Christine Arenson

Interprofessional education: a review and analysis of programs from three academic health centers.

The past decade witnessed momentum toward redesigning the U.S. health care system with the intent to improve quality of care. To achieve and sustain this change, health professions education must likewise reform to prepare future practitioners to optimize their ability to participate in the new paradigm of health care delivery. Recognizing that interprofessional education (IPE) is gaining momentum as a crucial aspect of health care professions training, this article provides an introduction to IPE programs from three different academic health centers, which were developed and implemented to train health care practitioners who provide patient-centered, collaborative care. The three participating programs are briefly described, as well as the processes and some lessons learned that were critical in the process of adopting IPE programs in their respective institutions. Critical aspects of each program are described to allow comparison of the critical building blocks for developing an IPE program. Among those building blocks, the authors present information on the planning processes of the different institutions, the competencies that each program aims to instill in the graduates, the snapshot of the three curricular models, and the assessment strategies used by each institution. The authors conclude by providing details that may provide insight for academic institutions considering implementation of IPE programs.

Potentially inappropriate prescribing for elderly patients in 2 outpatient settings.

Research has shown a high prevalence of potentially inappropriate medication prescribing (PIP) for elderly patients in outpatient settings, but little is known about whether a physician’s practice setting influences prescribing attitudes. This study examines the prevalence of PIP among elderly patients in 2 out-patient practices, 1 located in a senior citizens center and 1 in a general family medicine clinic. The authors conducted a retrospective chart review of a random sample of 50 individuals aged 65 years or older from each practice. The 2003 version of the Beers criteria was used to identify PIP. Results show that some one fourth of the elderly sampled in both practices had 1 or more incidents of PIP. The most common potentially inappropriate drug classes prescribed were psychotropic agents and anti-inflammatory drugs. Demographic patient variables were not significantly associated with PIP. This study suggests that PIP may be prevalent across physician groups.

Development of a comprehensive multidisciplinary geriatric oncology center, the Thomas Jefferson University Experience.

BACKGROUND The proportion of older patients with cancer is expected to grow exponentially in the next two decades. This population has large heterogeneity and it is well known that chronologic age is a poor predictor of outcomes. Research has shown that these patients are best served with a Comprehensive Geriatric Assessment (CGA) to formulate individualized treatment plans for better outcomes. However, the best model for CGA has yet to be determined. MATERIALS AND METHODS Our objective was to develop a highly functional model for the establishment of a comprehensive multidisciplinary geriatric oncology center in the setting of a university based NCI-designated cancer center. Each patient is evaluated by medical oncology, geriatric medicine, pharmacy, social work and nutrition. Expert navigation is provided to enhance the patient experience. At the conclusion, the inter-professional team meets to review each case and formulate a comprehensive treatment plan. The patient is classified as Fit, Vulnerable, or Frail based on the complete CGA. RESULTS The average age of patients seen was 80.7 with the most common diagnoses being breast, colorectal and lung cancers. Twenty four percent of patients were determined to be Fit, 47% Vulnerable, and 29% Frail. Twenty one percent of patients determined to be Frail by CGA received an ECOG score of 0-1 by the oncologist. Our pharmacists made specific recommendations in over 75% of patients and social work provided assistance in over 50% of patients. CONCLUSIONS We were able to observe some interesting trends such as potential discordance with ECOG score and assessment of Fit/Vulnerable/Frail but due to limitations in the data, this paper is not able to illustrate definitive correlations. Several challenges with the development of the clinic include 1) patient related issues, 2) navigation, 3) financial reimbursement, 4) referral patterns, and 5) coordination of care during office hours. We feel that we have been able to establish a model for a comprehensive multidisciplinary geriatric oncology evaluation center in the setting of a university based cancer center.

The (stalled) progress of interprofessional collaboration: the role of gender

Abstract Researchers have demonstrated that team-based, collaborative care improves patient outcomes and fosters safer, more effective health care. Despite such positive findings, interprofessional collaboration (IPC) has been somewhat stunted in its adoption. Utilizing a socio-historical lens and employing expectation states theory, we explore potential reasons behind IPC’s slow integration. More specifically, we argue that a primary mechanism hindering the achievement of the full promise of IPC stems not only from the rigid occupational status hierarchy nested within health care delivery, but also from the broader status differences between men and women – and how these societal-level disparities are exercised and perpetuated within health care delivery. For instance, we examine not only the historical differences in occupational status of the more “gendered” professions within health care delivery teams (e.g. medicine and nursing), but also the persistent under-representation of women in the physician workforce, especially in leadership positions. Doing so reveals how gender representation, or lack thereof, could potentially lead to ineffective, mismanaged and segmented interprofessional care. Implications and potential solutions are discussed.

Evaluation of the Chronic Disease Self-Management Program with low-income, urban, African American older adults.

A 1-group pretest–posttest design to assess for changes in outcomes at 10 weeks and 6 months was the method used to evaluate the standardized 6-session Chronic Disease Self Management Program (CDSMP) with low income, urban African American older adults. Participants included 153 older adults (primarily African American) with 1 or more chronic health conditions. Classes were provided in the community at senior citizen centers, senior housing, and churches. Significant improvements were noted in selected areas at 10 weeks and 6 months after the program completion. The CDSMP was feasible and well-received with the older adults who participated in the study. This study was funded by The Barra Foundation, Inc., Wyndmoor, Pennsylvania.

THE IMPORTANCE OF ADVANCE DIRECTIVES IN PRIMARY CARE

The advance directive has been acknowledged widely by patients and physicians as a desirable tool to promote patient autonomy at the end of life. Rates of completion of advance directives, however, remain low among all segments of the population. Significant patient and physician barriers to completion of advance directives are considered. Legal and ethical principles of advance directives, as well as some practical means of overcoming barriers to these important discussions, are reviewed.

The health mentors program: three years experience with longitudinal, patient-centered interprofessional education.

Abstract Increased emphasis on team care has accelerated interprofessional education (IPE) of health professionals. The health mentors program (HMP) is a required, longitudinal, interprofessional curriculum for all matriculating students from medicine, nursing, occupational therapy, physical therapy, pharmacy, and couple and family therapy. Volunteer lay health mentors serve as educators. Student teams complete four modules over 2 years. A mixed-methods approach has been employed since program inception, evaluating 2911 students enrolled in HMP from 2007 to 2013. Program impact on 577 students enrolled from 2009–2011 is reported. Two interprofessional scales were employed to measure attitudes toward IPE and attitudes toward interprofessional practice. Focus groups and reflection papers provide qualitative data. Students enter professional training with very positive attitudes toward IPE, which are maintained over 2 years. Students demonstrated significantly improved attitudes toward team care, which were not different across programs. Qualitative data suggested limited tolerance for logistic challenges posed by IPE, but strongly support that students achieved the major program goals of understanding the roles of colleagues and understanding the perspective of patients. Ongoing longitudinal evaluation will further elucidate the impact on future practice and patient outcomes.

Transforming chronic illness care education: A longitudinal interprofessional mentorship curriculum

Despite the growing burden of chronic disease globally, a number of reports have documented the failure of our health care systems to provide quality care for patients with chronic illness. Interprofessional education (IPE) is widely advocated as a key element to promote effective, redesigned health care and is increasingly recommended to develop skills in team-based, patient-centered chronic illness care. A growing body of literature now documents successful strategies for incorporating IPE in health professions education. However, as recently as 2008, a comprehensive review identified only six studies documenting IPE’s impact on patient-centered outcomes (Cameron et al., 2009). In a review of the literature, Reeves et al. (2010) found that ‘‘further rigorous mixed method studies of IPE are needed to provide a greater clarity of IPE and its effects on professional practice and patient/client care.’’ (p. 230) Recognizing the need to train students in team-based care, an interprofessional team of faculty at our university developed a longitudinal patient-centered team-based curriculum that builds on senior mentor programs and uses the Chronic Care Model (Bodenheimer, Wagner & Grumbach, 2002) as the conceptual framework. Senior mentor programs were initially designed to deliver geriatric education to medical students and to promote patient-centered care (Eleazer, Wieland, Roberts, Richeson & Thornhill, 2006). Using patients as educators is gaining recognition as a strategy to deliver patient-centered education (Towle et al., 2010). The Chronic Care Model is a new model of health care delivery redesign that promotes collaboration between an informed, activated patient and prepared, proactive health care teams (Bodenheimer et al., 2002). Applying theChronic CareModel to our curriculum, the Health Mentor represents the informed patient/teacher and the students are developing practice teams. The purpose of this study was to perform qualitative analysis of student reflection essays to assess the impact of a longitudinal mentor with a chronic condition on the training of future health care teams.

The Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC): development and multi-institution psychometric data

Abstract This study was designed to develop a psychometrically sound instrument to measure attitudes toward interprofessional collaboration in health profession students and practitioners regardless of their professions and areas of practice. Based on a review of the literature a list of 27 items was generated, 12 faculty judged the face validity of the items, and 124 health profession faculty examined the content validity of the items. The preliminary version of the instrument was administered to 1976 health profession students in three universities (Thomas Jefferson University, n = 510; Midwestern University, n = 392; and Monash University, n = 1074). Twenty items that survived the psychometric scrutiny were included in the Jefferson Scale of Attitudes Toward Interprofessional Collaboration (JeffSATIC). Two constructs of “working relationships” and “accountability” emerged from factor analysis of the JeffSATIC. Cronbach’s α coefficients for the JeffSATIC ranged from 0.84 to 0.90 in the three samples. Women obtained significantly higher JeffSATIC mean scores than men. Medical students obtained lower mean score on the JeffSATIC than most other health profession students at the same university. Psychometric support from a relatively large sample size of students in a variety of health profession programs in this multi-institutional study is encouraging which adds to the credibility of the JeffSATIC.

Racial differences in the recognition of cognitive dysfunction in older persons.

We assessed the influence of race and education on informants’ reports of cognitive decline in 252 community-residing older persons who were receiving services from senior health agencies. An expert consensus panel made diagnoses of normal cognition, cognitive impairment no dementia (CIND), and dementia based on clinical evaluations and standardized neuropsychological testing (using both population and race-adjusted norms). Informants were interviewed using the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). Informants of black participants with CIND reported less cognitive decline (lower IQCODE scores) than informants of white CIND participants [3.03 (0.61) vs. 3.23 (0.41); t (117)=2.12, P⩽0.036] even though there were no significant differences in the participants’ functional and neuropsychological impairments. An analysis of covariance which controlled for informant education indicated that this difference in IQCODE scores was attributable to the fact that black informants had fewer years of education than white informants. There was no statistically significant difference in IQCODE scores for black and white participants with dementia [4.0 (0.7) vs. 4.3 (0.7); t (67)=1.37, P=0.177]. We conclude that racially determined differences in perceptions of early cognitive decline and education may influence informant ratings of older persons. These differences may contribute to disparities in the detection and treatment of cognitive disorders in older black persons.