Transcript Document

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, teambased 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
30
25
24
20
18
15
12
10
5
3
3
0
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
13
Strongly Oppose
10
9
Somewhat Oppose
6
21
Neutral
23
29
Somewhat Support
31
26
Strongly Support
28
0
5
10
15
20
2006
2005
25
30
35
% of Public Supporting Requiring Health Professionals to
Work In Teams, 2006
Strongly Oppose
2
Somewhat Oppose
2
17
Neutral
37
Somewhat Support
39
Strongly Support
0
5
10
15
20
25
30
35
40
45
% Support by Group for Requiring Health Professionals to
Work in Teams, 2006
3
3
Managers
33
61
1
11
Nurses
29
59
1
Pharmacists
16
29
54
13
7
Doctors
33
29
18
2
2
Public
17
37
39
0
10
20
Strongly Support
30
Somewhat Support
40
Neutral
50
Somewhat Support
60
Strongly Oppose
70
% of Public Support Patients Required to Register with One
Family Doctor or Other Primary Health Care Provider, 2006
8
Strongly Oppose
6
Somewhat Oppose
Neutral
22
Somewhat Support
33
Strongly Support
26
0
5
10
15
20
25
30
35
% Support by Group Requiring Patients to Register with One
Family Doctor or Other Primary Health Care Provider, 2006
4
10
16
Managers
36
34
7
2
13
Nurses
29
49
5
9
13
Pharamcists
37
36
11
13
26
Doctors
31
19
8
6
22
Public
33
26
0
10
Strongly support
20
somewhat support
30
neutral
40
somewhat opposed
50
strongly opposed
60
% Public Support for Requiring Health Professionals to Work
in Specific Geographic Areas, 2006
Strongly Oppose
10
Somewhat Oppose
8
Neutral
26
Somewhat Support
30
Strongly Support
21
0
5
10
15
20
25
30
35
% Support by Group for Requiring Health Professionals to
Work in Specific Geographic Areas, 2006
12
14
Managers
21
36
17
9
11
Nurses
28
29
18
14
7
Pharmacists
33
31
13
41
22
22
Doctors
10
5
10
8
Public
26
30
21
0
5
Strongly Support
10
15
Somewhat Support
20
Neutral
25
30
Somewhat Oppose
35
40
Strongly Oppose
45
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 NonPhysician Clinicians, 2006
51
New Zealand
30
70
UK
81
38
Australia
32
56
Germany
49
22
Canada
32
39
US
29
0
10
20
30
40
% use multidisciplinary teams
50
60
% use non-MD clinicians
70
80
90
% of Practices That Routinely Use Non-physicians to Provide
Primary Care Services, 2006
57
New Zealand
73
UK
38
Australia
62
Germany
25
Canada
36
US
0
10
20
30
40
50
60
70
80
% of Population Served by Primary Care Teams, 2006
80%
NU
22%
NFL
18%
PEI
13%
ON
20%
SK
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Changes Made or Planned, Family Physicians, Canada, 2004
6.7
Become part of
practice network
5.8
3.1
Change to
multidisciplinary
2.2
2.7
Solo to group
practice
2.6
0
1
2
3
Change Made
4
5
Change Planned
6
7
8
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