What Works in Interprofessional Education Jodie Eckleberry-Hunt, Ph.D., A.B.P.P. Elie Mulhem, M.D. Barbara Joyce, Ph.D.

CONFLICT OF INTEREST STATEMENT The presenters have no conflicts of interest to report.

Objectives Describe the terms and theoretical underpinnings of interprofessional and interdisciplinary education Describe a method for developing interdisciplinary education within his/her institution, particularly relevant to residency education Identify the facilitators and barriers to interdisciplinary education.

Who is in the crowd?

Vocabulary Interprofessional Education: multiple professionals from different disciplines learn from, with, and about each other with a shared goal of improving health quality (Hammick et al. 2009) Interprofessional Collaboration: multiple professionals from different disciplines who share a goal of delivering the highest quality of care (Hammick et al. 2009) Multidisciplinary Education: multiple professionals from different disciplines learn together with some interaction. (Hammick et al. 2009)

Vocabulary Multiprofessional Education: multiple professionals from different disciplines learn alongside one another. Parallel vs. interactive. (Hammick et al., 2009) Team: people with complementary skills, committed to a common purpose, goals, and approach where each holds others mutually accountable. They have regular communication, coordinated process, distinct roles, shared norms, and interdependent tasks. (Hammick et al. 2009)

Vocabulary to Avoid Ancillary: subordinate; subsidiary (not as important as something else) Allied Health: professional health-care providers who are not physicians (e.g., medical assistants, physical therapists, technicians but not nurses)

Why? “Improved interprofessional teamwork and team-based care play core roles in many of the new primary care approaches.” 2011 Core Competencies for Interprofessional Collaborative Practice (AAMC, AACN, AACOM, AAMPADEA, ASPH) “Despite progress, true interprofessional learning and collaborative practice among health professionals is lacking in most GME training.”….“The most pressing problem in GME today is the paucity of interprofessional training” (Brienza et al. 2014)

Goal of Interprofessional Learning “to prepare all health professions students for deliberatively working together with the common goal of building a safer and better patient-centered and community/population oriented U.S. health care system” 2011 Core Competencies for Interprofessional Collaborative Practice (AAMC, AACN, AACOM, AAMPADEA, ASPH)

Core Competencies for Interprofessional Collaborative Practice Values/Ethics for Interprofessional Practice –e.g., patient centered, embrace diversity, ethical conduct Roles/Responsibilities –e.g., communicate responsibilities, recognize limitations, optimize complementary abilities Interprofessional Communication –e.g., active listening, respectful language, active expression, consistency Teams and Teamwork –e.g., consensus building, shared leadership, reflect on performance, conflict management

ACGME Systems Based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to: –work effectively in various health care delivery settings and systems relevant to their clinical specialty, –coordinate patient care within the health care system relevant to their clinical specialty, –work in interprofessional teams to enhance patient safety and improve patient care quality –participate in identifying system errors and implementing potential systems solutions

Interprofessional Education Outcomes Not a lot of published evidence on interprofessional education, particularly in the outpatient setting Variability in measured outcomes –Team member communication –Team member satisfaction –Team member general self report on quality Reeves S, Perrier L., Goldman J, Freeth D, Zwarenstein M. Interprofessional education: Effects on professional practice and healthcare outcomes (update) (Review) The Cochrane Collaboration.

Interprofessional Education Outcomes Much done in undergraduate medical education simulated settings Participants enjoy it Communication reportedly improved Collaboration reportedly improved But….. Does learning generalize beyond the simulation? Moreover… What is being in primary care?

What Conditions Make a Good Team?

When is a Team not a Team? Harvard Business School students observed four ward teams in the ICU in Boston area Found working groups only and no teams Team members did not feel able to speak freely and openly Rounds did not regularly include non-physicians (some nurses and some pharmacists and medical students) Hierarchical (Bharwani et al., 2012)

Interprofessionals Teams Need: –Clear objectives –Clear rules, responsibilities and strong leadership –Rules –Preparation and training –Norms of trust, respect, cooperation and support (longitudinal) –Regular review –Process to recognize achievements (Engum et al. 2012; Hammick et al., 2009)

What Rules Would You Make? How specific do you need the rules to be? What is the moderator role? More vs. less

Our Rules Say what you think even if it is different from what has been said. Listen. Let people finish their thoughts. Value everyone's contributions and, as well, rights to silence. Teach others what you know. Don't assume that there is a shared understanding among everyone. No one discipline is more important than another. The facilitator will keep time and make sure the group stays on track.

Our Rules Patient related information is to be kept confidential. There will be material that you don’t understand because this is a learning experience. It is okay to not understand, and it is okay to ask clarifying questions. Disagreement is alright and may even be creative. Let's stay on the subject for the most part. Use a respectful tone

What We Did Developed goals and objectives (see handout) and rules Invited PT, OT, SW, psychiatry, psychology, IM, dietary, pharmacy, and FM (include learners) Enlisted senior residents and faculty to present a difficult case Distributed MRN to participants one to two weeks in advance Introduce to the purpose and participants each time Read rules each time Case presentation Open feedback with facilitation

Attendees DateAttendeesDateAttendees 12/10/13n=27 13 Family Medicine 1 Psychology 1 Psychiatry 1 Pharmacy 1 Physical Therapy 1 Occupational Therapy 1 Dietetics 1 Integrative Medicine 7 Other 4/3/14 n=19 9 Family Medicine 2 Psychology 1 Physical Therapy 1 Occupational Therapy 1 Social Work 2 Integrative Medicine 3 Other 2/19/14 n=19 14 Family Medicine 1Pharmacy 4 Other 5/14/14 n=19 11 Family Medicine 4 Psychology 1 Pharmacy 1 Physical Therapy 1 Occupational Therapy 1 Integrative Medicine 3/31/14 n=17 9 Family Medicine 1 Psychiatry 4 Occupational Therapy 1 Social Work 1 Integrative Medicine 1 Other 6/3/14 n=24 18 Family Medicine 2 Psychology 1 Physical Therapy 3 Occupational Therapy

Outcomes Evaluation Question Average Response: 1 Strongly Agree to 5 Strongly Disagree Interdisciplinary conference is a safe environment to express my opinion even if I am disagreeing with other professionals I was able to recognize and respect the unique roles, responsibilities, and expertise of other health professionals I increased my understanding of evidence-based, team interventions I learned at least one strategy about how to work in an interdisciplinary team I have a coherent idea of the team-based treatment plan for the patient discussed Interdisciplinary conference increased my understanding of complex patients Interdisciplinary conference provided an effective venue for discussing challenging cases. 1.47

Outcomes: Sample Comments Managing pain with other method than drugs Take a more systems based approach and assessing ways alternative disciplines can contribute (e.g., occ health) Better management of chronic pain medication users More practical ways to better integrate primary care physician with the specialists Ensure better communication with patient’s primary care providers to optimize their treatment plans Setting an agenda and boundaries at the start of the visit How to deal with demanding/manipulating patients Sometimes less is more, i.e., referrals, testing, meds

Lessons Learned Think broadly about participants Organize, organize, organize Make it useful to patient care Rules are important to establishing culture Make a list of resources shared to distribute Enlist participation of senior residents Find a good psychiatrist

Lessons Learned Have 2-3 leaders or facilitators Evaluate outcomes

What Facilitators and Barriers Would You Anticipate? Do you have administrative support? How fast would your program recognize the importance of an out-patient interprofessional education conference? Do you have the time needed to organize such a conference? Can you find support from other disciplines?

Contact Jodie Eckleberry-Hunt Elie Mulhem Barbara Joyce