The landscape of health care delivery has changed considerably with the passage of the Patient Protection and Affordable Care Act, and a generation of baby boomers who are now getting older and using healthcare resources at an extensive rate. In order to keep costs from sky rocketing, the federal government has moved to incentivize health care providers to improve quality health outcomes by tying reimbursement to cost savings and service efficiency. With the patient taking center stage, value-based care is now being replaced for volume-based care as our system moves towards a pay-for-performance structure. Coming out of this push for more efficient care, the Centers for Medicare & Medicaid Services have implemented programs to encourage providers to create interprofessional care teams. These teams primary purposes are for coordinating care and providing patient education, for performing service evaluation of medical staff on improving overall patient health outcomes, identifying and treating health conditions before they become chronic, and helping patients effectively manage long term health conditions.
Interprofessional Team Composition
It has long been found that physicians are not able to provide all of the clinical and educational services that patients need in the new models of care that have been evolving. Staffing shortages, time, and sheer patient volume are encompassing much of the time of physicians, and patients are not able to receive their full “effort” in dealing with long term, individual care needs. To overcome these hurdles as stated in the IPEC Core Competencies: It is important to “integrate the knowledge and experience of health and other professions to inform healthcare decisions, while respecting patient and community values and priories/preferences for care” for more effective care. Interprofessional teams include physicians, nurses at different levels, certified medical assistants, dietitians, nutritionists, pharmacists, physician assistants, social workers, mental health workers, health navigators, health coaches, community health workers, exercise physiologists, and quality improvement and informatics specialists. Patients and family members are also being added to interprofessional teams at different levels of practive, and have been highly effective voices for patients as they contribute information to care and best practices for patients and the communities they are a part of.
The Historical Evolution of Interprofessional Teams
The concept of using health care teams is attributed to Martin Cherkasky at the Montefiore Hospital in New York. In an effort to provide home care services to patients in the local community, he developed a hospital outreach program which employed teams of physicians, social workers, and nurses. However, Royer notes that prior to the year 1900, mission hospitals in India sent out teams of physicians, nurses and auxiliary staff to provide health services to remote communities. The idea of collaborative health care teams was an integral part of the Peckham Experiment at London’s Pioneer Health Centre during the 1920’s This project in London was also noted to have inspired Sidney Kark and his colleagues in South Africa and at a later date in Israel to implement the concept of primary health teams in their community-based health programs. In the US, Theodore Brown cites the efforts of Richard Cabot at the Massachusetts General Hospital, who in his published work wrote about the “teamwork of the doctor, the educator, and the social worker” in the hospital outpatient department in the early part of the century. Cabot’s ideas were further elaborated by Michael Davis and Andrew Warner, early advocates of clinical ‘efficiency’, as well as ‘social teamwork’, at the Boston Dispensary.
The effectiveness of multidisciplinary medical and surgical care teams was demonstrated in World War II as efficient instruments of patient care. Specialty-oriented, multidisciplinary teams became established in the fields of surgery, burns, rehabilitation, cleft palate, long-term care, and mental health. Indeed, much of the early literature on teams records the experience of these multidisciplinary teams. If we jump ahead to the 1970’s, the Education for All Handicapped Children Act of 1975 required multidisciplinary team assessment of the special education needs of handicapped children”, taking “available evidence to inform effective teamwork and team based practices” (another competency for interprofessional collaboration) from the care models delivered by their predecessors during World War II
President Johnson’s program for the ‘Great Society’ and the ‘War on Poverty,’ the next major step in the development of the concept of teamwork in primary health care occurred during the 1960’s in the United States. Around the same time as well there was a period was the dissatisfaction of students in the health professions and student health organizations, and a strong push for interdisciplinary primary care projects for students in the health professions. During these years, the Student American Medical Association which later became the American Medical Student Association played a major role in providing interdisciplinary experiences for medical and other health professional students. By 1975, it was estimated that some 5000 students had formally participated in various interdisciplinary projects created by the AMSA.
Another major factor in the development of interdisciplinary primary health care teams during the late 1960s was the creation of the Office of Economic Opportunity at the federal level, and the ‘neighborhood health center movement’. As part of the ‘War on Poverty’, the Office of Economic Opportunity provided funding for a number of community health centers located nationwide. Many community health clinics or centers reported the use of the interdisciplinary team concept, primarily in urban underserved areas, included the ones at Watts, Yale, Denver, Gouverneur and Mile Square in Chicago. But not all community health centers responded to the call for the health teams – many considered them too difficult, time consuming and expensive.
Characteristics of Interprofessional Teams
The compositions of interprofessional teams are unique and ever evolving based upon the goals of the team. Personal attributes identified in various literate as being important to having an excellent team include approachability, appropriate delegation, being able to compromise, confidentiality, decisiveness, empathy, good organization skills, initiative; knowing ones strengths and weaknesses; open to learning; acquiring, demonstrating and sharing new skills and knowledge, patience, personal responsibility, protective, reflexive practice, tolerance. These attributes coincide with the core competency for interprofessional collaboration of “ express one’s knowledge and opinions to team members involved in patient care and population health improvement with confidence, clarity, and respect, working to ensure common understanding of information, treatment, care decisions, and population health programs and policies. Another characteristic to interprofessional teams that members find themselves having to be fluid on their approach with is communication. Within an interprofessional context, communication is primarily referred to as intra-team communication. It should be done in such as way that team members feel as though they could listen as well as speak out within the team context, and the ability to discuss and resolve issues within the team can be done seamlessly, and with little conflict. It was suggested that being part of a large team hinders good communication by limiting the “two-way” communication, and that some peoples’ views do not travel “upwards”. But these feelings can be thwarted when teams focus on the core competency of “listening actively, and encourage ideas and opinions of other team members.”
For teams to be efficient at what they do, it is important for the team to have appropriate team processes and resources in place for effective patient care delivery. This characteristic of an efficient team includes access to sufficient physical resources such as office space, parking, computers, privacy for work that is confidential in nature and having appropriate and efficient office systems and procedures in place to avoid the duplication of work flow. Workload management, having enough time to do the job, and time management were highlighted in literature by several teams that were interviewed as necessary components to effective team work. This characteristic goes along with the core competency of interprofessional collaboration of “using process improvement to increase effectiveness of interprofessional teamwork and team based services, programs, and policies.” Lastly, an important characteristic of interprofessional team work is respecting and understanding the roles of the other team members, understanding the limitations and boundaries of all roles, and understanding how those roles have the potential to impact on patients. Individual practitioners should maintain a constant awareness of their place within the team, and how their position differs from that of other team members.
Obstacles to Interprofessional Teams
A common barrier to interprofessional teamwork is the phenomenon of “turf battles.” The struggles over protecting the scope and authority of a profession involve issues of autonomy, accountability, and identity. The principle of autonomy is defined a the desire for each profession to define itself, to set its own criteria for practice, and to maintain sole influence over its area of expertise. Loss of autonomy may lead to undesired changes in modes of practice. Accountability, another key component of professionalism, refers to evaluation and assessment of standards of care. Professionals define how they want to practice, and how they are going to be held accountable to others in their profession for practicing according to these team standards. Collaboration introduces performance evaluation by team members from other professions and for some individuals it can represent an invasion into their own professional domain. Finally, identity as an individual practitioner is due in large part to the identity of the profession as a whole. Interprofessional collaboration blurs the margins that define the roles of the various professions, and it may impact the identity of individual providers. The task of collaborative teamwork is to identify and address these underling factors that lead to territoriality and to thereby facilitate team collaboration.
Another obstacle to interprofessional teamwork has been found to be a result of the segregation of students based on their chosen professional pathway. It continues to be the norm even though much research literature challenges this practice that this segregation is benefical to someones chosen career path. Segregation continues to foster ‘professional arrogance’ (Leathard, 1994) and feed the power base for a professional hierarchy. Health education institutes must actively develop multiprofessional preregistration programs to encourage newly qualified professionals in multiprofessional working practices.
Resource funding and staff salaries can be a source of conflict within an interprofessional group. Professionals have markedly different pay scales according to the professional group they belong in, and what role they occupy within the group. Seeing monies being used to employ staff from one group to provide a service normally provided by another group can lead to conflict and resentment. Staff shortages can also damage communications with the group as members attempt to withdraw back from group activity in an attempt to limit demands made upon them. Groups do not want to take full responsibility over work flow when they feel that a part of the group is not holding up there part of the workload, so depending on the circumstances of staffing shortages, relationships within the group can suffer.
Personal Experiences
There is not a profession within the healthcare system that does not share some sort of interprofessional relationship. Healthcare is a team effort – all the way from the care given by physicians to the environmental service workers that clean the room. At times, these interprofessional relationships go extremely well, and are beneficial to the patient, but other times they can be fraught with conflict. A good working example of how well interprofessional team work goes can be found on my unit that I intern at for field. I am currently at the University Of California Department Of Physical Rehabilitation. This unit is an acute rehab facility within the hospital. They’re primary patient population are stroke survivors, parazlyzed patients, traumatic brain injury patients, and those that may have a specific type of bone break. Physical Rehabilitation offers a staff of Speech Therapists, Physical Therapists, a Social Worker, Neuropsychologists, and a wonderful team of physicians who specialize in Rehabilitation for adults and pediatric patients. From the time a patient is admitted to the service, there is a coordinated effort between physicians and case management to make sure the patient is appropriate for the service. Then, after it has been established that the patient will come to the service, the patients clinical case manager will run all information and coverage information to get an idea as to what services the patient is eligible for while in house, and what type of medical equipment and therapies are covered when they go home. Once the patient is officially on the unit floor, they are scheduled for up to 4 hours a day of intense therapies such as occupational therapy and physical therapy. While the therapies are going, the patient is set up on the roster for clinical case conferences twice a week. These are weekly check in’s by the care team (social work, psychology, nursing, physicians, physical therapy etc. ) to discuss the patients progress. If it has been determined that the patient needs longer therapy time then it’s discussed there at conference (or shorter time). During this time the social work staff is working on a discharge plan for the patient. Social work identifies potential barriers to discharge, sets up family conferences with the patients family to discuss care needs of the patient once they are discharged, and connects the patient and their caregivers to resources in the outside community to aide them in their care journey. The Department of Physical Rehabilitation is an example of interprofessional team work at its best. Varied disciplines come together to bring the patient a comprehensive and efficient care model with very successful results. Patients are able to discharge home sooner due to the services they provide and it ends up being more affordable in the long run when the patient isn’t in need of services for lengthier times.
