech language pathologists and dietitians need to work together as a team to figure out what is wrong and how to help the patient.

Definition: Interprofessional Collaborative Practice An interprofessional process of communication and decision-making that enables the separate and shared knowledge and skills of care providers to synergistically influence the client/ patient care provided. Way, Jones & Baskerville, 2001

Definition: Interprofessional Education Occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care. CAIPE, UK Centre for Advancement of Interprofessional Collaboration, 2004 CIHC uses the term to include all such learning in academic and work based settings before and after qualification, adopting an inclusive view of "professional".

Interprofessional Practice & Education: What is the Evidence? Conclusions/ Questions

Interprofessional Collaborative Practice & Education: Conclusions Evidence to support interprofessional practice (especially for management chronic disease) Some evidence & lot of support for interprofessional practice Need to clarify understanding/ definitions re interprofessional practice & education Need for one set of interprofessional competencies for all professions Better evaluation/ research needed

Interprofessional Collaborative Practice & Education: Questions What is present status of Interprofessional Education? Do you feel present Interprofessional Education supports Interprofessional Practice?