Blog Article: Using interprofessional education to enhance knowledge and skills for integrated and person-centred care

Using interprofessional education to enhance knowledge and skills for integrated and person-centred care 

Dr Teresa Burdett

Facilty of Health and Social Sciences

Bournemouth University 

Contact: tburdett@bournemouth.ac.uk 

Introduction

An educational, person-centred initiative was designed to bring individuals from different clinical arenas and professions together. It was intended to enhance working collaboratively and move person-centred care forward jointly across the organisations involved, and in the practitioner’s own clinical arenas. This programme was designed, whilst being aware of potential implications such as limited resources, to achieve an impact in a number of areas including on the participants, their colleagues and their own patient populations. This interprofessional activity was assessed before and after its implementation and findings revealed that participants perceived it to be a valuable experience. Strategies on interprofessional education and person-centred care resulting from this programme are now being implemented. The programme has evolved in response to student feedback and evaluation and aims to continue to enhance interprofessional education, integration, workforce development and person-centred care.

Background

Multiple issues including resource limitations, an ageing workforce and increasing patient populations currently face health care systems both in the United Kingdom and internationally. Working together is often seen as a way forward and yet interprofessional education and collaboration but repeatedly curtailed due to modes of thinking, perceived time implications, organisational challenges and physical resources (Barr, 2013).  This innovation was designed so that all the individuals in health and social care would feel and be empowered so that they could learn and work together with equality to generate new knowledge and strategies so that person centred care could be improved through working together in a more integrated manner (Goodwin et al., 2012). It is believed that this innovative project could be replicated, nationally and internationally, to create new understanding and solve issues facing public services, leading to greater person centred care and level of services.

Implementation

Two programmes funded by Health Education Wessex were delivered across the South of England. Through the use of interprofessional education the aims of the programmes included enhancing the student’s knowledge and practical skills base through discussing and demonstrating integration in relation to seeing each person as an individual. This is an intrinsic aspect of person-centred care (Hewitt-Taylor, 2015). It was anticipated that this programme would lead to an enhanced level of care being offered.

Each participant was drawn from different professional groups, including, registered adult and mental health nurses, social workers, social care assistants, occupational therapists, rehabilitation therapists and health and social care co-ordinators. This mixed cohort supported the belief in the value of interprofessional education to enable “two or more professions to learn with, from and about each other to improve collaborative practice and quality of care” (CAIPE, 2002). The practitioners were drawn from primary and secondary care and a combination of genders, ages and work locations were represented in each cohort.

Participants were encouraged to work together in a pro-active manner to address issues that could potentially be enhanced by learning and working together in a more integrated manner.  A number of topics were covered in the programme including the challenges and benefits of integration (Ling et al., 2012) and local, national and international perspectives of integration (Rosen et al., 2011).  Ideas of how to enhance person-centred care through integration for specific groups (e.g. mental health service users) were also discussed.

 A variety of teaching methods and strategies were utilised including seminars, media and group participation. Solution-focused strategies and reflective exercises including individual and team-orientated sessions were utilised. Group work was deliberately designed to ensure individuals from different professions worked productively together. All participants were asked to work on an integrated, person-centred project based in their own sphere of care. A plethora of ideas came from the students, many of which were adopted in the clinical arenas including improving referral systems, a greater co-ordination between services and enhancing discharge packages. This array of approaches proved very useful for the individuals and their practice arenas resulting in significant, positive feedback.

Assessment

This feedback was gained by utilising pre-and post-programme questionnaires and the participants were asked, for example, “...please identify three key points which have had an impact on you...”  Open-ended questions were utilised in the questionnaires to gain a deeper understanding of the participant’s perspective including, “...what are your feelings about integration?”  Opportunities were offered have frank face-to-face discussions between the students to obtain qualitative data. Students also had a booklet to complete which asked a series of questions on each day of the programme including, “...how, if at all, do you envisage this will impact on your practice”.  Students were also given the opportunity to write and verbalise their thoughts and feelings in an unstructured and open format, “...do you have any other comments”.

Outcomes 

Initial impressions were positive, from the qualitative data received from the students undertaking both programmes and also from the practice arenas. This has included written, verbal, and ad hoc feedback that enhanced integration has been occurring, which has resulted in an improved level of workforce satisfaction, increased workforce initiatives and an increased focus and level of care being offered to the recipient of care. Other areas addressed included amending services and enhancing patient access to services.

Other outcomes included devising an interprofessional programme that encouraged learning and working together which has further added to the body of knowledge about how to achieve this. Such an approach is not always viewed as the way forward and often profession-specific training is provided. The results from this programme do challenge this viewpoint and lessons have been also been learned included language use and ensuring a balance of professions in groups and individuals.

Focusing directly on integration in an interprofessional programme has been novel. It has resulted in creative strategies being devised and innovative projects being implemented, which it is anticipated will result in enhanced, sustainable patient care. As the following data extracts indicate:

“…This course has opened my mind to how we deliver care in the future…”

 “…Best outcomes for the patients with patients being the centre…”

Teaching the subject of integration in an interprofessional manner has raised the profile of interprofessional learning/working and integration. This has created a momentum and renewed vigour which can be focused on helping address the multiple issues currently being faced by health and social care systems both nationally and internationally:

“…I ensure I challenge attitudes and promote integration…”

“…This course has strengthened my belief in the importance and value of integration…”

Discussion

Working together undoubtedly benefits the individuals we care for (World Health Organisation, 2016) and learning together can enhance and develop our skills with working with different disciplines (Frenk et al., 2010).  Hence the usefulness of this intervention which has gained a number of key outcomes including, providing students with more knowledge about integration and how to utilise it, and importantly, feeling more empowered to initiate change. Feedback has also identified that the students believed that their patient populations have gained from an enhanced person-focused level of services. The individuals on the programme gained more knowledge about each other’s roles and professions which led to increased levels of interaction and rapport which clearly continued into the clinical or community arenas.

The programme is now formalised as the Foundations of Integrated Care and Person Centred Services Programme because this more clearly reflects the philosophy of the curriculum. It is also being delivered on site at Bournemouth University which is in response to student feedback. Although, offsite delivery is still available if required. This is now an accredited programme and it can be undertaken as a standalone unit. The components of leadership and change and change management in integration have been strengthened in response to student feedback. This is due to the evolving and challenging nature of integration, in the UK and internationally and the need for change and leadership is inherent in the workforce who are seeing the patient population needs first hand.

Interprofessional education, learning and working together is one way of encouraging integration and enhancing person centred care. This innovative, interprofessional educational programme was designed to focus on these two issues and by bringing different disciplines together to learn together, according to participant and work force feedback this programme was successful. However, this was not without its challenges. These included venue choice, the differing needs of students, their perceived needs of specific professional roles, language use and knowledge base. There were also differing requests from the clinical arenas that needed to be accommodated. It was not a static programme and responded to the evolving nature of integration and the students, workforce development, the employer and clinical arena requirements and the patient and service user needs. Areas of the programme have already been re-developed and this will no doubt be an ongoing process to keep the programme relevant, up to date and responsive to student, work force and patient population needs and maintain its aim of being a truly interprofessional, educational programme.

References

Barr, H., (2013). Toward a theoretical framework for interprofessional education. Journal of Interprofessional Care. 27, (1) 4-9. Doi:10.3109/13561820.2012.698328

CAIPE. (2002).  Centre for the Advancement of Interprofessional Education – a definition. http://www.caipe.org.ik/resources/resources/defining-ipe/  

Frenk J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., … Serwadda, D., (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 376 1923-1958

Goodwin, N., Smith, J., Davies, A., Perry, C., Rosen, R., Dixon, A., Dixon, J., Ham, C., (2012). Integrated Care for Patients and Populations – improving outcomes by working together: a report to the Dept. of Health and the NHS Future Forum. London. Kings Fund

Hewitt-Taylor, H., (2015). Delivering Person Centred Care-A Practical Approach to Quality Health Care. Palgrave, London, UK

Ling, T., Brereton, L., Conklin, A., Newbould, J., Roland, M., (2012). Barriers and facilitators to integrating care; experiences of the English Integrated Care Pilots. International Journal of Integrated Care. 12 (24) 1-12

Rosen, R. Mountford, J. Lewis, G., Lewis, R., Shand, J., Shaw, S., (2011). Integration in action: four international case studies. London. Nuffield Trust

World Health Organisation (2016) Strengthening integrated people’s health services. Resolution WHA69.24 Geneva. Switzerland.

Blog Article: Continuing care and emergency medical services: A collaborative approach for urgent end of life care in the community

Continuing care and emergency medical services: A collaborative approach for urgent end of life care in the community

Julia Arsenault MAHSR, NP; Carmel Montgomery MN, RN; Colleen Berean MHS, RN; Charlotte Pooler PhD, RN; Cheryl Cameron MEd ACP; Robert Sharman MA, RN, ACP; Ingrid de Kock DA, MBChB

Alberta Health Services. Edmonton, Alberta, Canada

Contact: julia.arsenault@ahs.ca

Introduction

The aim of palliative and end of life (PEOL) care is to relieve suffering and to improve the quality of life of people with a progressive life-limiting or life-threatening illness.  Increased supports and services are often required for this population, as symptoms can intensify near the end of life.  For palliative patients in the community, this may include emergency department (ED) visits and acute care admissions to manage symptoms or unexpected events.

Alberta Health Services (AHS) is an integrated provincial health system in Canada that encompasses acute care services, community care programs, and emergency medical services (EMS).  Within the Edmonton Zone of AHS, which serves a population of approximately 1.4 million in urban, suburban, and rural areas, PEOL care is provided within the community in diverse residential homes and facilities.  Although 75-85 % of Albertans prefer home as the place of care at end of life, 65-75 % of patients die in hospital (Alberta Service Alberta, 2012).  Palliative patients in the community are at risk for visits to the ED and acute care admissions when their symptoms and other palliative needs cannot be met in a timely manner.  However, the ED environment is usually not best suited to manage acute symptom issues of this patient population: ED visits may result in long wait times, EDs often lack privacy to have sensitive conversations, and the ED treatment focus may be incongruent with the patient’s goals of care.

Prior to the start of the initiative, chart reviews and a literature review were conducted. PEOL patients in the Edmonton Zone between 2009 and 2012 had an average of 2-4 ED visits and 1.6 acute care admissions in the last six months of life.  A detailed chart review of patients admitted to two community hospitals within a six week period demonstrated the primary reason for admission was shortness of breath, followed by weakness and/or falls.

There is scant information on collaboration or initiatives with paramedicine in the community. Mercandante et al (2012) reported characteristics of emergency calls to a palliative care team over 6 months for 689 patients in three home care programs: of the 118 first emergency calls, the three primary reasons were dyspnea, pain, and delirium. A collaboration amongst EMS and a community palliative network in France demonstrated respect of the care plan in 83% of emergency situations, compared to 40% without collaboration (Burnod et al., 2012).

Patients in the community are at risk of needing urgent care in the last six months of life.  An Australian study found that in the last 108 days of life, 96% of patients with a palliative diagnosis required a hospital visit and two thirds required hospital admission (Rosenwax et al, 2011).  In Ontario, Canada, 33% of the 91,561 patients who died of cancer between 2002 and 2005 visited the ED during the final two weeks of life (Barbera, Taylor, & Dudgeon, 2010).  However, as many authors have discovered, not all emergency visits are necessary, and there is interest in understanding both reasons for visits and potential for avoidance (Barbera et al., 2010; Burnod et al., 2012; Delgado-Guay et al., 2015; Mercedante et al., 2012; Rosenwax et al., 2011; Smith et al., 2012).

There are physical, emotional, spiritual, and social benefits of enabling patients and families to participate in the choice to remain in the home or to be transported to an ED.  To address present challenges and enhance capacity to meet future needs of the PEOL population, innovative strategies to support patients in the community are needed.

Innovation

In a report by the Health Quality Council of Alberta (2012), recommendations were made that “AHS continue with innovative solutions to support palliative care patients in their community setting” and provide “options for immediate care at home that can obviate the need to go to an emergency department, and support the patient and family’s decision to remain at home” (p. 11).  A protocol was developed by AHS Calgary Zone in which EMS assisted with management of unexpected pain crises in identified palliative patients in the community.  Based on the chart review and existing programs, a collaborative initiative was undertaken by AHS Edmonton Zone Continuing Care and EMS to manage PEOL patients at home when they experienced a symptom event that was urgent but not emergent.  The primary goals of this quality improvement initiative were to provide the right care at the right location and to meet the patient and family’s wishes. In addition, the initiative was expected to reduce unnecessary ED and hospital admissions; facilitate staff and physician engagement and collaboration; and identify frequent causes and outcomes of palliative patients’ needs for urgent care.

The PEOL Care and Treat in Place initiative was implemented in February of 2013. A pilot was launched in a limited geographic area with activation by either registered nurses (RN), nurse practitioners (NP) or registered respiratory therapists (RRT). Three months later, the initiative was expanded to include all PEOL patients receiving care in the community across the Edmonton Zone, with activation by Continuing Care regulated healthcare professionals for identified palliative patients who either received home care or were in assisted living homes.

The Continuing Care healthcare professional assessed the need for urgent care and called the EMS deployment manager, who dispatched an ambulance without lights or sirens. The paramedic arrived at the patient’s home and collaborated with the healthcare professional in providing care and treatment within their respective scopes of practice. If indicated, the paramedic obtained direction from an emergency consult physician who also had access to a palliative care physician on call.  When it was possible, the patient remained at home and ongoing care was managed by the healthcare professional.  Communication with the primary care provider (family physician or nurse practitioner) was ongoing and reactivation was possible until the necessary longer term resources were arranged (e.g. home oxygen or repeat medication administration). It is important to note that if the situation became emergent, transport to hospital was an option.

A multifaceted and collaborative approach to education was delivered to the Continuing Care and EMS staff and physicians.  A combination of written materials and face to face presentations were utilized. Tracking of events was done both manually and electronically, however, not all activations were captured in the data collection because reporting of the calls was dependent on front-line staff and appropriate coding by EMS.

Between June 2013 and December 2014, there were 110 known activations. The median time between these calls and patients’ death was 9 days, which demonstrates these patients were in the last stage of life. The majority of activations were by the RN in the patient’s home during a palliative symptom crisis, with an EMS response time of approximately 15 minutes. There were various reasons for calling EMS, such as nausea, delirium, and lift assistance. The most common reason was for pain (31%), followed by dyspnea (24%).  Treatments were consistent with a palliative approach to symptom management: opioids and oxygen were used for dyspnea; opioids for pain; intravenous or subcutaneous fluids and anti-emetics were used for dehydration and nausea. In accordance with patients’ preferences and symptom management, the majority of calls (60%) resulted in patients staying at home.  The calls which resulted in transport (40%) were a result of the healthcare professionals’ assessment and recognition of the need for emergency care and acute care resources; the paramedics collaborated to provide patient-centered care to ensure comfort prior to transport. Patients and family members who were treated and remained at home rated high satisfaction with the initiative by survey.

Discussion

As anticipated, the majority of symptoms and conditions did not require a visit to the ED. The requirement of a healthcare professional in the home limited the number of calls, however also facilitated clinical judgement and collaboration. Some RNs modified the approach by activating the initiative for treatment and transfer to the ED when they recognized that a patient required emergency care but not a “911” lights and sirens approach, which affected the percentage of those transferred. One of the most valuable outcomes of the initiative was due consideration and discussion of the patient’s wishes to have symptom treatment at home or be transported to hospital.

In summary, this initiative enabled collaboration and innovation among and across sectors, including community care programs, EMS, and primary care. As of April 2015, this initiative expanded across the province of Alberta and continues to evolve. Opportunities were created to enable palliative patients to remain at home or be transported to ED as appropriate.

References

Alberta Service Alberta (2012).  Alberta vital statistics: Annual review. Retrieved from https://open.alberta.ca/dataset/691ec9c3-35b6-4068-86b7-c04d85b073e2/resource/075a7313-ab27-4e05-94d9-0384bd1276f4/download/2664467-2012-AB-Vital-Statistics-Annual-review.pdf

Barbera, L., Taylor, C., & Dudgeon, D. (2010). Why do patients with cancer visit the emergency department near the end of life? Canadian Medical Association Journal, 182(6), 563-568.

Burnod, A., Lenclud, G., Ricard-Hibon, A., Juvin, P., Mantz, J., & Duchateau, F. X. (2012). Collaboration between prehospital emergency medical teams and palliative care networks allows a better respect of a patient's will. European Journal of Emergency Medicine, 19(1), 46-47.

Delgado-Guay, M. O., Kim, Y. J., Shin, S. H., Chisholm, G., Williams, J., Allo, J., & Bruera, E. (2015). Avoidable and unavoidable visits to the emergency department among patients with advanced cancer receiving outpatient palliative care. Journal of Pain and Symptom Management, 49(3), 497-504.

Health Quality Council of Alberta (2012).  Review of the quality of care and safety of patients requiring access to emergency department care and cancer surgery and the role and process of physician advocacy. Calgary, Alberta: Author.

Mercadante, S., Porzio, G., Valle, A., Aielli, F., Costanzo, V., Adile, C., ... & Group, H. C. I (2012). Emergencies in patients with advanced cancer followed at home. Journal of Pain and Symptom Management, 44(2), 295-300.

Rosenwax, L. K., McNamara, B. A., Murray, K., McCabe, R. J., Aoun, S. M., & Currow, D. C. (2011). Hospital and emergency department use in the last year of life: a baseline for future modifications to end-of-life care. Medical Journal of Australia, 194(11), 570-573.

Smith, A. K., McCarthy, E., Weber, E., Cenzer, I. S., Boscardin, J., Fisher, J., & Covinsky, K. (2012). Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Affairs, 31(6), 1277-1285.