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 10.1 ). IPE is a newer concept in medical education; therefore, PAs who graduated only a few years ago will not have had the same experience in IPE as current students and doctors. Working as a part of a team with other professions is so important that the Accreditation Review Commission on Education for the Physician Assistant states 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.” Other health profession education accrediting bodies have similar requirements ( Box 10.2 ).
Interprofessional education (IPE) “occurs when two or more professions learn with, about, and from each other to enable effective collaboration and improve health outcomes.” IPE is intended to prepare students for interprofessional collaborative practice in the workforce.
Interprofessional practice (IPP) is often referred to as interprofessional collaborative practice. This occurs “when multiple health workers from different professional backgrounds work together with patients, families, care givers and communities to deliver the highest quality care.” Elements of effective IPP include respect, trust, shared decision making, and partnerships.
Triple Aim: A three-pronged approach to optimizing health system performance created by the Institute for Healthcare Improvement. This involves simultaneous efforts to (1) improve the patient experience of care (including quality and satisfaction), (2) improve the health of populations, and (3) reduce the per capita cost of health care. The Triple Aim is a goal for new collaborative health care systems and serves as the filter or lens through which new health care models will be evaluated. (Video Resource: www.ihi.org/engage/initiatives/tripleaim .)
Client vs. patient: Health care professionals who don’t prescribe medications, such as social workers and occupational therapists, will refer to the patient as their “client.” This may seem rather impersonal, but it is more accurate from their perspective.
Interdisciplinary vs. interprofessional: Some professions may use the word “interdisciplinary” instead of “interprofessional.” There are subtle differences between these words, but they are often used interchangeably.
Physician Assistant: ARC-PA Accreditation Standard B 1.08 . The curriculum must include instruction to prepare students to work collaboratively in interprofessional patient-centered teams. Such instruction includes content on the roles and responsibilities of various health care professionals, emphasizing the team approach to patient-centered care beyond the traditional physician–PA team approach. It assists students in learning the principles of interprofessional practice and includes opportunities for students to apply these principles in interprofessional teams within the curriculum.
Medicine: LCME Accreditation Standard 7.9, Interprofessional Collaborative Skills. The faculty of a medical school ensures that the core curriculum of the medical education program prepares medical students to function collaboratively on health care teams that include health professionals from other disciplines as they provide coordinated services to patients. These curricular experiences include practitioners and/or students from the other health professions.
Dentistry: CODA (Commission on Dental Accreditation) Standard 2-19. Graduates must be competent in communicating and collaborating with other members of the health care team to facilitate the provision of health care. Students should understand the roles of members of the health care team and have educational experiences, particularly clinical experiences that involve working with other healthcare professional students and practitioners. 2-19.1 Describe how students interact and collaborate with other health care providers, including but not limited to: a. primary care physicians, nurses, and medical students; b. public health care providers; c. nursing home care providers; d. pharmacists and other allied health personnel; e. social workers.
Social Work: Council on Social Work Education (CSWE) 2015 Educational Policy and Accreditation Standards Competency 1 – Demonstrate Ethical and Professional Behavior. Social Workers also understand the role of other professions when engaged in inter-professional teams … Social workers value principles of relationship-building and inter-professional collaboration to facilitate engagement with clients, constituencies, and other professionals as appropriate … Social workers value the importance of interprofessional teamwork and communication in interventions, recognizing that beneficial outcomes may require interdisciplinary, inter professional, and inter-organizational collaboration. Social workers.
Occupational Therapy: Accreditation Council for Occupational Therapy Education (ACOTE®) Standard B.5.21. A graduate from an ACOTE-accredited doctoral-degree-level occupational therapy program must effectively communicate, coordinate, and work interprofessionally with those who provide services to individuals, organizations, and/or populations in order to clarify each member’s responsibility in executing components of an intervention plan.
Physical Therapy: Commission on Accreditation in Physical Therapy Education (CAPTE) Standard 6F. The didactic and clinical curriculum includes interprofessional education; learning activities are directed toward the development of interprofessional competencies including, but not limited to, values/ethics, communication, professional roles and responsibilities, and teamwork. This element will become effective January 1, 2018. Standard 6L3 . The curriculum plan includes clinical education experiences for each student that encompass, but are not limited to, involvement in interprofessional practice. According to these standards, the programs should provide opportunities for involvement in interprofessional practice during clinical experiences and evidence that students have opportunities for interprofessional practice.
Nursing: The Commission on Collegiate Nursing Education (CCNE) Standards for Accreditation of Baccalaureate and Graduate Nursing Programs and the American Association of Colleges of Nursing (ACCN) publish The Essentials of Baccalaureate Education for Professional Nursing Practice – Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes. The nursing baccalaureate program prepares the graduate to: 1) Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e., scope of discipline, education and licensure requirements); 2) use inter – and intra-professional communication and collaborative skills to deliver evidence-based, patient-centered care. Sample content includes: interprofessional and intra-professional communication, collaboration, and socialization, with consideration of principles related to communication with diverse cultures; teamwork/concepts of teambuilding/cooperative learning; professional roles, knowledge translation, role boundaries, and diverse disciplinary perspectives.
Why does working collaboratively require new advances in medical education? Don’t all medical professionals work in teams already? 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 recently been implemented 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 newer approach, do not be surprised if you bring something new to settings that don’t 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 as well as practical ways to implement the competencies in the clinical environment as a student and as a PA.
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:
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.
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.
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.
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.