Team-based care will be central to the future of the health care system of the future, and allied health workers will be essential members of those teams. But many questions still surround team-based care. Who should be on a team? Who should do what? Who should be the head of the team? What are the different roles of the members of a team? How can people best learn to work together as teams?
In a session of the workshop addressing these questions, Kevin Lyons, director of the Office of Institutional Research at Thomas Jefferson University, examined the potential of interprofessional education to teach the skills needed for effective teamwork. Joan Rogers, professor of occupational therapy, psychiatry, and nursing at the University of Pittsburgh, looked at the rehabilitation team as a model of team-based care. Jean Moore, director of the Center for Health Workforce Studies at the State University of New York at Albany School of Public Health, discussed the scope-of-practice issues that inevitably arise when considering who can do what in medicine.
INTERPROFESSIONAL EDUCATION AND TRAINING
In 1988 the World Health Organization defined interprofessional education as a process by which a group of students from the health-related occupations with different educational backgrounds learn together during certain periods of their education, with interaction as an important goal, to collaborate in providing promotive, preventive, curative, rehabilitative, and other health-related services (WHO, 1988). The Center for the Advancement of Interprofessional Education has described interprofessional
education as what “occurs when two or more professions learn with, from, and about each other to improve collaboration and the quality of care” (CAIPE, 2002).
This concept has gone through a series of boom and bust cycles, observed Lyons. At the beginning of the 20th century, physicians in Boston began moving into hospitals and brought together the community of educators, social workers, and others with whom they had worked outside hospitals. After World War II, multidisciplinary teams in hospitals worked on health issues among veterans and the rapidly growing U.S. population. During the Great Society era of the 1960s, community health centers played a role in fostering interprofessional education.
In the 1970s, federal support for federally qualified health centers echoed the themes contained in the 1972 report by the Institute of Medicine Educating for the Health Team (IOM, 1972). After another lull in the 1980s, a series of reports in the 1990s and first decade of the 21st century renewed the emphasis on interprofessional education. “We are seeing now a much larger effort from more people than there has been in the past,” said Lyons.
Evidence of Effectiveness
Research has demonstrated that interprofessional education delivered in a variety of clinical settings is well received by participants and can enable students and professionals to learn knowledge and skills necessary for collaboration. There is also some evidence that team-based practice can have a positive effect on care. The research base is not yet as strong as it needs to be, Lyons stated, but it has steadily moved away from attitudes toward behaviors and outcomes.
At the same time, predictions of physician shortages, the aging of the health workforce, and growing recognition of the behavioral origins of illness have reemphasized the importance of interprofessional care. Lyons said that he expects this emphasis to endure. The federal government has again recognized interprofessional care as an important component of the health care system. Foundations such as the Josiah Macy Foundation and the Robert Wood Johnson Foundation are supporting investigations of interprofessional care. The Association of Schools of Allied Health Professions and professional associations are beginning to establish requirements for interprofessional education and practice. “The confluence is coming together so that it might last.”
Interprofessional education is also becoming globalized, said Lyons, with many European countries involved. A major dialogue has been occurring through the World Health Organization involving people from developed and underdeveloped countries sharing ideas and program designs
with each other through electronic media. The United States and Canada have been engaged in international collaborations through the Canadian Interprofessional Health Collaborative and the American Interprofessional Health Collaborative. The World Health Organization’s Framework for Action on Interprofessional Education & Collaborative Practice recommends changing health care practices on a worldwide basis (WHO, 2010).
Other groups are also paying attention to interprofessional education. The Interprofessional Education Collaborative (IPEC)1 comprises six national education associations of schools of health professionals and is supported by three private foundations. On the very day of the workshop, IPEC released its national core competencies for interprofessional collaborative practice at the National Press Club in Washington, DC (AACOM, 2011), which Lyons termed a “major advance.” The Association of Schools of Allied Health Professions also has been focused on interprofessional education. In particular, it has been looking at the barriers posed by faculty resistance that can make it difficult to offer interprofessional education.
Requirements for Successful Programs
Lyons pointed to three sets of factors required for successful programs: learner-focused factors, faculty factors, and organizational factors. In addition, the cultures of institutions need to change for interprofessional education to flourish. Students and clinicians need positive attitudes toward other professionals, knowledge about the contributions of other professions, skills in working with others, and behavior that is supportive of others. Several types of interactive learning methods can support interprofessional interactions, including seminars, patient visits, and role playing. Group dynamics work best with a balance of professions and stability so one profession does not necessarily dominate. To ensure that interprofessional education is valued, learning needs to be assessed in meaningful ways and have a clear clinical focus. Expert facilitation for faculty members is critical. “Putting three or four disciplines together in a room and assuming they are going to play as a team is not going to happen,” said Lyons. Faculty need to be chosen who have the ability to facilitate small-group learning, resolve conflict, and know health professions relationships. Facilitators themselves need support and training. At the organizational level, there is some debate about whether interprofessional education should occur prelicensure or postlicensure, said Lyons. Prelicensure is more difficult because so many barriers to interprofessional education exist at universities. Organizations
1 More information can be found about IPEC at http://www.aacom.org/InfoFor/educators/ipe/Pages/default.aspx.
need to be committed to interprofessional education and support it for success to occur.
The Jefferson Health Mentor Program
Most programs of interprofessional education are somewhat different, but Lyons offered the Jefferson Health Mentor Program at the Jefferson Center for Interprofessional Education as a brief case study (Thomas Jefferson University, 2011). The program seeks to change the attitudes, knowledge, skills, and behaviors of students and have them develop a patient perspective on care. The underlying philosophy is that students in the health professions need to understand that good chronic illness care requires expert interprofessional teams, and that professionals need to understand each other’s roles in the health care team. To practice patient-centered care, students must understand the patient’s perspective. They need to understand how a person’s health conditions and impairments interact with other personal and environmental factors.
All students in medicine, nursing, occupational therapy, physical therapy, pharmacy, and public health go through the 2-year program, with the first cohort of students entering in 2007. Teams of three or four students that contain two or three different disciplines are formed. Each team visits and works with a volunteer living in the community who has one or more chronic conditions. Teams work collaboratively with this health mentor on such issues as access to care, expectations of health care providers, and health care services. Teams return after the visit to debrief and reflect, and the volunteer in the community provides feedback. By using participants in the health care system as mentors, the teams of students experience and come to understand the perspective of someone with chronic conditions in the community, said Lyons.
The curriculum includes modules on comprehensive life and health history, preparing a wellness plan, assessing patient safety, reducing medical errors, and evidence-based practice, with continual debriefing and reflection. Numerous evaluations have looked at such measures as attitudes toward chronic illness, readiness for interprofessional learning, perceptions of health, faculty attitudes toward interprofessional education, and attitudes toward health care teams. Outside evaluations of the program over the last 4 years have led to significant program modifications.
According to the evaluations, prior to 2007–2008 medical and nursing students had relatively negative attitudes toward chronic illness care. Those attitudes improved significantly by the conclusion of the program. Students reported a better understanding of the training and perspective of those in other disciplines and an appreciation for the health mentors as teachers.
Students need to be involved in interprofessional education from the beginning, Lyons emphasized, including the planning process.
The evaluations also showed that students lacked an understanding of the goals of the experience. Students were accustomed to lectures, and the administrative aspects of the program such as scheduling and traveling to meetings with mentors were a burden. There were some complaints that some disciplines were not contributing because they were not required to participate, and there was a lack of understanding of the implications for future practice. These negative comments appear to be lessening as a result of program modifications, Lyons said.
A recently completed baseline survey of graduates in practice for 5 to 10 years revealed positive attitudes about interprofessional education, good understanding of the roles of other professions, and inclusion of patients in setting goals. “These are self-reports, so take this with a grain of salt,” said Lyons, but “there does seem to be more interprofessional care going on in practice than we thought.” Future plans call for more qualitative analysis and assessments of graduates in practice. Surveys also will look at faculty attitudes, since there is a strong correlation between faculty attitudes and student attitudes toward interprofessional education.
TEAM-BASED CARE AND HEALTH CARE REFORM
According to Rogers, an interprofessional health care team can be defined as a group of individuals from different professions who collaborate effectively with the patient and each other to solve patient problems that are more complex than can be managed by the knowledge and skills of any one profession alone. The interprofessional team is interdependent, reliant on good patient-team communication, patient-centered, and comprehensive at multiple levels. Such teams cannot exist in isolation. They thrive in a context that supports their birth and nourishes their development, and context, in this formulation, “could well be translated into management,” said Rogers.
Rehabilitation Teams and Geriatrics
Historically, the rehabilitation team was among the first in which allied health professionals made a contribution to team care. The team included occupational, physical, and recreational therapists, speech-language pathologists, and the patients along with physicians, nurses, and social workers. Evidence suggests that rehabilitation teams can produce positive patient outcomes. For example, a study of Veterans Administration hospitals found that 3 of 10 measures of team functioning were significantly associated with functional improvement: team orientation, order and organization, and
quality of information (Strasser et al., 2005). One measure, effectiveness, was associated with length of stay.
In a related study, the expectations of discipline-specific supervisors, hands-on leadership, and the involvement of the attending physician were associated with the extent to which the team reported functioning in a cohesive manner (Smits et al., 2003). The authors speculated that higher functioning on the cohesiveness scale indicated that patients’ services were likely delivered with greater interprofessional communication and joint effort.
A third study examined whether a team training intervention improved outcomes in patients with stroke (Strasser et al., 2008). The intervention was conducted over 6 months and included such items as team dynamics, problem solving, use of performance feedback, and action plans for process improvement. Both the intervention and the control teams received site-specific team performance data. The results showed that patient outcomes on the Functional Independence Measure for the intervention teams were almost 14 percent better than for the control teams.
Geriatrics has many parallels with rehabilitation, said Rogers. In geriatrics, as in rehabilitation, the impetus for team care is the patient, and the team faces multifaceted problems that can include dementia, depression, polypharmacy, and falls. The Program of All-inclusive Care for the Elderly (PACE) provides an excellent glimpse of the future of geriatric care, said Rogers. PACE provides primary, acute, and long-term care services to frail, elderly individuals in the community. At a minimum, the PACE team includes primary care physicians, nurses and social workers, physical and occupational therapists, recreational therapists or activity coordinators, dieticians, and personal care attendants.
A study of PACE found that team performance was significantly associated with better functional outcomes in both the short and long term (Mukamel et al., 2006). PACE improved functional outcomes by improving the functioning of the team. As with the rehabilitation studies, this provides evidence of the relationship between team functioning and patient outcomes, but in this case the findings extend to primary care.
Team Care and Health Care Reform
Experience with rehabilitation teams can make several contributions to health care reform, said Rogers. Disease prevention and health promotion are major themes of health care reform. According to the Centers for Disease Control and Prevention, one of every 10 Americans, representing more than 25 million people, has a chronic, disabling condition sufficient enough to limit activities of daily living (CDC, 2011). As a result, disease management will be an essential component of health care reform.
Based on its experience with rehabilitation, allied health can form the
base of teams ready to help people exercise regularly, eat right, and incorporate these tasks into their daily living routines. Rehabilitation personnel have historically motivated patients to do for themselves, said Rogers. Rehabilitation teams that include allied health workers have a wealth of practical experience related to self-management of daily activities despite disease. Team functioning can be enhanced through the inclusion of health educators, who can develop patient education materials that meet the standards of health literacy.
A significant component of disease management is medication management, Rogers observed. Many allied health professionals contribute to the safe use of prescribed medications, assessing the functional implications of medications, evaluating cognitive and dexterity skills for manipulating medications, developing learning aids, and assessing polypharmacy and prescribing patterns.
Screening for early diagnosis is a major strategy of health care reform, and two examples provide a rationale for the inclusion of allied professionals in screening, said Rogers. First, evidence indicates that screening patients with acute stroke for dysphasia reduces hospital pneumonia rates (Doggett et al., 2001). Because the development of pneumonia prolongs hospitalization and increases costs, screening stroke patients and others who have diseases that include risk factors for dysphasia would promote health and be cost-effective.
Second, screening for declines in functional status may alert physicians to emerging medical issues and disability. People often go to their primary care physicians not because they realize that their lungs are not expanding and contracting as they used to, said Rogers, but because they are having difficulty going up and down the stairs due to huffing and puffing. By monitoring change in functional status, physicians can be alerted to changes in body structures and functions. A study in which a 4-minute screening tool was used to predict functional status supports this approach (Min et al., 2009).
A major concern of health care reform is managing the increasing numbers of patients who will have access to care, especially in the areas of mental health services. Allied health personnel who have typically been involved in mental health care include art, dance movement, music, occupational, and recreational therapists. Role responsibilities for these professionals may need to be extended as health care reform progresses, Rogers said.
The educational standards of Roger’s own profession, occupational therapy, prepare occupational therapists to work in mental health. Yet occupational therapy is not recognized as a core mental health profession in the U.S. Code of Federal Regulations or as a qualified mental health profession, as defined by state statute and regulations, despite the close connection between psychiatric symptoms and dysfunctions in activities of daily
living. Ironically, occupational therapy had its origins in mental health, and therapists currently serve as mental health professionals in several federal settings, including the U.S. Army, where they are responsible for assessing soldiers for posttraumatic stress disorder and their readiness to return to the frontline.
As another example of the many regulatory constraints placed on the use of professional skills, dieticians who spend years learning about food science and diets generally cannot prescribe diets in many hospitals. Instead, it must be done by a physician. Similarly, in many states, dental hygienists require direct supervision from dentists, thus preventing them from independently practicing in nursing homes where oral hygiene needs are great.
The Potential of Telerehabilitation
Just as telehealth is extending medical services over land and sea, so, too, telerehabilitation can greatly extend rehabilitation services, Rogers observed. Telerehabilitation is projected to increase accessibility, improve continuity of care, and decrease costs. It also can be a way of facilitating assessment and intervention in a patient’s home and work environments. “This is particularly important in rehabilitation because it negates the need to then transfer information that is gained in a clinic situation about activities of daily living to the home or work situation,” said Rogers
These potential benefits of telerehabilitation will not be achieved unless patient outcomes are at least equivalent to what can be achieved in a face-to-face situation. Evidence of the effectiveness of telerehabilitation can be gleaned from a review by the Institute of Health Economics, which summarized 61 studies in 12 clinical areas, including cardiology and neurology (Hailey et al., 2010). Numerous studies demonstrated that in some clinical areas telerehabilitation was effective. However, the report concluded that compelling evidence of the benefits and impact on routine care for rehabilitation programs is still limited, and there is a need for more and better quality studies. Of the studies reviewed, 71 percent were deemed successful, 18 percent as unsuccessful, and 11 percent as having unclear outcomes.
Kairy and colleagues (2009) drew the same general conclusion. They ascertained that clinical outcomes were generally improved and tended to be similar or even better than alternative interventions face to face. Attendance and adherence were high. Consultation time was longer. Satisfaction was high, and it was somewhat higher for patients than it was for providers. Preliminary evidence also pointed to cost savings.
Schein and colleagues (2010) investigated the equivalence of in-person and remote assessment using video conferencing for patients needing a wheeled mobility and seating assessment. Their findings revealed no significant differences in the level of functioning that was achieved.
While telerehabilitation is technically feasible in remote clinic and home environments, more research is needed before it can be fully integrated into daily life in the clinic, Rogers concluded. In addition, there are some situations where patients and their caregivers may be able to manage the telesystem, but there might be others where they need an ancillary worker to manage the system.
Team-Centered Care
The increasing emphasis on accountability and data-driven patient outcomes has made health information managers essential members of the health care team, Rogers noted. For example, in recent years medical librarians have become essential team members. They have the needed experience in locating, evaluating, and summarizing information and alerting the team to relevant evidence. Also, computerization of health information has made it possible for the team to monitor a variety of information for numerous purposes.
“Collaborating effectively” is the operative phrase in the job description of teams, Rogers said, and communication is the essential ingredient of effective collaboration. Although allied health professionals have been team members, except for the rehabilitation team they have not been members of the core team. However, new technologies are changing the way in which teamwork is being done. Video conferencing and teleconferencing can enable allied health members to collaborate with other team members in real time for meetings, even if they are in remote locations. The virtual health care team holds promise for including allied health professionals in the primary care team as these emerge in medical homes and accountable care organizations.
Rogers concluded by addressing role competencies. Just as public health needs were served by empowering pharmacists to give flu shots, allied health professionals may need to be empowered with selected medical, nursing, or rehabilitation skills. For example, in their entry-level education, dieticians learn about special diets, occupational therapists learn how to facilitate hand-to-mouth movement, and speech-language pathologists learn about swallowing techniques. After working together as a team and taking specialized courses, each team member becomes more like the other team members, because at the point of care diet, feeding, and swallowing techniques are all needed, and the expert practitioner blends these patient care functions into one.
“At the point of care, it is not what profession has the expertise,” said Rogers. “It is what professional has the expertise. At the point of care, more attention needs to be directed toward who has the qualifications needed versus traditional roles.”
SCOPE OF PRACTICE AND TEAM-BASED CARE
Scope of practice sets the legal framework for service delivery by a specific health profession in a state. It defines the parameters of practice for a profession, specifies the required education or training, and restricts the use of a title to licensed holders. Based in state licensing laws and rules, scope of practice is designed primarily to serve consumer protection. Scope of practice is just one aspect of health professions regulation in a state, noted Moore. Other aspects include certification, licensure, license renewal, discipline and appeals, and education. Also, there is variation in scope-of-practice rules between states. Not all states license and define scope of practice for all health professions. Scope-of-practice rules can vary even within states for the same profession. In California, for example, the state defines a basic scope of practice for paramedics, but expanded duties can be approved at the individual county level.
Scope of practice can have substantial inconsistencies. It may be interpreted very broadly for some professions and narrowly for others. In some cases, scope of practice may not be particularly well defined. For example, scope of practice for auxiliary personnel is sometimes found under the delegation authority of other health professionals. These variations have important implications for cost, quality, and access to services. Restrictive scope-of-practice rules can create a mismatch between what a health professional is educated to do and what that person legally can do.
Some scope-of-practice rules have evolved considerably over the last decade for various reasons. One reason is health workforce shortages, which have been key to the development of new professions like nurse practitioners and physician assistants, according to Moore. A related reason is limited access to needed services. New York, for example, recently removed a requirement for midwives to have a collaborative practice agreement, so that midwives no longer need a collaborating physician to provide care. Emerging technologies can make health care easier and simpler or create complexities in the delivery of services that need to be reflected in scope-of-practice rules. Finally, controlling health care costs can be a factor behind changes in scope of practice.
Arrayed against these forces for change are forces for resistance. There can be concerns about quality or costs. An ever-present issue is the struggle over who can do what to whom and where. Furthermore, these discussions go on state by state, not at a national level, which can produce many additional complications. When changes do occur in scope of practice, they tend to be evolutionary and not revolutionary, said Moore. Many pieces need to be in place to effect a scope-of-practice change, and many stakeholders will be involved. For example, the steps involved in allowing nurse practitioners and physician assistants to write prescriptions included
a statutory change, an education component in pharmacotherapy, a process for certification and competency testing, changes in hospital agreements related to responsibility for standing medical orders, federal permission, and changes in insurance company procedures. As a result, there is often a time lag between the passage of a scope-of-practice change and the actual implementation of that change.
Team-Based Care
As patient-centered medical homes become more common, interdisciplinary teams will become central to the provision of health care services. The configurations of these teams will depend on patient needs. Team members will communicate and collaborate with each other in the delivery of care, and care will be coordinated among multiple providers and transitions. Efficiency will be a priority, and team members will be asked to work to their full scope, Moore said. Role overlap will be common in team-based care. Sometimes this will mean scope-of-practice overlap, as with physicians, nurse practitioners, and physician assistants. In the process, team-based care will uncover overly restrictive scopes of practice.
For example, diabetes self-management education helps people with or at risk for diabetes to manage the disease. Often, certified diabetes educators lead diabetes self-management education (DSME) teams, which can include dieticians, registered nurses, community health workers, and others. In a study of 1,000 certified diabetes educators in New York, Moore and her colleagues found that certified diabetes educators are drawn from a variety of health professions (Moore et al., 2010). Nearly all certified diabetes educators are either dietitians or registered nurses. Being certified requires meeting stringent standards, including 2 years of experience in the health profession, 1,000 hours of practical experience providing diabetes education, and passing a certification exam. Certified diabetes educators may head a team with other professionals and support personnel in the delivery of diabetes services. But despite their broad knowledge of diabetes, they sometimes are limited by scope-of-practice rules.
Scope-of-practice overlap is not always bad, said Moore. Provided the team members are comfortable with their limits and are willing to bring in the others that they need to provide care, it can facilitate better care. For example, a registered nurse who is a certified diabetes educator can counsel broadly on nutrition but may bring in a nutritionist if more detail and planning are needed. Conversely, if the certified diabetes educator is a dietician, the dietician may refer to a registered nurse for a medical problem.
States are developing strategies for examining and revising scope-of-practice regulations. Some require applications to be submitted for any effort to add a new profession or modify a scope of practice. Typical ques-
tions are What is the problem? Why is a change needed? What efforts have been made to address the problem? What are the alternatives? What are the benefits and risks? What are the costs?
Another approach has been to establish independent scope-of-practice review committees. Such committees can create much more systematic ways of assessing proposals related to changing the scope of practice. The composition of these committees can vary, but they generally are not limited to the health professions that are affected by the proposal. Also, once a change is made, impacts on cost, quality, and access to care need to be assessed.
At the national level, proposals have been made to provide uniform standards for educating and certifying health professionals in particular areas, such as those who administer radiation. A number of health professions have developed model practice acts, including national uniform scopes of practice to guide state legislatures. The most credible of these efforts are based on evidence, said Moore.
In response to a question about how best to evaluate changes in scope of practice as they relate to interdisciplinary education, Lyons pointed to the importance of randomized controlled trials to determine outcomes. Rogers added that inputs need to be measured as well. “Every medical technologist is not the same as every other medical technologist. We need to have some way of defining what that black box is,” Rogers said. One possibility is to measure input differences state by state since the variability among states is substantial. Moore pointed out that programs also vary, and resulting outcomes could be measured.
Electronic health records could be used to do comparative effectiveness research on the health workforce, especially if programs were more standardized, Moore observed. This evidence should be communicated across states, since all states are facing similar issues.
In response to a question about techniques to build appreciation of other’s roles in interprofessional education, Lyons said that he was not familiar with any. The bottom line is that the culture of an institution needs to be one of interprofessional respect. Once the culture changes, teams can work much more effectively. Rogers cited the example of interprofessional rounds as a way of building mutual understanding. Also, combining students from different fields during an internship increases exposure to other professions. Rogers added that not much is now known about outcomes of interprofessional education, but more will be learned over the next decade. It has worked in other professions, such as manufacturing. But it takes time for a team to develop, because it is a dynamic interaction.
In response to a question about the specific outcomes of interprofes-
sional education that should be studied, Lyons mentioned the recommended competencies for interprofessional education being released that day, which include measures like medical outcomes, patient satisfaction, and patient change of behavior. Moore added that an obvious metric would be turnover rates. Also, if people do leave a job, what are they doing afterward?
In addition, Moore emphasized the importance of career ladders in building professional responsibilities. An important question is, how much training would it take for a medical assistant to become a licensed practical nurse or a registered nurse? “While we want to create opportunities for people to do more, we also need to create opportunities for professional advancement. I am not sure we always think about those things together.”
Roy Swift said that the American National Standards Institute would encourage a national effort to look at national competencies related to practice areas, regardless of profession. “There is no career pattern or laddering in health care,” he said. “There are no standards related to health services moving into health care then into the subspecialties.” He said he is an advocate for stronger accreditation to address this issue. Swift stated we are not doing a good job in this area, which is why there is often a wide variance of outcomes among academic programs in the same profession.
