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Interprofessional Education: Capitol Hill Briefing
Federation of Associations of Schools of the Health Professions
June 25, 2015
Capitol Visitor Center, Washington, D.C.
Thank you, Dr. Shannon.
I’m going to frame my remarks today in a bit of backward fashion, because I believe a discussion of interprofessional education has to be preceded by a discussion of interprofessional care. And that’s because high-quality care is the outcome we’re striving for. Interprofessional education is the means to achieving it.
Interprofessional care involves professionals spanning several disciplines working together on behalf of a single patient—nurses, nurse practitioners, physicians and physician assistants, pharmacists, dentists, social workers, community health workers, lawyers, and more.
And it’s important because there’s mounting evidence that this kind of team-based care improves patient outcomes—while reducing health care costs.
The IPE movement gained momentum about 15 years ago, when the Institute of Medicine released a report that shook the health care industry. IOM estimated that 100,000 Americans die each year from preventable medical errors. (That number’s since been revised up to about 400,000 preventable deaths a year.)
And while IOM cited a number of factors leading to this epidemic of errors, the authors laid most of the blame at the feet of a decentralized and fragmented health care system—essentially, a “non-system.” They said that when patients see multiple providers in different settings—none of whom has access to complete information—it becomes easier for things to go wrong.
But things don’t have to “go wrong” for this fragmented system to fail. Because in a fragmented system, things are simply less likely to “go right.”
IPE and Chronic Diseases
This is particularly true with patients suffering from chronic illnesses, who have multiple needs spanning many health and social services disciplines.
This is an important point: Team-based practice isn’t for every clinical encounter, but the more potential you have for complex, high-cost health care—the more patients you have who present with chronic diseases like asthma, diabetes, heart disease, hypertension—the more you need a collaborative team delivering that care.
People with chronic diseases are the heaviest users of health care. And when their diseases aren’t managed well, they’re our heaviest users of the most expensive health care—emergency and inpatient treatment.
But there’s evidence that patients with chronic illnesses receiving team-based care make fewer visits to the emergency department than those receiving traditional care. They suffer fewer complications. They’re hospitalized less frequently. They’re better able to manage their illnesses and maintain a normal routine.
And with growing workforce shortages in health care—shortages exacerbated by the rising incidence of chronic conditions—team-based care actually promises better access for the under-served. Because team-based care makes highly effective use of non-physician providers—like nurse practitioners, physician assistants, and pharmacists.
IPE and Social Determinants of Health
There’s a corollary here worth noting: The people most at risk of developing chronic diseases and dying from them are poor people. Poor people are most disadvantaged by the social determinants of health: economic stability; personal and public safety; education quality and attainment; access to housing, to transportation, to nutritious food, social supports, and quality health care.
I’ll give you an example of how an interprofessional team can make a difference with these vulnerable populations.
When I was at Johns Hopkins earlier in my career, I was president of a practice that provided pediatric services to children in their own homes. My colleagues in the Division of Endocrinology had an 8-year-old child whose diabetes was out of control. Wild swings in glucose levels meant repeated admissions to the ICU. The doctors couldn’t figure out what the problem was, so they asked me to send a nurse to the child’s home.
And that’s when we found out there was no electricity in the house. The utility had shut off their service. So the patient’s mother couldn’t keep the insulin refrigerated, as it needs to be. And when she was measuring doses in the kitchen, she couldn’t actually see how much she was drawing into the syringe and injecting into her child.
What we needed to do wasn’t medical at all. We needed to get the lights turned back on. And we needed a social worker who knows how to do that.
Once the electricity was restored, there were no more ICU admissions—which, by the way, cost taxpayers a lot more than a subsidized utility bill.
My university sits in a place of significant challenges—challenges of poverty, violence, drug dependency, disinvestment, and chronic disease.
You’re all well-acquainted with Freddie Gray, whose death in police custody two months ago sparked outrage in Baltimore. Mr. Gray grew up two miles from our campus, in a house with lead paint peeling off the walls. He and his two sisters had damaging levels of lead in their blood, which contributed to academic problems, behavioral problems, health problems.
And so I’m here to tell you that when you’ve got a child in the pediatric ICU, and you’ve treated all of his symptoms associated with lead paint poisoning … you can’t send him back into the home that made him sick in the first place. That child no longer needs a doctor; he needs a lawyer.
Patient-Centered Medical Homes
So now let me speak briefly about how interprofessional care is operationalized and incentivized.
A popular model is the Patient-Centered Medical Home. CareFirst launched one of the nation’s very first large-scale programs in 2011, covering more than 1 million patients in Maryland, DC, and Virginia.
Physicians and nurse practitioners are at the center of health care teams that provide coordinated care for the patients who need it most. These primary care providers collaborate with medical specialists and other professionals to align and track care for the sickest patients and those most at risk for future illness. Comprehensive care plans, directed by the PCPs, are implemented with the support of coordination teams based in the community—teams headed by a registered nurse.
A report out last July on the first three years of the program showed that individuals treated through patient-centered medical homes had fewer hospital admissions than those receiving traditional care within the network (6 percent), spent fewer days in the hospital (11 percent), had fewer hospital readmissions for all causes (8 percent), and logged fewer outpatient facility visits (11 percent).
These drops in utilization are important for two reasons: 1) They point to better care delivery and better patient outcomes; and 2) They underpin significant cost savings. In fact, CareFirst cut the overall growth rate in medical spending from an average of 7.5 percent per year—in the five years preceding the program’s launch—to 3.5 percent in 2013.
More than 80 percent of primary care providers in the CareFirst network participate in the voluntary program. For the time and effort they invest in coordinating patient care, they get an across-the-board increase in their fee schedule, and additional fees for developing care plans for patients with chronic or multiple conditions. Plus, they get incentives—in the form of higher reimbursements—that are tied to care-quality indicators and cost savings.
CareFirst is good news for those of us who believe in interprofessionalism.
But it remains that high-functioning teams don’t just happen. You can’t throw people together and tell them to play like an orchestra.
We need to prepare the next generation of health and human services professionals to function like a team—to communicate effectively; to understand what each profession brings to the patient and client setting; to be open to the perspectives and contributions of others.
And complicating matters is that, to do this well, we need to educate the educators. Because they, themselves, haven’t been trained in this model.
The faculty in universities like mine need development support and development time to be educated in interprofessionalism. We need to build space and flexibility into the curricula—and into the faculty workload—to move the model forward.
At UMB, we have students in six professional schools—medicine, nursing, pharmacy, dentistry, social work, and law—as well as a graduate school. We include all of these students in training that helps them work together on behalf of their patients and clients. We bring students together in simulation labs, where they can practice team-based care on computerized mannequins. We have them create care plans for standardized patients—actors who are trained to portray real patients, with real illnesses—and then provide feedback on how the teams did in terms of communication, coordination, empathy, and efficiency.
And students get a feel for the real thing through my weekly President’s Clinic. Every Tuesday afternoon, students from each school join me in the hospital-based clinic to deliver team care to children with gastrointestinal disorders. It’s a terrific training ground for interprofessionalism.
But the fact is we can see only about a half-dozen patients a day.
We need to do more.
We need to add to the evidence base validating the interprofessional model. We need to persuade the people who pay for health care—whether that’s patients, insurers, or the federal government—that interprofessionalism is every bit as good as I say it is.
IPE Pilot Programs
To do this, we need to support pilot programs that include learners. We need to create clinical models that serve as platforms for educating students and staff while demonstrating the efficacy of interprofessionalism. Because if we’re not proving its value, then education is rather beside the point.
UMB has submitted to the Maryland health department a proposal for this kind of clinical model. It would operate in nearby Prince George’s County, whose residents suffer high rates of chronic disease.
The pilot involves health care teams—teams that include our students—working collaboratively to deliver comprehensive care in coordination with physicians in the community. The model mimics the CareFirst program—a medical home that integrates all primary, acute, behavioral health, and long-term services—the same model promoted by the Affordable Care Act.
I absolutely believe that this is how we’ll move the needle on population health, and that this is how we’ll finally bend the cost curve and contain runaway health care spending.
I can tell you a hundred more stories where interprofessional practice made all the difference in a patient’s health and a family’s well-being. But the representatives you serve don’t need anecdotes. They need an evidence base. And we need robust, high-quality pilot programs—grounded in clinical care—to provide it.