Among the many recommendations from last year’s groundbreaking Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, was a call for a transformed health care system in which “interprofessional collaboration and coordination are the norm.” The latest policy brief in the Robert Wood Johnson Foundation’s (RWJF’s) Charting Nursing’s Future (CNF) series is the second of four focused on the IOM report’s recommendations. It delves into what that recommendation means for health care systems, offers case studies of several collaborative care models already in place, and examines the implications for how we train nurses and other health care professionals.
The brief, “Implementing the IOM Future of Nursing Report—Part II: The Potential of Interprofessional Collaborative Care to Improve Safety and Quality,” notes that despite a decade’s worth of reforms aimed at improving safety and trimming costs, “the majority of health systems remain wedded to traditional ways of operating.” Among those methods of operation is what it describes as “siloed care delivery,” in which the various professions miss the opportunity to improve efficiency and effectiveness by failing to collaborate sufficiently.
According to the brief, that approach soon must give way, to meet coming health care challenges. For example, chronic conditions are increasingly common—not surprising given an aging population. But the health care system is poorly structured to provide the sort of coordinated care and preventive services needed to give these patients quality care while reducing costs.
Some health care institutions are gearing up for the challenge. In the Boston area, for example, Harvard Vanguard Medical Associates developed a congestive heart failure program run by nurse practitioners (NPs), registered nurses with advanced education and clinical training. According to the brief,
The program significantly reduced hospital admissions for enrollees and cut their emergency room visits by 92 percent in one year. Yet despite these initial results, over time, all-causes readmissions for the group’s CHF patients began to rise.... [Vanguard] discovered that patients frequently received conflicting advice from the specialists who treated their related conditions. For example, some patients were trying to follow several dietary plans at once. This lack of coordination among care providers appeared to be stymieing their best efforts.
So Vanguard refocused the program on managing heart disease, hypertension and diabetes—the causes of congestive heart failure—and developed a collaborative and interprofessional program to accomplish the task. Now each patient in the program is assigned an NP, who consults with the patient’s specialists and coordinates a single plan of care. The NP then coordinates care for the patient, and connects him or her to nutritionists and other professionals.
In New Jersey, the Camden Coalition of Health Care Providers is all about interprofessional collaboration. It is a community-based initiative that the brief credits with “revolutionizing health care delivery for Camden’s costliest patients. These individuals, sometimes called super utilizers, typically rely on hospital emergency rooms for care... Many have medically complex conditions compounded by mental illness, addiction, and/or the cumulative toll of homelessness.” Not surprisingly, such patients accounted for an outsized share of local hospital costs, often with diagnoses that would have been more properly handled in a primary care setting.
In response, the Camden Coalition developed a Care Management Project to reduce unnecessary emergency room visits, while still making sure patients are treated. A social worker, NP and bilingual medical assistant working for the project help patients apply for government assistance, find temporary shelter, enroll in medical day programs, and coordinate their primary and specialty care. The team visits patients where they reside, rather than maintaining a clinic. Many patients in the program have significantly reduced their use of hospital emergency rooms as a result.
Training the Next Generation to Collaborate
Of course the silo effect among health care professionals begins early. Most are trained in isolation from other professions and, as the brief notes, “graduat[e] with a limited ability to work collaboratively to care for the increasingly complex needs of today’s patients.”
Earlier this year, it says, six national education associations representing various health care professions formed the Interprofessional Education Collaborative (IPEC), and released a set of core competencies to help professional schools craft curricula that will prepare future clinicians to provide more collaborative, team-based care.
“These competencies are essential to changing the university and practice cultures,” says Frank Cerra, MD, professor of surgery, former senior vice president of health sciences and dean of the medical school at the University of Minnesota. The goal is “to reconnect education and practice so we actually teach what we want students to do in practice.”
Such efforts are already under way at a number of institutions. Maine’s University of New England has developed a common undergraduate curriculum for its health professions programs in nursing, dental hygiene, athletic training, applied exercise and science, and health, wellness and occupational studies. The curriculum includes shared learning in basic science prerequisites and four new courses aimed specifically at teaching interprofessional competencies. Students spend two years in the common curriculum before moving onto their professional programs.
In Nashville, Vanderbilt University is also pursuing an interprofessional education initiative that unites students from the medical and nursing schools with graduate students pursuing degrees in pharmacy and social work at nearby institutions. Students are assigned to interprofessional working-learning teams at ambulatory care facilities in the area.
The Veterans Health Administration (VHA) is piloting an interprofessional initiative, as well, focused on preparing medical residents and nursing graduate students for collaborative practice. “When people aren’t educated together, it is extremely challenging to get them to work as a team,” says Malcolm Cox, MD, chief academic officer of the VHA. “This disrupts care and places a huge financial and time burden on health systems.” As part of the initiative, five VHA facilities have been designated Centers of Excellence and received five-year grants from the U.S. Department of Veterans Affairs. Unlike traditional graduate medical education, which is profession-specific and designed with the host institution’s clinical coverage needs in mind, the VHA Centers of Excellence programs are competency-based and focused on the needs of patients and trainees. The VHA hopes the program will improve the primary care delivery experience for both patient and provider. Toward that end, each VHA Center of Excellence is developing its own approach to the mission of teaching patient-centered, team-based primary care.
In Aurora, Colorado, the University of Colorado built its new Anschutz Medical Campus with the explicit objective of creating an environment that promoted collaboration. It features shared auditoriums and simulation labs, as well as student lounges and other dedicated spaces in which students can pursue specific medical interests in a collaborative fashion. Entering students are channeled into one of two programs aimed at promoting interprofessional collaboration. One, the Health Mentors program developed at Thomas Jefferson University, is designed to help students experience the health care system from the perspective of patients. The other combines interprofessional simulations with the Team-STEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) curriculum developed by the Department of Defense and the Agency for Healthcare Research and Quality. Students from both tracks then move on to interprofessional classroom work and clinical experiences.
Such initiatives are clearly the wave of the future, if only because the pressures of caring for a larger, older and sicker population of patients in the years to come will drive efforts to identify efficiencies. In the words of Mary Wakefield, PhD, RN, head of the Health Resources and Services Administration, “As the health care community is looking for new strategies and new ways of organizing to optimize our efforts—teamwork is fundamental to the conversation.”