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Interprofessionalism and Interdisciplinary Team-Based Care in a Rapidly Changing Health Care Environment

Association of Schools of Allied Health Professions (ASAHP) Annual Conference

October 28, 2015

Ted Epperly, MD, FAAFP

President and Chief Executive Officer

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Major U.S. Health Care Problems

• 32.3 Million Uninsured* • Wrong Focus

– Disease Instead of Health

• Wrong Delivery Model

– Not Enough PCP’s – Poor Access • Staggering Costs • Quality Problems • Health Care Insurance Problems

SOURCE: Kaiser Family Foundation analysis of the 2015 ASEC Supplement to the CPS.

(3)

In An Average Month:

White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-892.

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National Health Spending in Billions

$27 $75 $256 $724 $1,378 $2,021 $2,486 $2,584 $2,708 $2,824 $3,227 $3,632 $4,080 $4,638 1960 1970 1980 1990 2000 2005 2009 2010P 2011P 2012P 2014P 2016P 2018P 2020P

Note: Selected rather than continuous years of data are shown prior to 2000. Years 2004 forward are CMS projections. Source: Centers for Medicare and Medicaid Services (CMS) of the Actuary.

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Health Spending

Everything Else

1935 3.8% GDP 2009 16% GDP

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Actual Causes of Death in the U.S.

Behaviors 40% Genetics 30% Socioeconomics 15% Medical Care 10% Environment 5%

McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.

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Preventable Causes of Death

3-4-50

Three

Behaviors:

– Physical Inactivity – Poor Nutrition – Tobacco Use

Four

Chronic Diseases:

– Cancer

– Heart Disease and Stroke – Pulmonary Disease

– Diabetes

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“Insanity: Doing the same thing over and

over again and expecting different results.”

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What Improves Health Care

Outcomes the Most!

1. Some type of insurance coverage.

2. A usual source of care.

Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance, Lisa A. Cooper and Neil R. Powe, The Commonwealth Fund, July 2004

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The Triple Aim

Better Health

Better Health Care

Lower Cost

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Patient Centered Medical Home

Place

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The Medical Home Neighborhood

Systems Level

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Innovation in Delivery – Systems Level

ACO

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“If you want to go fast, you go alone. If you

want to go far, you go together”

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Patient Centered Medical Home

Place

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Interprofessional Care

"The AAFP recognizes that high-functioning

interprofessional teams are one of the

cornerstones of the patient-centered medical

home (PCMH).”

-

Stan Kozakowski, M.D.

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Interprofessional Care

Concepts have been in existence in

healthcare for several decades – in the U.S.

and globally.

Recognized as important at the highest level

of all allied health professional guilds,

especially those associated with primary

care.

Interest has never been greater.

Variability across approaches, structures

and implementation is dramatic.

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Nine Elements of Team-Based Care

1. Stable Team Structure

2. Co-Location

3. Share to Care

4. Defined Roles with Training and Skills Checks

5. Standing Orders/Protocols

6. Defined Workflows and Workflow Mapping

7. Staffing Ratios Adequate to Facilitate New

Roles

8. Ground Rules

9. Communication: Team Meetings, Huddles, and

Minute-to-Minute Interaction

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Two Styles of Leadership

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Stakeholders (for each Discipline!)

Patients

Providers

Clinics

Payers

Professional Schools

Post-graduate Training Programs

Accrediting Bodies

Licensing Jurisdictions

Institutional Review Boards & Quality Councils

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Complexity

Five Disciplines, each with Eight

Stakeholder Groups

782 initial combinatorial pathways to

intersect in planning and setting up a IPE

program!

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Me d ic ine P sy cho lo g y Pharmacy Physicia n Ass istan ce Nu rse Pr ac titione r Nu rsing Soc ial W or k Old Model

train in silos  magically team together in practice?

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Moving Down Early in Training

Me d ic ine P sy cho lo g y Pharmacy Physicia n Ass istan ce Nu rse Pr ac titione r Nu rsing Soc ial W or k PCMH

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Examples of Inter-Professional and

Interdisciplinary Team-Based Care at FMRI

Family Medicine Physicians

Nursing

Medical Assistants

Pharmacy

Dietician / Nutrition

Psychology

Social Work

Community Health Workers / Promotoras

IT

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Modes of Collaboration

Multidisciplinary

– Knowledge is profession specific: learning about own discipline, but not others.

– Behavior: provides opinions from one perspective. Each discipline “expert” provides recommendations from their singular perspective.

Interdisciplinary

– Knowledge is profession bounded : learning about own discipline within the context and influenced by awareness of other expert perspectives. – Behavior: develops shared opinions. Each discipline affects the others,

working toward consensual goals. • Transdisciplinary

– Knowledge is professionally unbounded: an intuitive understanding of all perspectives and an instinctive understanding of how this applies to the group’s goals.

– Behavior: focus is shifted away from specific disciplines and individuals and toward successful group behaviors around heterogeneous domains.

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Structural Design

“Culture Eats Structure for Lunch”

– Be Deliberate

Physical Structures

– “Talk” Space

– Core Teamlet space, Visibly open to Patient Care Area

– Additional Office/Exam Room Space

– Additional Group/Family-Sized Room(s) – Telehealth Space?

– Shared Office Space

– Consider large undefined space with temporary partitions to allow dynamic changes to occur.

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Cultural Design

Vision

Inclusiveness, Membership, & Participation

– Health IT is Part of the Team – Huddles (macro and micro)

Co-Leadership Models

Establish “Norms” (e.g., power, conflict)

Getting to “know” others’ professional

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Collaboration in Complexity

Collaborative processes, such as

interprofessional training clinics, are

inherently messy and dynamic with multiple

legitimate points of view, natural tensions,

ambiguity, and uncertainty.

It can be useful to temporarily suspend holistic

complexity in order to design “good-enough”

processes that facilitate initial action and a

basis for reflection.

The goal is to achieve high levels of integrated

care and the potential for transdisciplinary

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Implications for Institutions

Accrediting Bodies Should:

Create Space for Emergence to Occur – Adopt Inter-Professional Competencies – Emphasize Shared Workspace Learning – Establish Policy for Inter-Professional

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Implications for Institutions

Payers Should:

– De-Emphasize Utilization-Based and

Consult/Referral-Based Reimbursement.

– Emphasize all contact towards patient care and de-emphasize reimbursement around face-to-face time.

– Reward Elements Towards Conversion to Team-Based Care (e.g., Bundled Payments,

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Implications for Institutions

Sponsors Should:

– Consider commitment requirements for IPE vs. uniprofessional training programs.

– Push profession-specific internal structures (services/departments) and external

(accrediting and policy) for continued attention to improved functionality of IPE.

– Recognize importance of communication, reflection, and psychological safety when

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Implications for Institutions

Professional Schools Should:

– Focus on sustained, longitudinal workplace IPE experiences for their trainees.

– Facilitate “time together” for trainees to learn roles and identity of other professions.

– Evaluate schedule and timing of curricula and training opportunities to improve cross-over amongst professions.

– Work closely with sponsors, payers, accrediting stakeholders with eye constantly towards IPE.

– Coordinate collecting data from trainees to avoid evaluation fatigue or undue burden on trainees.

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Population Health

Green – Yellow – Red Registry Dashboard

V20.2 250.0 V04.81 401.1 427.31 786.50 496 465.9 724.2 466.0 462 599.0 493.90 784.0 0% 20% 40% 60% 80% 100%

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What are the Social

Determinants of Health

• Food Assistance • Housing Assistance • Utilities Assistance • Transportation Assistance • Daycare Assistance • Legal Assistance • Employment Assistance • Education Assistance • Substance Abuse Assistance • Safety Assistance • Domestic Violence Assistance • Others

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The River of Life

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YOUR ZIP CODE

IS MORE IMPORTANT

TO YOUR HEALTH

THAN YOUR

GENETIC CODE!

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www.fracturedhealthcare.com

amazon.com

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Summary

Interprofessionalism and Interdisciplinary Team-Based Care in a Rapidly Changing Healthcare Environment

This is the Future

Integration not Fragmentation

Teams Passing the Ball

Leveraging Technology

Person-Centered Care

Complicated and Complex Work

Right Direction; Right Thing to Do

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“Never doubt that a small group of thoughtful,

committed citizens can change the world.

Indeed, it is the only thing that ever has.” -Margaret Meade

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“Never, never, never,

give up.”

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References

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