A Key to Success in Integration: Interdisciplinary Training

1. Session #D1a October 5, 2012 A Key to Success in Integration: Interdisciplinary Training William Gunn Jr. PhD Nancy Ruddy PhD Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A.

2. Faculty Disclosure I/We have not had any relevant financial relationships during the past 12 months.

3. Objectives • Participants will understand the history of interdisciplinary training and recent efforts to describe competence in this area. • Participants will understand the difference in training in an ongoing clinical practice from an academic institution

4. Objectives (cont.) • Participants will be able to describe how curriculum, goals and objectives, methods of instruction, and evaluation strategies can occur around interdisciplinary training • Participants will be able to describe ways in which interdisciplinary training can occur in their home settings.

5. Learning Assessment Participants will be able to describe the components of a curriculum in interdisciplinary education and how they currently teach this component in their clinical or academic programs

6. The Future of Healthcare

7. Interprofessional Education Needs to Start Now (or yesterday….)

8. Interprofessional Education Needs to Start Now (or yesterday….)

9. The Time is Now…. Strengthing the primary care network New medical schools opening Other disciplines worried about impact of health care reform Awareness in higher education that models need to change Almost no interprofessional training in health care professional training programs

10. The Systemic Barriers Accreditation systems that are very discipline specific Payment systems that don’t support interprofessional practice Training systems that limit interaction among disciplines, instill professional pride by deriding other professionals Professional associations that focus solely on the benefit of one discipline and don’t collaborate

11. Overcoming Systemic Barriers Change the systems from within: Serve on accreditation boards for discipline Lobby state legislatures for payment reform Use interprofessional network to find opportunities for professional organizations to collaborate Consult with curriculum designers to promote interprofessional elements in curriculum Create specific courses that can be implemented in multiple settings at multiple training levels Create opportunities for health professions trainees to interact during training.

12. Interprofessional Competence Every profession must meet its own discipline’s core competencies Additionally, need to develop team-based competencies by engaging in interprofessional learning experiences Expands basic training model acknowledges that interprofessional practice requires unique competencies Necessitates interprofessional experiences during training Interprofessional Education Collaborative Expert Panel. (May, 2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

13. Resident Competencies • Participate in the education of patients, families, students, residents and other health professionals • Work in interprofessional teams to embrace patient safety and improve patient care • Works effectively as a member or leader of a health care team or other professional group

14. Interdisciplinary Competencies • Core Competencies for Interpersonal Collaborative Practice – Report of an 2011 expert panel – endorsed by 6 national agencies • Team Based Competencies: Building a Shared Foundation for Education and Clinical Practice – Conference sponsored by RWJ and Josiah Macy Foundations

15. http://www.aacn.nche.edu/education-resources/ipecreport.pdf

16. Goals of Interprofessional Education Embed essential content in education of all health professionals Ensure curricula and assessment processes result in well trained health care professionals Make interprofessional training foundational Support research in the area of interprofessional education

17. Goals of Interprofessional Education Ensure educational competencies “fit” with demands of collaborative practice Integrate interprofessional elements into accreditation standards for all health care professionals Help accreditation panels across health care professions set common accreditation standards Work with licensing and credentialing bodies to integrate interprofessonal competencies into standards

18. Movement is Occurring…. Recent headline in STFM Messenger STFM Collaborates With PAEA (Physician Assistants Education Assocation) to Promote Interprofessional Education

19. Key outcomes of Training • Attitudes – Curiosity in how someone else sees their role, your role and how each adds value to quality, safety, a satisfying experience for all. • Knowledge – Able to state ones own value added to the team, to state others roles and value and to express the overall mission of their team (s) • Skills – Ability to demonstrate skills of both “push” and “pull” communication domains

20. Outcomes Research Needed • Do psychology trainees feel better prepared to work in medical settings with medical professionals? • Do medical teams understand and utilize the various roles behavioral health can plan? • Do teams trained together produce better outcomes, patient/family satisfaction, clinical, cost? • Other?

21. Orientation/First Month • Shadow residents at different levels, attendings – discuss MD development • Shadow staff – understand roles & pt pop • Explain their role – ask questions, “insert self” • Review patient charts, how to determine when intervention warranted • Computer training • Case conference, particularly complex cases held together

22. Managing the Caseload • Manage 50 minute hour “creep” –banish? • Severity of pathology • “Primary care” vs need specialty care • Readiness to change • Diversity of presenting problems, intervention • Who on the team can best meet the immediate needs? Long term needs? • Patient resources – could they go elsewhere?

23. Summary • Competencies need to be established about working as a team • Training programs need to adopt goals, methods, and evaluation about attitudes, knowledge, and skills working together • Complex patient and family situations need “a village”

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

25. Trend #1: Decline of “Traditional” psychotherapy • Between 1998 and 2007: • % in psychotherapy declined: 3.37% to 3.18% • % in outpatient MH care receiving psychotherapy declined: 55.9% to 42.6% • Mean # of therapy sessions declined: 9.7 to 7.9 • Mean $per session declined: $122.80 to $94.59 • Total expenditure declined: 10.94 to 7.17 billion • Olfson & Marcus, 2010

26. Trend # 2: Interdisciplinary Team Care in Primary Care Create “one stop shopping” experience for patients “Complex patients” (aka high cost patients) need expertise of multiple disciplines “Siloed” care  poor access, fragmentation of care

27. Trend # 3: Patient Centered Medical Home Coordinated “whole person” care Continuity of Care Focus on prevention Chronic Disease Management – proactive care for people with DM, HTN, etc. Electronic Health Record & INTEGRATED BEHAVIORAL HEALTH!

28. Trend #4: Moving away from “Fee for Service” Fee for service linked to higher utilization and higher overall healthcare costs Pay providers a set rate to take care of patient during an “episode of care.” Pay certified “medical homes” more than others to allow them to provide services not reimbursable under current system May lead to sharp reduction in independent practice for ALL healthcare providers

29. Competencies for Integrated Primary Care(McDaniel, Belar, Schroeder, Hargrove & Freeman, 2002) Biological and cognitive components of health & illness Behavioral and developmental aspects of H&I Sociocultural components of H&I Common primary care problems Assessment and intervention in PC Interprofessional collaboration in PC Ethical, legal & professional issues in PC

30. Developing the Skill Set: Review IPC Skills • Warm handoff • Consultation • Crisis Management • Screening/assessment • Substance Abuse • Medication Consults • Brief interventions/one session work • Motivational interviewing/lifestyle modification • Common PC presenting problems (esp chronic) • Collaboration & education role • Managing pt/provider conflict, triangulation • Group medical appointments

31. Systemic Initiatives to Support IPC Created a committee within a division of APA Developed presentations for psychology training program students and faculty about IPC Worked with Commission on Accreditation Developed directory of existing IPC training opportunities Presented to behavioralists in PC residencies Facilitated linkages between doctoral programs and PC residencies Helped internships develop PC rotations Worked with state psychology associations on state level educational programs and legislative initiatives

32. Nuts and Bolts: How to Get Started • Students generally unprepared for IPC • Challenging 50 minute hour: short visits, brief therapy • Consultation • Medical knowledge • Motivational interviewing • Health behavior change • Group intervention • “Jumping in”

33. Factors Driving the IntegratedPrimary Care Movement National healthcare → decline of siloed care? Improved provider satisfaction Interdisciplinary care for “complex” problems Improved access to mental health care Improved outcomes and reduced healthcare costs?

34. Preparing faculty, residents & staff • “Sell” IPC to everyone • Explain how to • select appropriate pts • explain service to pts • complete successful warm handoffs • Goal is collaborative care NOT dumping pt • Get preceptors to suggest collaboration • Address staff concerns

35. NH Dartmouth FMRP - Concord 6 Receptionists/Registrar 20 Medical Assistants 6 Nurses 24 Residents 6 PT Residency faculty 3 Physician Assistants 1 Family Psychologist 1 Marriage and Family Therpist/Manager

36. Roles (cont.) 6 Social Workers 5 Behavioral Health Interns 1 PT psychiatrist 4 Advanced nurses 3 OB/GYN specialist 2 Pediatric specialist 1 Internist Geritrician