Background and Rationale for Interprofessional Practice and Interprofessional Education

The population of adults older than the age 65 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 NIA 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 for patients, particularly for 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 an increased need for additional 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 in order to encourage them to develop a collaborative model that would reduce costs. Under the old fee-for-service approach, doctors and hospitals would be paid extra to care for patients with preventable complications of a surgery, for example. Under the ACA, health systems are no longer rewarded financially for preventable complications. Instead, doctors and health systems are rewarded for providing high-quality preventive care and for good patient outcomes. Studies show that IPP can address the Triple Aim by 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. 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 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 them to develop this team mentality and the relationships needed to enact change. Universities that train health professionals use a variety of strategies and instructional methods to begin 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.

Physician assistant students who are able to work in these clinics should take advantage of the opportunity to speak with students from other professions. Students should ask them 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 type of health professional is an important competency to master in school, before going out into practice.

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 philosophical 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. 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 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 opportunities to volunteer in interprofessional activities to 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 ought to promote the development of IPE, the variety of standards and the lack of guidance from accrediting agencies about which activities may fulfill this requirement can inhibit the implementation of IPE. For example, some standards may permit a school to simply provide one lecture on roles and responsibilities of different professions or provide a clinical opportunity for students to interact with another health professional. Other standards may require actual clinical training to be conducted interprofessionally. With each profession trying to meet the standards set for them in the context of already overcrowded curricula, it can be difficult for different professions to agree on the IPE activities for the institution.

  
  
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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. Adding a common course is a hardship. 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 changing 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.