Introduction
Hugh Tilson, Jr., JD, MPH, and Adam J. Zolotor, MD, DrPH, of North Carolina Area Health Education Centers (NC AHEC) gathered leaders of North Carolina health profession associations to discuss the role of interprofessional practice (IPP) in their members’ training, practice, and patient experience. The panel included Chip Baggett, JD, CEO and Executive Vice President of the North Carolina Medical Society (NCMS); Emily Adams, MPA, CEO of the North Carolina Academy of Physician Assistants (NCAPA); Valerie L. Arendt, MSW, MPP, Executive Director of the National Association of Social Workers North Carolina Chapter (NASW NC); and Tina Gordon, MPA, CAE, FACHE, CEO of the North Carolina Nurses Association (NCNA).
Also referred to as team-based care, or the collaborative model, collaborative practice is the goal of interprofessional education. In health care, it “occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, careers and communities to deliver the highest quality of care across settings”.1
The panelists agreed that while interprofessional education and practice are not always explicitly defined, the concept of collaborative learning that includes multiple professions and the practice of team-based care are increasingly embraced.
“Interprofessional practice is just the natural evolution of what we’ve been calling team-based care for a number of years, where the patient is the center and we’re learning from each other, working with each other, working side by side or connected through remote spaces, all to benefit the patient better,” said Baggett.
There was also consensus that more intentional efforts are needed at state and local levels to reach IPP goals in North Carolina.
“I think the opportunity is there to continue to help the practice environment evolve to fully meet the opportunities that interprofessional practice offers to everyone,” said Gordon.
The following Q&A has been edited for length and clarity.
Hugh Tilson: How do you see IPP in relationship to the delivery of health care?
Chip Baggett, NCMS: It sounds to me like the evolutionary process of team-based care is occurring within the professional education world, and that’s nice to see, because we practice the way we’re trained.
Valerie J. Arendt, NASW NC: The holistic approach to both physical and behavioral health is influenced by risk and protective factors that include both biological and social influences. Making sure that team-based care includes all of the variety of providers in both behavioral and physical health is incredibly important.
Emily Adams, NCAPA: I think IPP is important for intentional communication and those hand-off pieces. As we work in team settings without this, we can create unintentional slowdowns in the patient care continuum. As we focus on improving and increasing interprofessional practice, those things go more smoothly and we have better outcomes.
Tina Gordon, NCNA: Nurses are naturally collaborative, and I think this approach to practice just helps that blossom for the benefit of the patient. The approach to practice that allows providers to customize their approach and their decisions around what’s going to best serve that patient’s need, that is a win for everyone, with the patient at the center. It also helps providers utilize their own bandwidth and services as efficiently and as effectively as possible.
Adam Zolotor: We’ve talked about how IPP is important for patients. Is it important to your members? Is this something they are calling for?
Arendt (NASW NC): The answer is yes. Our members are working in hospitals and in primary care settings where they provide screenings and interventions and address behavioral health problems. Within these teams, I’m hearing from our members other circumstances that are not immediately visible to others. They bring that unique perspective to the team. And the schools of social work across North Carolina are funded by HRSA (Health Resources and Services Administration) grants to continue to incorporate this into their education, so a lot of these students are graduating and entering these team-based care settings.
Adams (NCAPA): The team-based, collaborative model is really a hallmark of the way PAs have always worked. It’s called out explicitly, it’s on the wall, it’s in our conversations. On the ground level, what we hear is oftentimes folks having mixed experiences with people understanding the PA role when they go into new teams. There are opportunities to improve there.
We’re seeing a lot of good focus in the training space, so PAs are going out and precepting with other medical learners and they’re being very intentional. Often, PA programs are housed alongside other professions, whether it be medical schools, nursing schools, schools of social work; they’re all training side by side.
Gordon (NCNA): Yes, this is firmly on the radar of our members regardless of their role or their practice setting. I think that’s important to consider, especially as nurses have been called further beyond the acute care walls. We’re seeing more calls to address the whole person and hopefully keep them out of that acute care setting. If we are asking our members for examples of innovation in the practice arena, oftentimes the examples that come forward include some element of interprofessional practice. If we are going to get unsolicited feedback from our members, it’s going to be about experiences they’ve had where they think there were missed opportunities or things could have been improved for the benefit of the patient.
Baggett (NCMS): When we talk to our members about how they’re structuring their practices, how they’re working in communities, how they’re delivering better care to patients, team-based care or IPP is a natural part of that conversation, but the label isn’t used. When we’re talking with our medical students, it’s a part of their vernacular in school now. I still remember the days when everybody was trained in their own corners and then they had to get out in the world and figure it out together. Now this is coming up early in the process, first- or second-year med students, and it’s building a much better mindset of how the various professionals are going to come together later on.
Gordon (NCNA): I agree, but nurses sometimes find the practice environment offers up challenges, and it is not as natural of a progression as they might like to see.
NCMJ: It sounds like we still have some room for improvement.
Adams (NCAPA): To build on what Tina [Gordon] was saying, as we think about onboarding and orientation, especially if we’re transitioning new grads into new practice spaces, integrating IPP thinking into that process has to be a little more deliberate and a little more focused. I think there is potentially a gap between the training space and the practice space. We know of folks who have chosen to find other opportunities when they feel like they weren’t well utilized or even just given the tools that they needed to succeed initially. And I think IPP is a real opportunity. Those conversations, that training, that ongoing work in that space during that transition to practice is something we could continue to evolve and explore.
Baggett (NCMS): I would say we have that in a lot of different spaces in health care, not just in a professional collaborative practice. Medicine is constantly innovating, but it’s also one of the slowest to innovate. And that’s most often because we’re dealing with real lives here. The evolution is occurring, and that’s why I say I’m excited and encouraged by it, but it’s probably not going to happen near as fast as any of us would want it to happen.
Gordon (NCNA): The beauty of the whole opportunity is to be able to customize it to the needs of the patient. I hear nurses talk a lot about opportunities to lead a professional team and I know of nurses who are doing a great job with this. But it’s patient-specific, and depending on the needs of the situation and the outcomes they are seeking, should the same provider always be the leader? Of course not. If we have behavioral health issues that are driving a patient’s conditions, we need behavioral health providers leading that team. So, the beauty is also the greatest challenge.
Adams (NCAPA): To borrow a concept, building psychological safety within those interprofessional teams is so critical so that these conversations can happen when you have maybe a more traditional hierarchy. Setting aside space, leaning into a more novel approach that’s more patient-centered and allows the individual team member to take the lead in one aspect. Being able to trust each other and have the ability to be flexible is really important right now, especially as we think about the stress on the health care system.
NCMJ: What is your association doing to promote interprofessional practice?
Adams (NCAPA): I think this is a space to grow into and be conscious of. Even though we talk around it, and we probably describe it often, we’re not using that same shared language of IPP or interprofessional collaboration. So, I think there is an opportunity there.
Baggett (NCMS): We’ve been talking about team-based care in the population health space for nearly two decades. Three ways we’ve been supportive of this come to mind just off the top of my head. The first is the training space that Emily [Adams] was talking about, with expanding physician preceptor shifts to a whole variety of different professionals, not just medical students or fellows or residents. The second piece is that we have either been supporting legislation or evaluating legislation that would promote the team-based care model. Thirdly, three years ago we started a Future Clinician Leadership College program specifically to promote interprofessional collaboration, where we have medical students, PA students, pharmacy students, social work students, and nursing students of all different backgrounds coming together. We’re doing this out of a grant specifically for Wake Forest University, and we’re looking to expand that because of the success. When those students get out into the real world, you’ve got bonding across professions. You’ve got understanding of people’s abilities and training, and you’ve got a network of people who are naturally already talking with one another instead of graduating and having to go build a network somewhere else.
Arendt (NASW NC): I’ll echo what Emily [Adams] said. I don’t think we have the same shared language as we’re talking about interprofessional practice, and I think we can also do a better job of promoting this practice, as the majority of social workers aren’t in these primary care settings. Our members are all over the place, but they should be in these spaces more often. We do provide a number of different conferences and workshops and trainings and do invite a variety of voices to come and talk about these settings. The biggest mutual support that we’ve had is within the universities that are really thriving in the interprofessional education space. They are working really hard to work with other health professions to educate social workers to enter the workforce in these team-based care settings.
Gordon (NCNA): We look to include opportunities in our continuing education offerings on a regular basis, both for learning and staying up to speed on the latest best practices and for ways to support nurses who may not have had education about interprofessional practice as part of their formal education. We can help fill some of those gaps, at least in the RN space. We also like to give members a forum for sharing best practices and learning from one another.
NCMJ: As we go through Medicaid expansion, we increasingly talk about whole-person care. We increasingly think about things like “making care primary” and “advanced medical homes.” Are those models correct for moving us toward more team-based care? And if adopted, do those problems that you articulated persist?
Baggett (NCMS): Yes, and yes. These models are directionally great, fantastic, moving in the right direction. The funding problems persist because different groups are funding it in different ways. How do we create something that is consistent, that we can actually predict and build models off of? That’s still a challenge out there that hasn’t fully come around.
Gordon (NCNA): We still have challenges as simple as not everyone agreeing on the definition of interprofessional practice. I don’t know if it’s reasonable to get everyone to agree on it.
I do think professional associations are very well positioned to support providers in the pursuit of best practices on this.
NCMJ: What do you see as the role of our educational institutions in advancing and promoting interprofessional practice?
Gordon (NCNA): Their role is absolutely essential. The biggest need is helping our educators and our new graduates make sure that the practice environments support the ability to implement what they have learned.
Adams (NCAPA): There have been some great examples of PA programs across the country doing a really great job of this. They have their students shadowing individual professionals, not just training next to each other but being intentional about observing and asking questions. We sometimes run into a real disconnect between how PAs are educated and trained with other providers they’re working with; sometimes there’s still this feeling of being siloed. But they’re doing a remarkable job; 85.5% of PA students report they have IPP training during PA school,2 so that seems really remarkable, but what about the other 14%? It’s important that we have these spaces to talk about it and learn from what has worked well.
Arendt (NASW NC): I already mentioned the importance of our education programs incorporating IPP into the learning environment, and I believe a lot of social work programs in North Carolina do an amazing job. However, a lot of social work programs don’t necessarily have the funding for one or two specific faculty members to take the lead on that and build relationships with the other departments at the university and build that space for that learning environment. I think that’s a challenge, but the universities that do have that are succeeding very well.