module-4.pdf

Education &
Training
Curriculum
on Multiple
Chronic
Conditions
(MCC)
Strategies & tools
to support health
professionals
caring for people
living with MCC.
Module 4 Interprofessional Collaboration
Full citations for this presentation appear in the notes section of the
slides.

Speaker Notes
This is the fourth module of the HHS Education & Training Curriculum on Multiple Chronic Conditions (MCC)—a six-module curriculum designed
for academic faculty, educators and trainers to inform healthcare professionals caring for persons living with multiple chronic conditions. Based
on the MCC Education and Training Framework (http://www.hhs.gov/ash/initiatives/mcc/education-and-training/index.html), these modules
provide knowledge and tools healthcare professionals can use as they improve quality of care of persons living with MCC.
Terminology used throughout this presentation:
• Multiple chronic conditions (MCC) is defined many ways in the literature and in practice. For the purposes of this presentation, MCC is
defined as a person with two or more concurrent chronic conditions. Other similar terms used are complex patient, multimorbidity and
comorbidity for this population.
• “Persons living with multiple chronic conditions” (PLWMCC) is used instead of “patient” to place greater emphasis on the individual
being at the center of care.
Each module has a PowerPoint® slide presentation that can be saved, modified, and used in your presentations with health professionals at any
stage of education (undergraduate, graduate or continuing education). The notes in the presentation will help guide your talking points during
the presentations.
Visit http://www.hhs.gov/ash/initiatives/mcc/education-and-training/index.html to download this and other modules—and to access
helpful tools and resources.
Suggested citation:
U.S. Department of Health and Human Services. Multiple Chronic Conditions Initiative. Education and Training Curriculum on Multiple Chronic
Conditions. Washington, DC. June 2015.

Learning Objectives for this module
After completing this module, you will be able to:
 Articulate why Interprofessional Collaboration (INTER)
is beneficial to persons living with multiple chronic
conditions (PLWMCC)
 Apply INTER strategies for continuity of care for
PLWMCC across settings
Interprofessional Collaboration: Module 4
2

Speaker Notes
This module, “Interprofessional collaboration” of the MCC curriculum provides:
1. An overview of interprofessional collaboration as an effective mechanism for healthcare professionals to help people manage their
multiple chronic conditions, and;
2. Practical strategies and resources for integrating interprofessional collaboration into practice.

Overview of Contents in this module
 How interprofessional collaboration helps PLWMCC
 Components of an effective interprofessional
collaboration
 Putting interprofessional collaboration into practice
3

Speaker Notes
This module is divided into three sections: How interprofessional collaboration helps PLWMCC, components of an effective interprofessional
collaboration and putting interprofessional collaboration into practice. These modules address interprofessional collaboration components,
strategies and tools to better help you care for persons living with multiple chronic conditions.

SECTION 1
How Interprofessional Collaboration Helps
PLWMCC

Speaker Notes
This section will define Interprofessional collaboration, identify key INTER competencies to care for PLWMCC and the benefits of INTER for
clinicians and PLWMCC.

Interprofessional Collaboration (INTER)
Definition:
The ability of healthcare and other professionals, as well as
direct care providers, community health workers, persons
living with MCC (PLWMCC), families and caregivers, to work
effectively within and between professions and with
PLWMCC, families, caregivers, and communities to provide
appropriate and effective healthcare.
Person- and Family-Centered Care: Module 1
5

Speaker Notes
The ability of healthcare and other professionals, as well as direct care providers, community health workers, PLWMCC, families and caregivers,
to work effectively within and between professions and with persons living with MCC (PLWMCC), families, caregivers, and communities1
to
provide appropriate and effective healthcare.
1
Schmitt, M., Blue, A., Aschenbrener, C. A., & Viggiano, T. R. (2011). Core competencies for interprofessional collaborative practice: reforming health care by
transforming health professionals' education. Acad Med, 86(11), 1351.

INTER Competencies
1 Recognize that PLWMCC are central members of their own healthcare
teams.
2 Negotiate roles and responsibilities with all team members that facilitate
working within their full scopes of practice.
3 Collaborate with all team members in executing the care plan to meet
the complex needs of PLWMCC.
6

Speaker Notes
The following six competencies for Interprofessional Collaboration are needed to appropriately provide care for PLWMCC. The underpinning
concepts that support these competencies will be discussed in greater detail in this presentation.
The competencies are
INTER 1. Recognize that PLWMCC are central members of their own healthcare teams.
INTER 2. Negotiate roles and responsibilities with all team members that facilitate working within their full scopes of practice.
INTER 3. Collaborate with all team members in executing the care plan to meet the complex needs of PLWMCC.

INTER Competencies (Continued)
4 Support culturally competent care of PLWMCC by the interprofessional
team.
5 Engage community partners as key members of the interprofessional
team.
6 Coordinate team-based synergistic interventions that address all
person-centered goals.
7

Speaker Notes
INTER 4. Support culturally competent care of PLWMCC by the interprofessional team.
INTER 5. Engage community partners as key members of the interprofessional team.
INTER 6. Coordinate team-based synergistic interventions that address all person-centered goals.

Benefits for using INTER
For Clinicians
 Improves productivity of
the team
 Creates synergy between
team members
 Makes resources available
to PLWMCC
For PLWMCC
 Improved quality of care
 Safer and more effective
healthcare system
 Higher satisfaction
8

Speaker Notes
Growing evidence and emerging healthcare models support the importance of effective interprofessional collaborations. Collaborating through
an interprofessional team increases productivity of the team thereby decreasing burden on individual clinicians, creates synergy between team
members that leads to higher quality care and makes resources1
available to the PLWMCC that may not have been otherwise.
Many aspects of interprofessional collaboration can result in improved care quality, safer and more effective health care system for PLWMCC2
;
and higher PLWMCC satisfaction3
.
1
Vanderwielen, L. M., Vanderbilt, A. A., Dumke, E. K., Do, E. K., Isringhausen, K. T., Wright, M. S., Enurah, A. S., Mayer, S. D., & Bradner, M.
(2014). Improving public health through student-led interprofessional extracurricular education and collaboration: a conceptual framework. J
Multidiscip Healthc, 7, 105-110.
2
Aston, S. J., Rheault, W., Arenson, C., Tappert, S. K., Stoecker, J., Orzoff, J., Galitski, H., & Mackintosh, S. (2012). Interprofessional education: a
review and analysis of programs from three academic health centers. Acad Med, 87(7), 949-955.
3
Schoenbaum, S. C., & Okun, S. (2015). High performance team-based care for persons with chronic conditions. Isr J Health Policy Res, 4, 8.

SECTION 2
Components of an Effective Interprofessional
Collaboration

Speaker Notes
This section – Components of an effective interprofessional collaboration - describes the configuration of teams, key components, models of
care that utilize INTER and challenges of INTER.

Members of an interprofessional team
Healthcare
Professionals
Clinicians
Office Staff
Community–
Based
Resources
Specialists
PLWMCC,
caregivers &
families
10

Speaker Notes
There are many different configurations of interprofessional teams, depending on the healthcare system, but often the team is comprised of:
Clinicians, professional staff and non-professional staff 10
The interprofessional team can also extend to include direct care workers, community
health workers and staff in the community that care for PLWMCC as well as PLWMCC and their families and caregivers.
Each member of the team understands their roles and responsibilities which are appropriate to scope of practice and knowledge and engage
with other team members regarding questions and concerns that facilitate shared person-centered problem solving1
. Interprofessional teams
include those who work to meet the needs of the individual person with MCC.
For example:
• Clinicians2
(physicians, nurse practitioners, and physician assistants);
• Professional staff (registered nurses, Licensed practical nurses, pharmacists, dentists, psychiatrists/psychologists, behavioral health
providers, social workers, physical & occupational therapists);
• Specialists (cardiologists, pulmonologists, surgeons)
• Other office staff (Medical assistants, front office staff, community health workers and patient navigators);
• Community-based staff (public health workers; program facilitators/coordinators and health coaches)
• PLWMCC, their families and caregivers3
.
• Inclusion of PLWMCC and their families and caregivers is essential as managing their disease and symptoms, along with carrying out
activities of daily living, will most often occur outside of a clinical setting.
1
Schmitt, M., Blue, A., Aschenbrener, C. A., & Viggiano, T. R. (2011). Core competencies for interprofessional collaborative practice: reforming health care by
transforming health professionals' education. Acad Med, 86(11), 1351.
2
Ladden, M. D., Bodenheimer, T., Fishman, N. W., Flinter, M., Hsu, C., Parchman, M., & Wagner, E. H. (2013). The emerging primary care workforce:
preliminary observations from the primary care team: learning from effective ambulatory practices project. Acad Med, 88(12), 1830-1834.
3
Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. . (2011).
Washington, D.C.: Interprofessional Education Collaborative.

Effective interprofessional teams
 Clear understanding of roles & required tasks
 Shared leadership
 Established means of communication
 Prioritizes activities based on PLWMCC’s
preferences and severity of health conditions
 Work collaboratively to optimize outcomes
 Allows all members to practice at the top of their
licenses
 Share common goals
11

Speaker Notes
Members of an interprofessional team organize themselves through common goals, work collaboratively to optimize outcomes1
, and have a
clear understanding of their role on the team and the tasks required of them to optimize the health of the PLWMCC. Leadership is distributed
throughout the team and changes as tasks change and goals of the care plan are met23
. Teams strive to be actively interdependent and work
through established means of communication to ensure various aspects of PLWMCC health care needs are addressed4
.
1
Vanderwielen, L. M., Vanderbilt, A. A., Dumke, E. K., Do, E. K., Isringhausen, K. T.,… & Bradner, M. (2014). Improving public health through
student-led interprofessional extracurricular education and collaboration: a conceptual framework. J Multidiscip Healthc, 7, 105-110.
2
Tubbesing, G., & Chen, F. M. (2015). Insights from exemplar practices on achieving organizational structures in primary care. J Am Board Fam Med, 28(2), 190-
194.
3
Agency for Healthcare Research and Quality Clinical-Community Linkages. Retrieved from http://www.ahrq.gov/professionals/prevention-
chronic-care/improve/community/.
4
Boyd, C. M., & Lucas, G. M. (2014). Patient-centered care for people living with multimorbidity. Curr Opin HIV AIDS, 9(4), 419-427.

SECTION 3
Incorporating Interprofessional Collaboration
into Practice

Speaker Notes
This section “incorporating INTER into practice” provides effective mechanism for healthcare professionals to help people manage their multiple
chronic conditions.

Models that Utilize Interprofessional Teams
Guided
Care
Model
Patient
Centered
Medical
Home
Camden
Coalition’s
Model
GRACE
Model
13

Speaker Notes
Healthcare providers and systems are developing team-based models of care that encourage working relationships between clinical and
community-based providers, PLWMCC, their caregivers and families to achieve the Institute for Healthcare Improvement’s Triple Aim of high
quality care, improved health at optimal costs1
. Several models have improved PLWMCC’s quality of care and quality of life. Here are three
examples of models of care that utilize interprofessional teams:
1. The Guided Care Model uses nurse-led teams to meet the complex care needs of PLWMCC. Other programs are experimenting with
other team configurations to improve care for PLWMCC.
2. Patient Centered Medical Home (PCMH) models support interprofessional team care that optimizes roles of each team member
including the primary care provider (i.e., physicians, nurse practitioners, physician assistants), nurses, medical assistants, pharmacists,
social workers, psychologists, dieticians, and specialists.
3. The Camden Coalition of Healthcare Providers has developed an innovative care management model for high needs / high costs patients
in Camden NJ. The Care Management Team relies on home visits with patients to coordinate doctors’ appointments, transportation,
and social services. The Team provides holistic medical care as well as root cause analysis and solutions to the often intertwined issue of
poverty and disease that plague its patients2
.
4. The Geriatric Resources for Assessment and Care of Elders (GRAMCE) model utilizes nurse practitioners and social workers to meet with
patients in their home and then consults with an interprofessional team to develop an individualized care plan.
1
Institute for Healthcare Improvement Triple Aim Initiative. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx.
2
Abraczinskas, J., Brenner, J. (2012). Camden Coalition's Model for High Needs Patients. Physicians News Digest.

Opportunities to Integrate INTER into
Practice
Care
Plans
Clinical-
Communit
y
Linkages
PLWMCC &
Interprofessiona
l Teams
14

Speaker Notes
Interprofessional collaboration
to understand how to provide more person and family centered care. The following four strategies are further described in the next two slides -
• PLWMCC and Interprofessional Teams
• Clinical Community Linkages
• Care Plans

The Role of PLWMCC on Interprofessional
Teams
PLWMCC
 Serve as a core member of the team
 Provide input into their health concerns,
goals and strategies
 Monitor their care plans and
communicate with all members of the
team
15

Speaker Notes
PLWMCC are integral to the Interprofessional Team as they know best their own chronic conditions in the context of their lives.
Interprofessional teams strive to provide culturally and linguistically appropriate care by integrating team members who can help achieve this
goal.
PLWMCC are core members of interprofessional teams.
PLWMCC and their families and caregivers are included in:
discussions about their health concerns and goals, and;
developing strategies for addressing those concerns and meeting goals.
PLWMCC help develop and monitor their care plans and communicate with members of the Interprofessional team when needed.

Care Planning: Interprofessional Team
Approach
Care Plans
are:  Living documents
 Developed with input by all members of
the team including PLWMCC
 Accessible by all team members &
revised regularly
16

Speaker Notes
Care plans place the concerns of PLWMCC at the forefront of the plan.
The care plan should include a clear communication strategy to ensure all team members are aware of goals that have been met or modified.
Care plans are:
• Living documents that elaborate on goals, strategies, and processes for optimizing the care and health of PLWMCC;
• Developed by and agreed upon by all members of the team including PLWMCC;
• Accessible by all team members and reviewed and revised regularly as goals are changed and met1
.
For PLWMCC who are children or have cognitive impairments (i.e., dementia or Alzheimer’s), their designated family member or POA (Power of
Attorney) should be highly involved in their care plan. Not all PLWMCC in this group will have the ability to review, understand, provide input
and agree to a care plan because of their conditions affecting their cognitive abilities.
1
Harris, M. F., Dennis, S., & Pillay, M. (2013). Multimorbidity: negotiating priorities and making progress. Aust Fam Physician, 42(12), 850-854.

Interprofessional Teams and Community
Linkages
Clinical-
Community
Linkages  Improves PLWMCC access to community
resources and support
 Offers augmented interventions and
services
 Increases care for PLWMCC
17
Ongoing clear and consistent communication is central!

Speaker Notes
Effective relationships between clinical and community partners can provide a win-win situation for PLWMCC, clinicians and community
partners.
Community Partnerships require time and effort to create and maintain. It is the responsibility of one or more members of the interprofessional
care team to identify appropriate resources and connect the PLWMCC to those resources as needed. One of the most critical responsibilities is
to ensure communication between the clinical and community organizations is clear and consistent1
.
Creating sustainable, effective linkages between the clinical and community settings can:
Improve PLWMCC access to community resources and support to prevent, delay, or manage their chronic diseases;
• Offer augmented interventions and services that the clinical health care setting may not have the time, resources, or expertise to
provide;
• Increase care for PLWMCC, who use community resources2
.
1
Agency for Healthcare Research and Quality Clinical-Community Linkages. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-
care/improve/community/.
2
Woolf, S. H., Dekker, M. M., Byrne, F. R., & Miller, W. D. (2011). Citizen-centered health promotion: building collaborations to facilitate healthy living. Am J
Prev Med, 40(1 Suppl 1), S38-47.

Barriers & Solutions to INTER
Barriers/Challenges
 Unplanned visits with
unrealistic agendas
 Inadequate support to
meet the PLWMCC’s need
for care
 Insufficient time for
documenting and complying
with administrative
requirements
Solutions
 Schedule previsit planning
 Share the care among the
team and expand
responsibility of select
team members
 Sharing clerical tasks
collaboratively and
employing scribing
18

Speaker Notes
Growing evidence and emerging healthcare models support the importance of effective interprofessional collaborations. Collaborating through
an interprofessional team increases productivity of the team thereby decreasing burden on individual clinicians, creates synergy between team
members that leads to higher quality care and makes resources1
available to the PLWMCC that may not have been otherwise.
Many aspects of interprofessional collaboration can result in improved care quality, safer and more effective health care system for PLWMCC2
;
and higher PLWMCC satisfaction3
.
Here are some barriers that interprofessional teams face which cause them to be suboptimal along with potential solutions.
• Barrier: Unplanned visits with unrealistic agendas; Solution: regularly scheduled visits with time specific agendas
• Barrier: Inadequate support to meet the PLWMCC’s need for care; Solution: to share the care among the team and/or expand
responsibilities of team members and to ensure that all team members are working within their full scopes of practice.
• Barrier: Insufficient time for documenting and complying with administrative requirements; Solution: sharing clerical tasks
collaboratively or employing scribing.
1
Vanderwielen, L. M., Vanderbilt, A. A., Dumke, E. K., Do, E. K., Isringhausen, K. T., Wright, M. S., Enurah, A. S., Mayer, S. D., & Bradner, M. (2014). Improving
public health through student-led interprofessional extracurricular education and collaboration: a conceptual framework. J Multidiscip Healthc, 7, 105-110.
2
Aston, S. J., Rheault, W., Arenson, C., Tappert, S. K., Stoecker, J., Orzoff, J., Galitski, H., & Mackintosh, S. (2012). Interprofessional education: a
review and analysis of programs from three academic health centers. Acad Med, 87(7), 949-955.
3
Schoenbaum, S. C., & Okun, S. (2015). High performance team-based care for persons with chronic conditions. Isr J Health Policy Res, 4, 8.

Barriers & Solutions to INTER (Continued)
Barriers/Challenges
 Poor communication
 Team meetings are too
time-consuming.
 Computerized technology
that causes more work for
physicians
Solutions
 Establish workflow
mapping and new
systems planning
 Schedule huddles or
regular team meetings
 Utilize in-box
management and verbal
messaging
19

Speaker Notes
Poor communication is the main cause of poor outcomes and errors in healthcare and can cause fragmented care. Effective communication may
reduce healthcare errors and improve satisfaction of care teams.1
Practicing and improving communication techniques are required all of the
time from all team members. Utilizing standardized documentation practices along with verbal messaging and in-box management2
are ways to
ensure that quality and continuity of care are achieved for PLWMCC.
Time constraints may be a challenge that prevents interprofessional teams from meeting whether there are conflicting schedules or not enough
time for everyone to meet all together. Establishing work flow mapping and new systems planning2
coupled with conducting time efficient
meetings can improve workflow for all. Scheduling huddles or regular team meetings in a specific timeframe allow the meetings to be more
efficient and effective.
Some EHR barriers include differing electronic communications tools and documentation errors due to the differing electronic communications
tools. When at all possible, using shared electronic records or other electronic communication methods may reduce burden for the
interprofessional team.
1
Scotten, M., Manos, EL, Malicoat, A., & Paolo, A.M. (2015). Minding the gap: Interprofessional communication during inpatient and post discharge chasm
care. Patient Ed and Counseling, 98, 895-900.
2
Sinsky, CA, Willard-Grace, R, Schutzbank, AM, Skinsky, T.A., Margolius, D, & Bodenheimer, T. (2013). In search of joy in practice: A report of 23 high-
functioning primary care practices. Ann Fam Med, 11(3) 272-278.

INTER Resources
 An Interprofessional Approach to Chronic Conditions
Module 5: Caregiver and Family Support in Managing
Chronic Conditions
http://www.pogoe.org/productid/20651
 Interprofessional Standardized Patient Exercise (ISPE):
The Case of “Elsie Smith”
www.mededportal.org/publication/9507
 HHS MCC Education and Training Repository
http://www.hhs.gov/ash/initiatives/mcc/educationalresources
20

Speaker Notes
The following resources may further support interprofessional collaborations.
- An Interprofessional Approach to Chronic Conditions 5: Caregiver and Family Support in Managing Chronic Conditions is a 30-minute
module that gives healthcare professionals and students an understanding of the caregiver role using an interprofessional approach to
care.
- The Interprofessional Standardized Patient Exercise (ISPE) provides students with a structured learning experience working within an
interprofessional health care team. The case of “Elsie Smith” involves multiple complex chronic medical conditions in an older adult with
many needs and limited resources. It highlights the need to address medical, functional status, and social domains, among others, and
accordingly is designed to be relevant to many health professions.
- To find more MCC related education and training resources for health professionals, visit the HHS MCC Education and Training
Repository at http://www.hhs.gov/ash/initiatives/mcc/educationalresources.
Borden C., & Waddell-Terry, T. MS (2010). An Interprofessional Approach to Chronic Conditions 5: Caregiver and Family Support in Managing
Chronic Conditions. Retrieved on June 12, 2014 from http://www.pogoe.org/productid/20651

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