Interprofessional Education: Preparing for Continuity in Transition of Care

1. Interprofessional Education:Preparing for Continuity in Transition of Care Liliane Asseraf-Pasin, PT, Ph.D. (C) Margaret Purden, RN, Ph.D. Fay Strohschein, RN., M.Sc. (A) Camelia Birlean, M.Ed. & The McGill Interprofessional Initiative Team

2. Margaret Purden, RN, Ph.D. Hélène Ezer, RN, Ph.D Bruce Shore, Ph.D. Yvonne Steinert, Ph.D. Aliki Thomas, OT, Ph.D. (C) David Fleiszer, M.D. Liliane Asseraf Pasin, PT, Ph.D. (C) Nancy Posel, N. M.Ed. Linda Snell, M.D. Jeff Wiseman, M.D. Project Assistants Diane Bateman, Ph.D. Camelia Birlean, M.Ed. Ph.D.(C) Sonia Faremo, Ph.D. Judy Margison, M.Ed. Ph.D. (C) Fay Strohschein, M.Sc.(A) N. McGill Interprofessional InitiativeWe’re in This Together! Steering Committee Patients Students Educators Administrators Practitioners

3. Project Goal & Objectives • Goal: To address the development of interprofessional education (IPE) and practice (IPP) toward patient and family-centered care. • Objectives: • Develop the attitudes, knowledge and skills required to teach IPP among university and clinical educators • Build a range of resources and tools that can facilitate the teaching of IPP • Mount a comprehensive IPE program that is delivered within and across student groups over the course of their programs • Develop clinical learning environments that enhance and enable IPP

5. Literature on IPE/IPP Previous work has focused on: • Characteristics of interprofessional teams(D’Amour, 2004 & 2005; Headrick, 1998; West 1997) • Determinants of interprofessional practice(D’Amour, 2004; Heinemann, 2002; Rodriguez, 2005) • Outcomes of interprofessional practice

6. Characteristics of Interprofessional Teams • Shared beliefs • Nature of Partnership • Interdependency—synergy • Shared Responsibility • Process

7. Determinants of Interprofessional Practice • Systemic determinants(definitions of professional jurisdictions) • Organizational determinants (governance structures, availability of space, time)

8. Outcomes of Interprofessional Practice In relation to the team members: • Satisfaction • Higher job productivity • Feeling of solidarity • Improved achievement of clinical goals (Corser, 1998)

9. Outcomes of Interprofessional Practice In relation to patients and families: • Interprofessional practice improves outcomes in a number of patient populations studied to date Geriatrics, ER care for abused women, STD screening, Adult immunization, fractured hips & neonatal ICU care, depression care, and in simplifying medications (Zwarenstein et al., 2004)

10. Study Questions • What are the characteristics of the IPP sites in our system? • Is there a fit with the existing literature on IPP sites? • What implications does this have?

11. Methods • Phone survey to medical, nursing, allied health leaders in the 2 institutions to identify IPP sites • Selection of two sites • Open-ended interviews with key informants • Participant observation at the 2 sites

12. Telephone Survey Sample Questions: • What sites come to mind for you as demonstrating exceptional interprofessional collaboration? • Can you describe them to me? • What makes the site outstanding or unique?

13. Site Visits Sample Interview Questions: • What do you think makes the team work well together? • Can you describe a patient/family situation that was a challenge for the team and how the team dealt with this? • What would you recommend to sites that are developing their interprofessional practice ?

14. Site Visits Observations: • General layout of the unit • Who are the key players • Where and how do interactions happen • The nature of interactions between professionals and with patients and families • Meetings (who guides the meeting, who participates)

15. Results Telephone Survey: • 11 respondents nominated 22 sites in Hospital A • 25 respondents nominated 45 sites in Hospital B • Nominated settings included: • Geriatrics, Oncology, Neurology, Psychiatry, Palliative Care • ICU, General medical, Surgery

16. Results Inpatient Geriatrics Unit: • 36 bed unit • Team together 5 years • Team composition: • Head nurse - 2 social workers • 6 Geriatricians (rotate) - 29 nurses • 1 physiotherapist - 5 orderlies • Clinical nurse specialist - Unit agent • Occupational therapist - Dietician • Speech language therapist - Pharmacist

17. Results Traumatic Brain Injury Program: • Provided service to over 500 patients/year, followed ~ 45 patients at any given time • Team formed 12 years ago • Team composition: • 2 Neurosurgeons - Physiatrist • 2 Clinical nutritionists - 2 Physiotherapists • 2 Speech Therapists - Neuropsychologist • 2 Social Workers - Coordinator • Administrative Technician - 2 Occupational • Secretary Therapists

18. A Balance Between the Common and the Unique

19. Common Attributes of Interprofessional Practice

20. Team Characteristics • Sharing information • Working towards consensus • Dealing with disagreements • Valuing the contributions of others • Understanding other professional roles • Evolving over time

21. Determinants of Collaboration • Leaders who coordinate the group effort, bring professionals together • Shared goals, clear objectives • Group discussions • Flattened hierarchy among professionals • Time to interact

22. Unique Attributes of Interprofessional Practice

23. The ‘Heart’ of IPP Standing around the board “It’s our ‘town square’ it’s where we gather” “A lot of informal conversations are in front of the board because you will have several professionals gathering there” “That board is the focal point, the nucleus of the floor” “It is a religious moment looking at the board….(it) indicates what we do here, very very important”

24. The ‘Heart’ of IPP Coming to the table “There is this interdisciplinary play back and forth, where people share information, openly, freely and particularly in this rounds setting that we have once a week” “All the team members hold different pieces to the same puzzle and rounds is where they come together to put those pieces together” “To share as well…the small celebrations of successes”

25. Tuning into our Partners Learning the dance “If you have a dance partner that you are with for a while…you almost know how the moves are going to go and you can predict a little bit. For me it is knowing other people well enough…so I can adapt myself”

26. Tuning into our Partners Listening for the cues “Listening and hearing…the reactions that each of the team members have when they hear certain facts - if they have a reaction like ‘oh it would have helped to know this in advance…’ So a lot of it is just good listening”

27. Not for the Novice A steep learning curve “Walking into the TBI program is not an easy walk…to produce concise assessments in a short period of time” “Its basically a TBI 101..in terms of what kind of acronyms will you hear…, what kind of markers do you look for in a medical chart, and the biggest part of the learning…was the importance of sharing information”

28. Not for the Novice High expectations “Expectations are high here...you have to know your cases, you have to be on top of things... I've been on other services so it was easier for me....but [in rounds] at the beginning…I spoke before the dietician and they said, 'No, you have to wait your turn...' 'My turn?' and I looked around and said, 'What are you talking about?' 'No, we go in order.’ and I thought, ‘Okay, it wasn't a big deal but...’”

29. Negotiating Boundaries Establishing boundaries “In the beginning it was not obvious that people would let go of their territory. They have many areas that overlap…[but] who has the best tools and knowledge to do it? It was really by discussing, giving examples and describing roles that things settled slowly and now they are all working together.”

30. Negotiating Boundaries Knowing the boundaries “On this floor there is very little overlapping. The division of labour is quite boundary clear and it is very, very important…it has to do with the patient who is admitted and what their needs are” “As a social worker I have to listen to [patients’] grievances….after I listen I will acknowledge their complaints—I will direct them appropriately to the HN, the ombudsman, the physician or the physiotherapist. I will let my colleagues work on their issues. They do that reciprocally.

31. Part of our Culture The way we see things “A team represents a small society, different people with different personalities with different strengths, weaknesses…You have to make sure that you always go and get the best from each person in your little society”

32. Part of our Culture The way we do things “There are a lot of contributory individuals who are going into this river. . . like different streams, and that is how the floor works” “On a floor like this, everything is up for discussion” “That is part of the culture on the floor that continuous access to each other and having these formal mechanisms and informal mechanisms, like looking at the board”

33. Discussion • The findings support previous work and also highlight unique attributes that presented differently in the two settings. • Methodology that is sensitive to the nuances of interprofessional practice

34. Implications • Promoting interprofessional practice requires: • Fundamental building blocks • A culturally sensitive approach • Resources that enable

35. Transition of Care • “The goal of transition in health care for young adults with a special health care need is to maximize lifelong functioning potential through the provision of high quality, developmentally appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood” (AAP; ACFP; ACP; ASIM – Consensus Statement, 2002)

36. Interprofessional Continuity in Transition of Care Adult System Pediatric system Patient /Family Collaborative Interprofessional Pediatric-Adult team

38. Education Living Arrangements Medical Care Deliberate Guidance Vocational Training Recreation Communities Cultures Social Services

39. Transition of Care Patient & Family Centered Coordination Comprehensiveness Continuity Responsiveness Flexibility Communication Collaboration Health Care Professionals & Other Care Givers Adapted from Consensus Statement (2002)

40. Interprofessional Continuity in Transition of Care

41. Take Home Messages • Challenges Encountered • Organizational boundaries that get in the way • Unclear roles and responsibilities • Unclear accountability • Different views of care • Ineffective communication

42. Take Home Messages • Educational Opportunities • Conduct an open house – Come & see what we are all about… • Plan for shadowing experiences – Walk in my shoes for a day… • Create a mentoring program – Young adult with an adult patient • Develop Community Partners – Come together around the table • Scaffold the transition of care for the patient • Conduct a Needs Assessment • Include Transition of Care in the Academic Curriculum of Health Care Programs • Use existing structures – “MUHC Harmonization Project”

43. How to Ensure Successful Transition of Care? • Step 1 • Identify a HC professional who attends to the unique challenges of transition & assumes responsibility for current HC, care coordination & future HC planning, ex: Nurse “Pivot” (at the Breast Center) • Step 2 • Identify core knowledge & skills required to provide developmentally appropriate HC transition services to young people with special HC needs and include these in the curriculum of future HC professionals and in continuing education programs of HC professionals ex: Interprofessional Student Workshop on Professionalism (at McGill for all 500 students in the Faculty of Medicine)

44. How to Ensure Transition of Care? • Step 3 • Prepare and maintain up-dated medical summary that is portable & accessible, ex: Patient Flow Chart for Spina Bifida Clinic (at the Shriners Hospital) • Step 4 • Create a long term health care plan before the young patient reaches age 15 and update it with the patient & their family every year or sooner if there is a transitional change Note: Take into account the maturity of the child & his/her support system & his/her personal goals

45. How to Ensure Transition of Care? • Step 5 • Recognize that young people with special needs will require more services and resources than other young people to optimize their health • Step 6 • Become aware of accessibility issues within the patient’s community, ex: services offered, transportation & financial means & support • Become aware of cultural differences with regard to the patient’s health care values and belief system, ex: societal roles of a child versus an adult in western society versus another

46. Acknowledgements • Health Canada Initiative on Interprofessional Education and Practice • All of the health professionals in these two settings who welcomed us into their teams and gave of their time to help us learn how they do what they do.

47. We’re in this Together!

48. References • A consensus statement on health care transitions for young adults with special health care needs (2002). Pediatrics., 110, 1304-1306. • Christakis, D. A., Wright, J. A., Zimmerman, F. J., Bassett, A. L., & Connell, F. A. (2003). Continuity of care is associated with well-coordinated care. Ambul.Pediatr., 3, 82-86. • Freed, G. L. & Hudson, E. J. (2006). Transitioning children with chronic diseases to adult care: current knowledge, practices, and directions. J.Pediatr., 148, 824-827. • Hagood, J. S., Lenker, C. V., & Thrasher, S. (2005). A course on the transition to adult care of patients with childhood-onset chronic illnesses. Acad.Med., 80, 352-355. • Heywood, J. (2002). Enhancing seamless care: a review. Paediatr.Nurs., 14, 18-20. • Richards, M. & Vostanis, P. (2004). Interprofessional perspectives on transitional mental health services for young people aged 16-19 years. J.Interprof.Care., 18, 115-128. • Viner, R. (2001). Barriers and good practice in transition from paediatric to adult care. J.R.Soc.Med., 94 Suppl 40:2-4., 2-4. • While, A., Forbes, A., Ullman, R., Lewis, S., Mathes, L., & Griffiths, P. (2004). Good practices that address continuity during transition from child to adult care: synthesis of the evidence. Child Care Health Dev., 30, 439-452. • Zwarenstein, M., Reeves, S., Barr, H., Hammick, M., Koppel, I., & Atkins, J. (2001). Interprofessional education: effects on professional practice and health care outcomes. Cochrane.Database.Syst.Rev., CD002213. • Zwarenstein, M., Reeves, S., & Perrier, L. (2005). Effectiveness of pre-licensure interprofessional education and post-licensure collaborative interventions. J.Interprof.Care., 19 Suppl 1:148-65., 148-165.