Interprofessional Health Care Education
American health care's greatest challenge is cost.
Expenditures in the United States on health care are closing in on $3 trillion, more than 10 times what they were in 1980, and the equivalent of about $8,000 per resident annually. Soon health care spending will account for 20 percent of the economy.
Stanching the flow of cash into health care is a major national concern, clearly understood by health care professionals at the University of North Dakota School of Medicine and Health Sciences and others in disciplines related to health care across campus.
One positive step in that direction is the School's Interprofessional Health Care Course (IPHC), an integrative program launched under the tenure of former UND SMHS Dean Dr. David Wilson.
The course, codirected by Eric L. Johnson, MD, assistant professor, and Maridee Shogren, MSN, of the UND College of Nursing, involves every allied health profession on campus and is run on a collaborative model that doesn't assign a "higher" value to any one profession or specialty over any other.
"We want this course to provide the students with an opportunity to develop their own professional roles and their functions as members of a health care delivery team," said Johnson, a boardcertified family practitioner.
The IPHC is modeled on the School's acclaimed patient-centered learning (PCL) small-group curriculum.
The focus of the course is to learn about the role of other health care professionals and how to interact as a health care team. Eight disciplines are involved in the course: medicine, nursing, occupational therapy, physical therapy, music therapy, communication sciences and disorders, social work, and nutrition and dietetics. Each semester, two six-week sessions are held on Tuesday evenings from 5:30 p.m. to 8:30 p.m.
The small groups consist of seven to nine students from the various disciplines and meet in rooms across campus. The course is offered pass or fail.
"Teamwork is essential in health care because it leads to a much more collaborative and holistic approach to patient care," Johnson said. "Thus we want students from each health care profession to learn what the role of others on the team is."
This approach is countercultural—one might say revolutionary—in medical and health care education. In "traditional" health professions education, specialists from one area—such as medicine—know very little about areas outside their training—such as physical therapy or nutrition and dietetics.
"Our approach with this course helps health care professionals learn from each other," Johnson said. "The result: improved patient outcomes." And that, he noted, leads to a much more cost-effective health care system.
"This kind of team-based approach works especially well for chronic diseases, such as diabetes," said Johnson. "I know this because I was diagnosed with Type I diabetes when I was 29. Patients with diseases such as mine are much better served by a team approach that includes a range of medical professionals: physicians, diabetes educators, dietitians, et al."
For example, he notes, the value of the team approach in treating diabetes results from the rapidly evolving technology of diagnosis and long-term treatment of this chronic—and so far incurable—disease.
"Diabetes technology changes so fast, such as glucose monitors, that usually the only folks who can keep up with those changes are the diabetes professionals—they're equipped to keep up with those changes, and they can then share that knowledge with care team partners," Johnson said. "So diabetes care teams that have diabetes educators are ahead because of their interprofessional approach."
From direct medical care, there's a natural segue into other team-related approaches to helping a patient manage a disease such as diabetes.
"Teams can do a lot of other things, such as help support groups, hold patient education events, and organize things like diabetes conferences," Johnson said.
Insurance companies have an eye on the team-based approach, which insurers interpret with a view to the future.
"Insurers are definitely getting behind this kind of case management strategy," Johnson said. "Many third-party payers— insurance companies—pay for group visits such as diabetic and cardiac where they didn't before. Medicare also encourages group visits, especially for folks with diseases such as Type II diabetes."
"Team members that represent each department are outstanding to work with," Johnson said. "They are in frequent e-mail contact with each other, and the class is so well constructed that it really makes it easier, going forward. It's not like we're doing periodic updates—we're constantly updating and refining."
Financing the IpHC
Originally the lion's share of the Interprofessional Health Care Course budget fell on the SMHS.
"But we developed a relatively simple formula—a budget mechanism—based on a proportional system," Johnson said. "Each department that participates pays according to its share of total participation in the program; we will start doing that soon."
Accreditation for the course is not that complicated, Johnson noted.
"We demonstrate that we have some interprofessional education component— some universities do more, some less— and our approach is more formalized than many," Johnson said. "Some schools only schedule a few interprofessional lecture seminars per year. And on our team, every department involved has a voice—it's a very democratic process."
The UND College of Nursing is a major player in the IPHC, Johnson noted.
"You bet," said Maridee Shogren, MSN, a clinical instructor in the college and co-team leader of the course.
Each small group is led by a preceptor, a faculty member from one of the various health professions taught at UND.
"Preceptors facilitate and lead students through the process, but the students have to work the case themselves," said Shogren. "One thing we all learn is that every person on a team is a patient advocate. We believe that significantly reduces errors in the health care system. The team approach tends to do that better, and that's likely to improve cost efficiency, too, and that's an appropriately important issue for the twenty-first century."
"So with the team approach, each member notes a responsibility to both other members and to the patient," Shogren said. "So we're not engaged in 'handing off' care from one professional to another. Unlike the stereotype of medical care, we don't keep people in a box, we share information and ideas. We want everyone on the team to bring all of their expertise and experience to the table—it's all about respectful communication."
For Gwen Halaas, MD, MBA, a family physician and senior associate dean for academic and faculty affairs, the Interprofessional Health Care Course is integral to the philosophy of health care education at the UND School of Medicine and Health Sciences and its allied health partners across campus, such as the College of Nursing and the Department of Social Work.
Halaas has seen a lot over her career as a physician, health system administrator, and educator that inspires her views on interprofessional education.
A graduate of Concordia College, Moorhead, and Harvard Medical School, she's done just about everything a family physician can do and then some, including delivering babies, making house calls, and writing several acclaimed books. She was previously director of the Rural Physician Associate Program and was the founding director of the Center for Interprofessional Education at the University of Minnesota.
"Interprofessional means across the health professions," Halaas said. "Historically, I would say that health care in America is multiprofessional, which means we work with other health professionals, but only in a serial manner—we receive and refer, but we rarely function as a team. It's more of a handoff."
But that's changing.
"The interprofessional movement—which includes what we're doing here at UND—is toward collaborative practice; it includes pharmacists, nurse practitioners, social workers, and people in the therapies such as occupational and physical," Halaas said."As a result of this trend, the potential for the improvement of our health care system is tremendous. There already are pockets of interprofessional practice, for example, pediatrics groups working with kids with disabilities or chronic diseases, and hospice care, but we need to do a lot more of that."
The team is most effective when the individual patient is a member of that team."
"Self-care and patient self-management are important for good health and better outcomes," said Halaas, who got an inside track on the system within the group she founded at Minnesota. "Working with interprofessional education at Minnesota was a terrific experience for me. Being responsible for the development of interprofessional education programs, I recognized the challenges as well as the value, and I networked with national and international leaders in interprofessional education."
Halaas said team-based competencies—such as those shared by an interprofessional health care delivery group—build a shared foundation of useful and applicable knowledge.
"The important thing about interprofessional teams is that the teamwork is visible," Halaas said. "That means team members, actively communicating with each other, always include the patient. Ultimately this is about both safety and quality in medicine—it helps to develop very specific communications skills and tools to prevent errors. Eighty percent of errors in medicine are communication errors."
"Our post-course satisfaction survey indicates that students tend to be very happy with the course; they find it very useful," Halaas said.
To date, UND's Interprofessional Health Care Course has had about 1,700 students.
Playing the Right Kind of Music
"We're a lot like King Arthur's Round Table," said Andrew Knight associate professor and director of the UND Music Therapy Program and a preceptor in the Interprofessional Health Care Course.
"There is one of us at the table from each of the medical and health carerelated professions on campus," said Knight. "As course preceptors we do a lot of probing, prompting, relying on our experience, to help students get the full benefit of the course. We ask them questions like 'Did you think about this aspect of the case?'"
Knight said it's a lot different than teaching other classes, which require a more formalized preparation, such as course notes.
"Compared with teaching a regular class, there's a lot more spur-of-themoment stuff in the InterprofessionalHealth Care Course," Knight said.
"We actively try to get students to participate, to compare stories, to learn from each other's experiences," said Knight, an accomplished performer on several instruments, including guitar and piano. "I actually take the case-based learning models we use in IPHC into my music therapy and other music classes."
In the IPHC case-based learning model, there isn't always a clear answerto the specific scenario under discussion.
"How do you take an imperfect scenario and come up with reasonable answers?" Knight asked. "Well, they've been doing this a long time at the medical school, especially with these interprofessional courses, and I think it's a great addition to Music Therapy."
"Of course our perspective as music therapists is good for students in other areas of health care," Knight said. "We each get to know clients in different ways, sort of like the blind men and the elephant."
Writer/Editor University Relations