Providing Interprofessional/Collaborative Care

Presentation at the National Continuing Competence Conference For Regulated Professions

November 1, 2007

Toronto, Ontario

Cathy Fooks

President and CEO

The Change Foundation

Presentation Overview

What is Interprofessional/Collaborative Care?

Why Should We Care?

What Do People Think?

What Does Success Look Like?

How Are We Doing with Implementation?

What are the Implications for Current Practice?

What Is Interprofessional Care?

Definitions – Interprofessional Care

• The provision of comprehensive health services to patients by multiple health caregivers who work collaboratively to deliver quality care within and across settings.

(Health Force Ontario, 2007)

• The positive interaction of two or more health professionals, who bring their unique skills and knowledge, to assist patients/clients and families with their health decisions

(CAOT, 2005)

Definitions – Interprofessional Care

• Interprofessional care is a multidisciplinary, team-based approach to practice, with health care professionals interacting to solve common issues.

(Ontario Medical Association, 2007)

Definitions – Collaborative Care

• Collaborative care requires a broad network of collaborative interactions among a variety of health service providers, patients, their families and caregivers, and the community, with patients being both the focal points and full-fledge partners of the overall effort. (Health Canada, 2004)

• Collaborative patient-centred practice involves the continuous interaction of two or more professions or disciplines, organized into a common effort, to solve or explore common issues with the best possible participation of the patient.

(V. Curran, Centre for Collaborative Health Professional Education, 2004)

Definitions - Collaboration

• Collaboration is a process that requires relationships and interactions between health professionals regardless of whether or not they perceive themselves as part of a team.

(Oandasan et al, 2006)

Definitions (mine)

• Has generally boiled down to some combination of health professions – beyond a physician and a nurse – working in some form of a team to provide patient care.

• Some include patients and family members as part of the decision making.

• Some highlight the notion of across physical locations or settings.

Why Should We Care About Interprofessional Care?

It’s Good for You

• Increased access to care

• Reduced errors

• Improved outcomes for people with chronic disease

• Better use of resources

• Increased employee/personnel satisfaction

Increased Access

“Collaborative care can be an important element of a more comprehensive solution to improving patient

access to care.”

(CMPA, web site accessed October 2007)

Increased Access – Reduction in Wait Times, Saskatchewan Family Practice Clinic

24

18

12

33

0

5

10

15

20

25

30

Apr-07 May-07 May-07 Sep-07 Sep-07

Reduced Errors

Research on impact of teams in reducing error:

• Lower emergency department clinical error rates (J Health Ser Res, 2002)

• Improved teamwork could have prevented or mitigated events leading to malpractice claims in 43% of the events under study

(J Healthc Risk Manag, 2001)

• Reduced unexpected cardiac arrest in hospital by 50%(BMJ, 2002)

Improved Patient Outcomes for People with Chronic Disease

• Increased patient and provider satisfaction as well improved outcomes through collaboratives

(Medical Care, 2005; American Journal of Managed Care, 2005; Diabetes Care, 2006; Rand Corporation, 2006)

• Teams overcome barriers such as lack of physician time, lack of care coordination, lack of information systems, lack of patient education efforts

(Milbank Quarterly, 1996; Institute for Healthcare Improvement, 2007)

Improved Patient Outcomes for People with Chronic Disease

Other benefits include:

• Closer alignment to established CPGs• More education and support for family caregivers• Increased self care within best practice frameworks

Improved Patient Outcomes for People With Chronic Disease: Case of Diabetes

• Better sugar control (JAMA, 2006)

• More timely adjustment of meds by case managers (JAMA, 2006)

Improved Patient Outcomes for People With Chronic Disease: Case of Diabetes

Saskatchewan Chronic Disease Management Teams:

• 39% improvement in kidney screening• 26% improvement in appropriate prescribing against CPG• 16% improvement in cholesterol management• 5% improvement in education referrals

Better Use of Resources

2003 Commonwealth Fund Study on Care Coordination Among Sicker Adults – Canadian Numbers – people not seen by teams

• 50% reported they had to repeat the same story to multiple health professionals

• 19% reported their records/results did not reach the doctor’s office in time for their appointment

• 20% reported they were sent for duplicate tests by different health professionals

• 23% reported they received conflicting information from different health professionals

Increased Employee/Personnel Satisfaction

• Well functioning teams improve health professional satisfaction

(Journal of Management, 1997)

• Group cohesiveness is positively associated with performance

(Cohen and Bailey, 1997)

What Do People Think?

% of Public Supporting Increased Use of Non-Physician Providers, 2006 and 2005

28

31

23

6

10

26

29

21

9

13

0 5 10 15 20 25 30 35

Strongly Support

Somewhat Support

Neutral

Somewhat Oppose

Strongly Oppose

2006 2005

% of Public Supporting Requiring Health Professionals to Work In Teams, 2006

39

37

17

2

2

0 5 10 15 20 25 30 35 40 45

Strongly Support

Somewhat Support

Neutral

Somewhat Oppose

Strongly Oppose

% Support by Group for Requiring Health Professionals to Work in Teams, 2006

39

18

54

59

61

37

29

29

29

33

17

33

16

11

3

2

7

1

1

3

2

13

0 10 20 30 40 50 60 70

Public

Doctors

Pharmacists

Nurses

Managers

Strongly Support Somewhat Support Neutral Somewhat Support Strongly Oppose

% of Public Support Patients Required to Register with One Family Doctor or Other Primary Health Care Provider, 2006

26

33

22

6

8

0 5 10 15 20 25 30 35

Strongly Support

Somewhat Support

Neutral

Somewhat Oppose

Strongly Oppose

% Support by Group Requiring Patients to Register with One Family Doctor or Other Primary Health Care Provider, 2006

26

19

36

49

34

33

31

37

29

36

22

26

13

13

16

6

13

9

2

10

8

11

5

7

4

0 10 20 30 40 50 60

Public

Doctors

Pharamcists

Nurses

Managers

Strongly support somewhat support neutral somewhat opposed strongly opposed

% Public Support for Requiring Health Professionals to Work in Specific Geographic Areas, 2006

21

30

26

8

10

0 5 10 15 20 25 30 35

Strongly Support

Somewhat Support

Neutral

Somewhat Oppose

Strongly Oppose

% Support by Group for Requiring Health Professionals to Work in Specific Geographic Areas, 2006

21

5

13

18

17

30

10

31

29

36

26

22

33

28

21

8

22

7

11

14

10

41

14

9

12

0 5 10 15 20 25 30 35 40 45

Public

Doctors

Pharmacists

Nurses

Managers

Strongly Support Somewhat Support Neutral Somewhat Oppose Strongly Oppose

What Does Success Look Like?

Success Factors for Team Members

• Members possess professional assertiveness• Strong clinical skills• Communication skills• Knowledge of the community• Ability to contribute to care planning, case

conferences etc.• The more experience with teams, the better

(Bergman, CHSRF 2006 PHC Symposium)

Success Factors for Shared Care

• Initial co-location of members• Active engagement of all team members• Open communication• Shifting leadership, depending upon expertise

and patient need• Trust and respect between team members• Shared goals

(continued…)

Success Factors for Shared Care (2)

• Readiness for change• Confidence in team competence• Evolution of roles and functions• Promotion of the team over any one individual

(Bergman, 2006 CHSRF PHC Symposium)

Check List for Success

• Are the roles and responsibilities of each team member clearly defined?

• Does every team member know their role and the roles of others?

• How will decisions be made?• Is there a QA mechanism to monitor team function

and pt outcomes?(Continued)

Check List for Success

• What are the anticipated health care outcomes the team is striving to achieve?

• Does the team have sufficient resources to achieve desired outcomes?

• How will the team respond to patient expectations and concerns?

• How is effective communication achieved?(Based on Collaborative Care: A Medical-Legal Perspective, CMPA, 2006)

Signs of Team Deterioration

• Members cannot articulate clear purpose, goals or expectations

• The team cannot make decisions• Arguments occur at team meetings and are not

resolved• Performance drops off for no obvious reason

(Continued)

Signs of Team Deterioration

• Team members start skipping meetings• Leadership is reluctant to lets others take on

leadership roles• Team members are less willing to support or assist

each other• Development of small groups within the team that

function autonomously(Ontario MOHLTC, Guide to Collaborative Team Practice, 2005

How Are We Doing with Implementation?

Physician Report of Use of Multidisciplinary Teams and Non-Physician Clinicians, 2006

29

32

49

32

81

30

39

22

56

38

70

51

0 10 20 30 40 50 60 70 80 90

US

Canada

Germany

Australia

UK

New Zealand

% use multidisciplinary teams % use non-MD clinicians

% of Practices That Routinely Use Non-physicians to Provide Primary Care Services, 2006

36

25

62

38

73

57

0 10 20 30 40 50 60 70 80

US

Canada

Germany

Australia

UK

New Zealand

% of Population Served by Primary Care Teams, 2006

20%

13%

18%

22%

80%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

SK

ON

PEI

NFL

NU

Changes Made or Planned, Family Physicians, Canada, 2004

2.6

2.2

5.8

2.7

3.1

6.7

0 1 2 3 4 5 6 7 8

Solo to group

practice

Change to

multidisciplinary

Become part of

practice network

Change Made Change Planned

Implications for Current Practice?

Bring Public On Side

• Still not a lot of actual experience at the population level

• Will need public support • More attention to public education• Want people to think differently about how to access

the system • Want people to think differently about first point of

contact and the types of support required for episodic and chronic situations

Bring Educational Institutions On Side

• Development of interprofessional/collaborative programs (UBC, U of T, George Brown, Michener, Memorial)

• Huge progress compared to five years ago

• What is the tipping point?

• Implications for content, assessment, even physical space

Development of Different Competencies

• Articulate role and responsibilities to others

• Recognize, respect role and responsibilities of others in relation to one’s own

• Work with others to assess, plan and treat

• Facilitate communication about patients across professions

• Accept different accountabilities for patient care (Adapted from Barr, 1998)

Bring the Professions On Side – Are We There Yet?

Recent OMA Policy Paper on Interprofessional Care (September 2007)

Principles• The OMA believes that the physician, having greater breadth of

training and larger scope of practice, should be the clinical lead in interprofessional teams.

• The physician or group of physicians should be the only health care providers to whom patients roster.

• All new patients should be reviewed by a physician.

Bring the Professions On Side - Are We There Yet?

Recent OMA Position Paper on Comprehensive Primary Care (September 2007)

Recommendations:• Within collaborative teams in primary care, the comprehensive

primary care physician should be acknowledged as the clinical lead.

• The comprehensive primary care physician should be the only member of the primary health care team responsible to determining when the skill set of the team has been exceeded, and when a referral is necessary.

Bring Regulators Onside

• Implications of team/shared accountability• How do you assess competencies of the team with a

regulatory lens?• Is there thinking about joint panels?• What if the complaint is actually about the team and

the way it functioned and not about a specific individual?

• Implications for liability schemes (group, not individual?)

Bring Employers/Work Places On Side

• Process engineering to redesign care pathways• Team training at the work site?• Different types of employees?• Implications for clinical placements?• More complicated labour relations

Government Support for New Arrangements

• Requires policy and legislative support• Requires different funding models (flexibility, money attached to

different providers, money attached to patients) • Information technology to support secure transfer of pt info,

issues of multiple access to info

• Recent Ontario report lays out a framework:

Interprofessional Care: A Blueprint for Action in Ontario. July 2007