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Interprofessional Collaborative Practice: The whole is greater than the sum of the parts Prof Sarah Strasser Associate Vice President Academics & Interprofessional Practice Health Science North Academic Health Centre for NOSM

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Vast Remote Sparsely populated Indigenous Chronic health issues Large disease burden Tropical - desert The Northern Territory

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Interprofessional collaborative practice Prof. Sarah Strasser

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In, by and for Northern Ontario Northern Ontario Southern Ontario Sioux Lookout

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27-30 October 2014 Uluru, Northern Territory, Australia Latest Muster information is available at www.flinders.edu.au/muster2014 muster2014@flinders.edu.au 27 30 October

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Interprofessional Collaborative Practice: The whole is greater than the sum of the parts A partnership between a team of health professionals and a client in a participatory, collaborative and coordinated approach to shared decision-making around health issues (Orchard et al., 2005). There is a set of competencies that describe the desired collaborative practitioner at a team level. The knowledge, skills, and attitudes that shape interprofessional practice are reflected in the competency framework which can be applied in different situations. There is a sub-set of competencies that strives to put the I back in TEAM and challenges individuals to take responsibility for their collaborative practice skills. Thanks to Lesley Bainbridge for sharing

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Interprofessional Collaboration (IPC) A.An interprofessional process of communication and decision making that enables the separate and shared knowledge and skills of health care providers to synergistically influence the patient care provided. (Way et al, 2000) B.Occurs when multiple health care providers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings. (WHO Framework for Action on IPE & CP, 2010) C.A partnership between a team of health care providers and a client in a participatory, collaborative and coordinated approach to shared decision making around health and social issues. (CIHC Framework) D.Interprofessional collaboration is a process through which clients and providers can examine different aspects of a problem and constructively explore their differences, searching for solutions that go well beyond their own vision of what is possible. (Gray, 1989) E.Interprofessional collaboration implies interdependence among clients and providers, constructive handling of differences, joint ownership of decisions and collective responsibility for outcomes. (Hartman et al, 1999)

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Competency Domains Canadian Framework: Patient/Client/Family/Community-Centered Care Role Clarification Interprofessional Communication Team Functioning Collaborative Leadership IP Conflict Resolution

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An Example Domain: Interprofessional Conflict Resolution COMPETENCY STATEMENT: Learners/practitioners actively engages self & others including the client/patient/family, in positively & constructively addressing disagreements as they arise. DESCRIPTORS: To support interprofessional collaborative, team members consistently address conflict in a constructive manner by: Valuing the potential positive nature of conflict Recognizing the potential for conflict to occur & taking constructive steps to address it Knowing & understanding strategies to deal with conflict Setting guidelines for addressing disagreements Establishing a safe environment in which to express diverse opinions Developing a level of consensus among those with differing views; allowing all members to feel their viewpoints have been heard no matter what the outcome

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Competency framework considerations Background considerations: Quality improvement Simple through complex Context of practice Rather than focusing on demonstrated behaviours to determine competence, the framework relies on the ability to integrate knowledge, skills, attitudes, and values in arriving at judgments. Five characteristics complexity (the dynamic organization of components); additive (application of knowledge, skills, attitudes to formulate judgments) integrated (diversity of individual resources); developmental (over the lifespan); and evolutionary (within a given context; actualization creates new understandings).

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Examples of application of a competency or other framework Capacity building Strategic planning Educational planning and implementation Team/Self assessment Organizational changes

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Interprofessional Communication Patient & Family Focused Care Team Function Collaborative Leadership Conflict Resolution Role Clarification Interprofessional Collaboration NEW GRADUATE EARLY PRACTITIONER EXPERIENCED PRACTIIONER Simple Complicated Complex Immersion Exposure Mastery Attitudinal Change Capacity building & strategic planning

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Education

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I. Role Clarification Learners/practitioners understand their own role and the roles of those in other professions, and use this knowledge appropriately to establish and achieve patient/client/family and community goals. Describes own role and that of others Never Rarely Sometimes Almost Always Does Not Apply Team / Self assessment

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One size does not fit all: IP team needs to fit the purpose Comprehensive patient centred care on a consistent basis (same team): Rural practice Palliative Care Cancer Care Stroke Care Care of the elderly COACH Team

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Care of the elderly: Coach team 48/5

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48/5 for >65 Bowel & bladder Management Cognitive functioning Functional mobility Medication management (+ pain) Nutrition & hydration many things wrong, all at once Dr Janet McElhaney

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Interprofessional Communication Patient & Family Focused Care Team Function Collaborative Leadership Conflict Resolution Role Clarification Interprofessional Collaboration NEW GRADUATE EARLY PRACTITIONER EXPERIENCED PRACTIIONER Simple Complicated Complex Immersion Exposure Mastery Attitudinal Change Coach team

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Intermittent IP team pockets of care/education & training Operating theatre Out patient clinics based on a scenario: pain, diabetes, bariatric surgery Technology enabled Virtual ICU, telehealth Simulation Lab

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Virtual Intensive Care Unit

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HSN Helicopter pad

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Interprofessional Communication Patient & Family Focused Care Team Function Collaborative Leadership Conflict Resolution Role Clarification Interprofessional Collaboration NEW GRADUATE EARLY PRACTITIONER EXPERIENCED PRACTIIONER Simple Complicated Complex Immersion Exposure Mastery Attitudinal Change Virtual ICU

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HSN Simulation Lab: Anaesthetic Boot Camp

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Beyond clinical care Quality Improvement Patient safety Health Care Management (allocation of resources) quality based funding/procedures (QBF/QBP)

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Organizational Excellence training Quality Improvement

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Interprofessional Communication Patient & Family Focused Care Team Function Collaborative Leadership Conflict Resolution Role Clarification Interprofessional Collaboration NEW GRADUATE EARLY PRACTITIONER EXPERIENCED PRACTIIONER Simple Complicated Complex Immersion Exposure Mastery Attitudinal Change OE

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Quality Based Funding/Procedure Health Service Providers will be reimbursed for the types and volumes of patients they treat, using rates based on efficiency and best practices that are adjusted for each procedure. Adjusted for: Patient complexity Quality of health care delivered QBP Equation = Price X Volume 5

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QBPs Addressed in the NE LHIN Clinical Services Review 1.Medical I.CHF II.COPD III.Stroke 2.Surgical I.Cataracts II.Total Joints Replacement ( Knee and Hip) III.Hip Fractures (2014/15) IV.Vascular Surgery 3.Outpatient I.Endoscopy II.Chemotherapy 9

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QBP Hip Fractures HUB Hospital (4) Smaller Hospital (21) For most part all hip fractures will be done at HUB (except Parry Sound as they do total joints) Transfer from the Emergency to the Operating Room goal is within 48 hours After Acute Hospital stay for fracture is complete, patient will be transferred to home hospitals for inpatient rehab. If they do total joints, they must do hip fractures! Transfer from the Emergency to the Operating Room goal is within 48 hours After Acute Hospital stay for fracture is complete, patient will be transferred to home hospitals for inpatient rehab - - with telemedicine support from HUB rehab outreach. 18

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Interprofessional Communication Patient & Family Focused Care Team Function Collaborative Leadership Conflict Resolution Role Clarification Interprofessional Collaboration NEW GRADUATE EARLY PRACTITIONER EXPERIENCED PRACTIIONER Simple Complicated Complex Immersion Exposure Mastery Attitudinal Change QBF

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Risk of team working - knotworking Engestrom 1999

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Organizational support: access to resources (time & money), senior management commitment Improved quality of team work: teamwork: Organizational rewards for improvements in work practices Encourage use of innovation & implementation of change High support for team innovation Support to implement team changes Xychris & Lowton 2008

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No hard evidence of patient outcomes (other than patient safety) Lack of consensus, focus & vision Lack of consistent funding & short funding cycles Lack of leadership & succession planning Lack of incentives/ perverse funding/ work arounds Not all positive outcomes

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If you dont control the money you dont control anything IP Competencies/capabilities & supervision IP communication & trust Physician & patient engagement Clinical Leadership & governance Regulations & organizational support Scaling up/ UHC/ transprofessional care Health literacy PCM & End of life care Context, complexity & costs Team changes, space and EMRs

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Call to action

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Health care in NZ in 2012 Challenges: Focal deficiencies and shortfalls; Falling productivity; Unsustainable reliance on immigrant health workers; Costs of health care growing faster than national wealth; Challenges: Ageing of the community and growing demand for health care; and Ageing of the community and retirement of the baby- boomer generation of health care providers. D. Gorman 2014

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Jaws of death NZ: D. Gorman 2014

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NZIER (2005) NZ Population Projections by Age Cohort (Assuming medium population growth) 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 0-45-9 10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-89 90+ 200120112021 D. Gorman 2014

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Towards a sustainable and fit-for-purpose NZ health system A shared care record. A new way of funding services and of rewarding providers and consumers. A diversified and fit for purpose community based health workforce that works as much as is possible at the top end of their licence. Genuine patient-directed and centred care Advanced care planning D. Gorman 2014

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Rogue physicians Health is too diverse to have one person making decisions any more, in fact negative when one is left alone: Canada, Globe & Mail 2014: Reports solo physician renders vaccines ineffective by mixing them, for over 20 years.

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Putting the I back in team.

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The alternative lens PATIENT- CENTRED COLLABORATIVE PRACTICE SOCIAL CAPITAL RHETORIC (FRAMING) NEGOTIATING PRIORITIES PERSPECTIVE TAKING ADDRESSING CONFLICT RELATION- SHIP BUILDING G. Regehr

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Differing forms of interprofessional work networking coordination collaboration teamwork Integration & interdependence S. Reeves

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Thank You