Transcript The McGill Educational Initiative in Interprofessional

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
McGill Interprofessional Initiative
We’re in This Together!
David Fleiszer, M.D.
Liliane Asseraf Pasin, PT, Ph.D. (C)
Nancy Posel, N. M.Ed.
Linda Snell, M.D.
Jeff Wiseman, M.D.
Margaret Purden, RN, Ph.D.
Hélène Ezer, RN, Ph.D
Bruce Shore, Ph.D.
Yvonne Steinert, Ph.D.
Aliki Thomas, OT, Ph.D. (C)
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.
Steering
Committee
Students
Educators
Administrators
Patients
Practitioners
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Project Goal & Objectives
◙
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Goal: To address the development of
interprofessional education (IPE) and
practice (IPP) toward patient and familycentered care.
Objectives:
1. Develop the attitudes, knowledge and skills required to
teach IPP among university and clinical educators
2. Build a range of resources and tools that can facilitate
the teaching of IPP
3. Mount a comprehensive IPE program that is delivered
within and across student groups over the course of
their programs
4. Develop clinical learning environments that enhance
and enable IPP
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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
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Characteristics of
Interprofessional Teams
◙ Shared beliefs
◙ Nature of Partnership
◙ Interdependency—synergy
◙ Shared Responsibility
◙ Process
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Determinants of
Interprofessional Practice
◙ Systemic determinants
(definitions of professional jurisdictions)
◙ Organizational determinants
(governance structures, availability of space,
time)
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Outcomes of
Interprofessional Practice
In relation to the team members:
◙ Satisfaction
◙ Higher job productivity
◙ Feeling of solidarity
◙ Improved achievement of clinical goals
(Corser, 1998)
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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)
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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?
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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
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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?
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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 ?
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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)
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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
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Results
Inpatient Geriatrics Unit:
◙ 36 bed unit
◙ Team together 5 years
◙ Team composition:
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Head nurse
6 Geriatricians (rotate)
1 physiotherapist
Clinical nurse specialist
Occupational therapist
Speech language therapist
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2 social workers
29 nurses
5 orderlies
Unit agent
Dietician
Pharmacist
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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
2 Clinical nutritionists
2 Speech Therapists
2 Social Workers
Administrative Technician
Secretary
-
Physiatrist
2 Physiotherapists
Neuropsychologist
Coordinator
2 Occupational
Therapists
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A Balance Between the
Common and the Unique
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Common Attributes of
Interprofessional Practice
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Team Characteristics
◙ Sharing information
◙ Working towards consensus
◙ Dealing with disagreements
◙ Valuing the contributions of others
◙ Understanding other professional roles
◙ Evolving over time
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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
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Unique Attributes of
Interprofessional Practice
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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”
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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”
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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”
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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”
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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”
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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...’”
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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.”
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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.
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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”
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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”
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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
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Implications
◙ Promoting interprofessional practice
requires:
◙ Fundamental building blocks
◙ A culturally sensitive approach
◙ Resources that enable
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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)
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Interprofessional Continuity in
Transition of Care
Pediatric system
Adult System
Patient
/Family
Collaborative
Interprofessional
Pediatric-Adult
team
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Education
Living
Arrangements
Medical
Care
Deliberate
Vocational
Training
Recreation
Guidance
Communities
Cultures
Social
Services
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Transition of Care
Patient & Family Centered
Flexibility
Responsiveness
Continuity
Comprehensiveness
Communication
Health Care Professionals
& Other Care Givers
Adapted from Consensus Statement (2002)
Coordination
Collaboration
Interprofessional Continuity in
Transition of Care
Adult System
Pediatric System
Provides a
Nurturing & Coaching
Environment
Deals with
Complex Multisystem
Disorders &
Chronic Illnesses
Is Family-Centered
Coordinated
Care
Privacy &
Confidentiality
Cultural
Competence
End-of-Life
DecisionMaking
Understand
Logistics
Promotes
Autonomy & Independence
Has ↓ Knowledge
in Matters of
Children’s Chronic Illnesses
Unfamiliar with the
Management
of these Illnesses
Is Patient-Centered
Take Home Messages
◙ Challenges Encountered
◙ Organizational boundaries that get in the
way
◙ Unclear roles and responsibilities
◙ Unclear accountability
◙ Different views of care
◙ Ineffective communication
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Take Home Messages
◙ Educational Opportunities
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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”
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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)
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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
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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
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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.
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We’re in this Together!
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References
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A consensus statement on health care transitions for young adults with special health
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Freed, G. L. & Hudson, E. J. (2006). Transitioning children with chronic diseases to
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