Jason Ricco, MD, MPH, Assistant Professor Jerica Berge, PhD, MPH, Associate Professor

1. Session # A4a October 17, 2015 Interprofessional Education in Practice: Teaching and Evaluating Collaborative Practice Among Interprofessional Learners at a Family Medicine Residency Program Jason Ricco, MD, MPH, Assistant Professor Jerica Berge, PhD, MPH, Associate Professor University of Minnesota North Memorial Family Medicine Residency Program Collaborative Family Healthcare Association 17thAnnual Conference October 15-17, 2015 Portland, Oregon U.S.A.

2. Faculty Disclosure The presenters of this session • have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe how interprofessional education (IPE) is integral to helping the healthcare workforce achieve the Triple Aim through collaborative care • Discuss various interprofessional education approaches within a family medicine residency program • Identify the role for more robust evaluation of interprofessional education activities by focusing more on assessment of IPE competencies to measure preparedness for collaborative practice

4. Bibliography / References Brandt B, Lutfiyya MN, King JA, Chioreso C. A scoping review of interprofessional collaborative practice and education using the lens of the Triple Aim. J Interprof Care. 2014; 28(5):393-99. Chong WW, Aslani P, Chen TF. Shared decision-making and interprofessional collaboration in mental healthcare: a qualitative study exploring perceptions of barriers and facilitators. J Interprof Care. 2013;27(5):373–379. Farrell B, Pottie K, Woodend K, et al. Shifts in expectations: Evaluating physicians’ perceptions as pharmacists become integrated into family practice. J Interprof Care. 2010;24(1):80-89. Hughes L, Tuggy M, Pugno P, Peterson L, Brungardt S, Hoekzema G, Jones S, Weida J, Bazemore A. Transforming training to build the family medicine workforce our country needs. Fam Med. 2015;47(8):620-7. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: report of an expert panel. Washington, DC: Interprofessional Education Collaborative, 2011. http://www.aacn.nche.edu/education-resources/ipecreport.pdf. Accessed June 20, 2011. World Health Organization. Framework for action on interprofessional education & collaborative practice. Geneva, 2010.

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Introduction/Terms • Increasing emphasis on interprofessional collaboration for improving health care quality • Interprofessional education (IPE) is a means to prepare professionals to engage in such collaboration • WHO definition of IPE: “Two or more professions learning with, from and about each other to improve collaboration and quality of care.”

7. Background • IOM’s 2001 Report- “Crossing the Quality Chasm: A New Health System for the 21st Century” • Health care redesign Preparing the workforce Interdisciplinary training among health professions • WHO 2010- “Framework for Action on Interprofessional Education and Collaborative Practice” • WHO recognizes “interprofessional collaboration in education and practice as an innovative strategy that will play an important role in mitigating the global health workforce crisis.” • Nearly universal support from professional organizations for IPE

8. World Health Organization, 2010. Framework for Action on Interprofessional Education & Collaborative Practice. WHO. Geneva, p. 9.

9. Background • IPE Collaborative practice Optimizes health services and improves health outcomes • Evidence for improved: • Access to health services • Chronic disease outcomes • Patient safety • Appropriate use of clinical resources • Also a decrease in: • Hospital admissions, length of stay, hospital complications • Clinical error rates • Mortality1-5 Reeves S et al. Interprofessional education:effects on professional practice and health care outcomes. Cochrane Database of SystematicReviews, 2008, Issue 1. Reeves S. A systematic review of the effects of interprofessional education on staff involved in the care of adults with mental health problems. Journal of Psychiatric Mental Health Nursing, 2001, 8:533–542. McAlister FA et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission. Journalof the American College of Cardiology, 2004, 44:810–819. Mickan SM. Evaluating the effectiveness of health care teams. Australian Health Review, 2005, 29(2):211-217. Lemieux-Charles L et al. What do we know about health care team effectiveness? A review of the literature. Medical Care Research and Review, 2006, 63:263–300.

10. Collaborative Practice and the Triple Aim • Healthcare Triple Aim1 as the overarching framework to fix the U.S. healthcare system: • Quality • Cost • Experience • IPE/Collaborative practice interwoven in all three aims

11. Problem • Widespread, systematic implementation of IPE has not yet occurred in the U.S. • “A quick scan of most health professions schools today reveals a collection of siloed educational structures, working in parallel with little dialogue, integration, or collaboration between them.” -B. Brandt and M. Earnest • More success in other countries • Previously documented structural, cultural, organizational, and interactional barriers to IPE Earnest M, Brandt B. Aligning practice redesign and interprofessional education to advance triple aim outcomes. J Interprof Care. 2014 Nov;28(6):497-500

12. The challenges • Integration of longitudinal IPE activities within primary care training sites • Evaluating IPE curriculum effectiveness to prepare professionals to engage in collaborative practice

13. Evolution of IPE Evaluation • IPE concepts around since 1970s • Linked to healthcare delivery and outcome improvement processes • Resurgence of IPE initiatives in response to the Affordable Care Act

14. Evolution of IPE Evaluation • Prior evaluation of IPE activities largely based on learner self-assessment of: • Attitudes towards other professions and IPE activities • Readiness to work collaboratively in a healthcare team • Intent to practice in an interprofessional setting

15. IPE Competencies • 2011 IPE Collaborative Core Competencies • Based on WHO definitions of collaborative practice • 38 competencies within 4 domains of IPE

16. The Age of Milestones • ACGME Family Medicine Milestone Project • Developmentally-based assessment of demonstrable attributes and behaviors throughout residency training • Linked to domains essential for family medicine physician competency

17. Our Story • Who we are • Our IPE Curriculum • Our evaluation methods

18. North Memorial Family Medicine Residency Program • A University of Minnesota residency program, 10-10-10 • Affiliated with a community hospital • Broadway Family Medicine, our clinic, is located in North Minneapolis • Patient-Centered Medical Home • Longstanding interprofessional culture preceding the era of IPE initiatives

19. Staff • Faculty • MD and DO physicians • Clinical pharmacists • Behavioral medicine (LMFT) • NP • Residents • MD/DO • PharmD • Behavioral health interns

20. Other Staff • Care coordinators (LICSW, RN) • Triage RN • Various students from different health professions programs

21. IPE Initiatives • Team meetings • Care plans • Student pairings • Resident pairings • Video recording

22. Interprofessional Team Meetings:Avenue for multidisciplinary input on the integrated physical and mental health needs of complex patients. • Purpose: 1. Learn and practice a biopsychosocial approach to patient care 2. Increase learner ability to provide interprofessional care to increase quality and continuity of care 3. Provide opportunities to practice new skills: • Conducting a family meeting • Motivational interviewing or counseling skills • Structuring a medical visit 4. Provide time for substantive case discussions: • Increase understanding of “whole person” in context • Assess relationship with patient • Develop treatment/interactive approaches • Evaluate treatment effectiveness

23. Participants in Team Meetings • Include: • 4 Resident teams (7-8 residents per team) • 1-2 MD faculty • 3 Behavioral health (mental health) faculty (LMFT, LICSW) or Intern • 1 PharmD faculty and/or resident • 1 Triage nurse (occasionally) • 1 Care coordinator • 1 Patient advocate • 1 Front desk staff (occasionally) • Patient • Family • Community support (PHN, social worker, etc.) • Observers (students)

24. Who are “Team Patients”? • Team members bring patients that are “complex”: • Multimorbidity • Mental Health diagnoses • Any combination (biopsychosocial) • Communication problems • “Dreaded” patient • Uncertain diagnosis or treatment plan • “Practice” interactions • Need for collaborative care between multiple providers

25. Team Meetings • Logistics: • Each team meets one morning per week from 8-8:40 am followed by team clinic until noon • 30-45 minutes: Case discussion and consultation with team members; debrief/updates from last team patient visits • 3 hours: Patients seen by any combination of team members (each resident given one 40 minute slot for a “team” patient)

26. Care Plan Team

27. Interprofessional Paired Visits • Designed as a developmental step to prepare learners to collaborate effectively as a team • Ultimately, this will happen asynchronously (warm hand-offs, etc.) in the real world • First learners need orientation to the other professions’ strengths and assets • First step is a paired visit with 2 learners from different professions learning “from, about, and with” each other during real patient encounters

28. Student Interprofessional Pairings • Started in 2009 • Pair students on 2 half days a week • Previously evaluated change in attitudes towards IPE with pre and post questionnaire • Readiness for Interprofessional Learning Scale • Validated questionnaire • Overall, positive attitudes towards IPE both before and after paired visits

29. Resident Interprofessional Pairings • Started in 2010 • Pair residents on 1 half day a week • Initially MD and PharmD residents, now including behavioral health interns • Previously evaluated: • Individual feedback and perception of value • Amount of contribution to patient care tasks by each team member as viewed by other member • Shared decision-making by team during visit1 1. LounsberyJL, Moon JY, Prasad S. Assessing collaboration between family medicine residents and pharmacy residents during an interprofessional paired visit. Fam Med. 2015;47(5):397-400.

30. Video Review • A/V capabilities in clinic to capture patient encounters • Used originally to assess individual family medicine resident communication and exam skills during quarterly video review with faculty • Videos captured of paired interprofessional (IP) visits to evaluate both team and individual performance in IPE competencies

31. Current Evaluation Process • Development of an evaluation tool to assess IPE competencies during video review • Ideal tool attributes: • To have demonstrable behavioral anchors for assessment of IPE competencies within each domain • Can assess both individual and team performance in relation to IPE competencies • Can be used both for formative team feedback and longitudinal tracking of an individual learner’s progress with IPE competencies

32. Example Video of a Paired IP Visit • Assess effectiveness of visit, team dynamic, patient-centeredness, IPE competencies: • Values/ethics for interprofessional practice • Roles/responsibilities • Interprofessional communication • Teams and teamwork • During video think about evaluation strategy • Team and individual evaluation? • Formative and summative evaluation capabilities?

33. Discussion • What do you think of the paired visits? • Comments on IPE curriculum? • Suggestions or challenges in evaluating IPE competencies during video review process? • Next steps

34. Questions?

35. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!