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Interprofessional Education and Collaborative Practice: A Conversation with Lucinda Maine

Lucinda Maine for website

Lucinda Maine, Ph.D., R.Ph., Executive Vice President and CEO of American Association of Colleges of Pharmacy (AACP), was recently interviewed by Clyde Evans, Ph.D.,AAL’s Senior Consultant and Board of Directors Member of American Interprofessional Health Collaborative. They talked extensively about interprofessional education (IPE) and collaborative practice, in which Dr. Maine touched upon the unique roles pharmacists are playing in IPE, the different factors that have fostered the recent explosion of IPE, and the efforts of some key organizations in the contemporary IPE movement.

Dr. Lucinda Maine is the Keynote speaker at this year’s AAL Chairs & Academic Administrators Management Program (CAAMP). In the interview, she also talked about why it is important for this year’s CAAMP participants to learn about IPE and how they can get involved. CAAMP 2014 will be held at the Georgia Tech Hotel and Conference Center in Atlanta, Georgia on July 17-19, 2014. For more information, please visit www.aalgroup.org/CAAMP.

Interview Excerpts:

Evans: How did you come to your interest in IPE and collaborative practice?

Maine: At a fundamental level, I believe that medication use is, and always will be, what I’d like to call a “team sport”. Early in my career I was interested in drug use in the elderly—and caring for the elderly, especially complex older adults, should be a team effort. Just think of the number of specialists, primary care providers, and other caregivers involved in caring fora complex older patient taking too many drugs. And so, innately, there’s probably always been a part of my clinical mindset that says as a pharmacist I have a lot of value to add to unscrambling this kind of drug regimen and supporting this kind of patient. As a result, it’s really the team that I’m supporting in providing the best care possible. So while I never imagined that I would spend a good portion of my time over these last few years working elbow-to-elbow with other colleagues to advance the IPE and collaborative practice agenda, I’m sure glad I have.

Clyde: I’m glad, too. What you said about medication and drug use is very interesting, because I wanted to ask your opinion about the unique role you see for pharmacists in interprofessional education and collaborative practice.  I’m reminded of a study several years ago that found the presence of clinical pharmacists in a hospital significantly reduced medication errors. So what you said about medication being a “team sport”—especially for the elderly–really rings true to me.

Maine: It really does. Somebody asked me in a recent IOM forum about why he rarely noticed pharmacists being “bristly” with their medical colleagues and vice versa—especially when compared to the long-running and often-discussed tension between physicians and nurses. This is due, in part, I believe, to the fact that pharmacists rarely aspire to independent practice, because so many different care givers are engaged in the medication use process.

Evans: It’s like medications are always in the service of “something else”, a higher goal—viz., the improved health of [or the best quality care for] the patient–and attending to medications helps the entire team to keep that “something else” in focus.

Maine: And pharmacists can really help pull a team together around a common “enemy”, which is a complicated drug regimen.

Evans: Now that you are working elbow-to-elbow with colleagues in advancing IPE and collaborative practice, how do you find your colleagues accepting pharmacists into this team sport?

Maine: I would say we are beyond the tipping point in terms of the recognition of pharmacists by those people who really understand team-based care. For those who have not seen the pharmacists in action recently and who still have the stereotype of pharmacists hunched over a computer screen at a CVS or any other community practice, it can be difficult to picture a pharmacist being involved in the delivery of team-based care. Two examples will show how pharmacists are being integrated into this work.  Yesterday I was on an executive call for the Patient-Centered Primary Care Collaborative—which has done a lot of work on medication management in the patient-centered medical home. Participants were from multiple disciplines, including pharmacy. The Collaborative has dedicated the month of May to a focus on medication management—offering two webinars this month, one from the VA, and one from an integrated care delivery system in Minnesota, describing what the medication management practice model looks like and how it relates to team-based care. During a second call yesterday, again with a very diverse set of participants, I was asked to describe how the evolution in pharmacy education has kept pace with the need to prepare pharmacists to be more clinically-focused and to work in teams. Several participants described practice models they are involved with in which pharmacists are working as part of the team. This kind of pharmacist involvement is much more mainstream today. It’s worth remembering that the PharmD program–which really matured in the 70s and 80s—is not new anymore. All PharmD programs have been around for more than 10 years now. Half of the licensed pharmacists in the country now have PharmDs. So the chances are pretty good that a current physician in training (M3, M4, or resident), has probably worked at some point in an environment that did provide exposure to a mature clinical pharmacist role. So the very idea of an engaged clinical pharmacist working side-by-side with physicians is no longer out of bounds.

Evans: Not only it is no longer out of bounds, it may be that pharmacists are in a unique position, precisely because they do not come to the team–rightly or wrongly—with the kind of strained relationship baggage you described earlier.

Maine: In fact, I have been using this very idea in my commencement address this year. I started out by talking to the students about keeping change in perspective, and shared with them that up until 1969 the professional codes maintained by the American Pharmacists Association included the following tenant: “a pharmacist should never divulge the purpose of a prescription or its composition to a patron”. And that shows you what the physician-pharmacist relationship was at that time. Since those days, we have made a 180 degree turn in our social obligation as an ethnical profession. There are still some physicians who trained and practiced in that era, no question about it. So we’re not completely there yet. But younger (and even mid-career) physicians these days, have more than likely had interactions, hopefully positive, with pharmacists as colleagues on their team.

Evans: Reminds me of that old Virginia Slim ad: You’ve come a long way, baby!

Maine: Come a long way, baby. You’re right about that.

Evans: I know you have been quite engaged with colleagues to advance interprofessional education and collaborative practice. I’ve been struck by how much this activity has exploded in recent years—in spite of the fact that some of our most respected colleagues have been working on it for decades. Now all of a sudden, it’s the fashion.  Why is that?  Do you have any theories?

Maine: I think it’s a confluence of different forces. The first force is the emphasis–for nearly a decade and half now–on patient safety and quality. This was catalyzed by the 2003 IOM report, Health Professions Education: A Bridge to Quality, which presented the results of a comprehensive study on the future of health professions education. The IOM declared that the health professionals of the future need to be prepared to be patient-centered, evidence-based, working in teams, and supported by informatics and quality improvement. Once those recommendations were released, they began to influence accrediting standards across the professions. In fact, the AACP House of Delegates adopted those recommendations and incorporated them into the accrediting standards in pharmacy by 2005. Nursing has also made great strides to integrate the IOM recommendations into their accrediting Essentials.  So there has been a nation-wide recognition of a new and compelling rationale for health professions education that is linked to the improvement of the quality and safety within the care delivery system.

A second factor driving the explosion of interprofessional education and collaborative practice is the changing models of health care organization and financing. One expression of those changes is the so-called Triple Aim of improved healthcare outcomes, reduced costs, and improved experience of healthcare. It is clearer than ever that we really need to overcome our policies and our payment practices. We’ve seen the coalescence of medical practice into more integrated care delivery systems. As Barbara Brandt has said, “we’ve got to create the nexus between growing demand for team-ready clinicians and the nature of the graduates we produce across the health professions.”

Another driver has been the inclusion of interprofessional expectations within accrediting bodies across nearly all of the core disciplines. As a result of these multiple drivers, we have “pull factors” and “push factors”. And finally, lo and behold, it seems that interprofessional education and collaborative practice are more satisfying both for patients and for clinicians working together in teams.

Another factor propelling the current interest in IPE is the fact that there are now enough models of IPE and collaborative practice in existence(demonstration projects, clinical care in the more matured health systems, etc.) that we can show people what IPE and CP could actually look like and how they really work–rather than just talking about it.

One final factor helps explain the explosive nature of what’s happening. If medicine (as a discipline) were not actively participating in all this, we would never have the credibility needed for people to believe that this actually is going to work. And so, the commitment of Darrell Kirsch and Carol Aschenbrener (AAMC) and Steve Shannon (AACOM) has been absolutely essential to work of the Interprofessional Education Collaborative. Two other groups have also played key roles: The American Interprofessional Health Collaborative and its counterpart, The Canadian Interprofessional Health Collaborative—which together sponsor the biennial Collaborating Across Borders IPE conference.

Evans: I agree with you completely about the significance of the physicians being on board. In the old days, even with successful IPE activities, a common complaint was that “docs don’t play well with others—if at all.” Physicians (faculty, more so than students) were often the last ones who wanted to participate. Fortunately, that has changed dramatically and the three people you mentioned have been critical in making all this work. Without them we’d be nowhere near where we are today.

Maine: A key question, of course, is about sustainability. Two things will help with that: accreditation pressure and pressure from employers to produce graduates who are truly ready to practice, i.e., appreciative of the core characteristics of teamwork and collaboration and skilled in communicating with each other on behalf of the patient.

Evans: I know that the National Coordinating Center for Interprofessional Education and Collaborative Practice is trying to harness all those various drivers.

Maine: We must have all the incentives aligned, otherwise teams will fail. Recently, Geisinger Health System announced that it is abandoning its nurse care coordination services, because they could not afford them. The payments were just not aligned with that level of care. This is sad because we know what would happen in the absence of care coordination, but they couldn’t find a way financially to continue those proven services.

Evans: Speaking of reimbursement, are there pieces of the payment system that we still need to figure out in order for IPE and collaborative practice to be successful?

Maine: I believe that sorting out the concept of bundled payment will be very important. Some models have created a way to allocate resources for care coordination. While these are important accomplishments, I still believe that outmoded payment systems are our primary impediment to progress in collaborative practice– and will also represent an impediment to progress in education as well.

The care delivery system is under such stress that our capacity for clinical education is being threatened—and this is happening all across the health professions. At a Macy meeting last year, one of the premiere integrated care delivery systems described one of its most exemplary team care units. When asked “what roles do learners play in that care delivery unit?” the speaker looked at us and said: “Oh, we can’t let learners in this unit. It would be too inefficient. It would negatively influence the care by the team.” I wanted to scream: “Don’t tell me that I’m not sending team-ready graduates if you are not letting them learn from your best teams!” So these stresses are very real and have to be addressed.

One way to address that, of course, is with simulation. Simulation has an important role to play, but is idealized and can never substitute completely for what care actually looks like out there in the real world. The same applies to learning teamwork.  Some of this learning can be done didactically, some in the laboratory, and some in extracurricular work the students do in student-run and free clinics. But we have to have more authentic teams in actual practice ready and able to simulate team of learners in order to really equip our learners.

AACP has recently embarked upon something that we hope will not only be really fun but will also add another dimension to the learning opportunity. We’ve created a company that’s in the process of developing our first multi-player, serious educational game, that’s underpinned by the IPEC core competencies across health professions learner space. We think it has post-graduate learner applications as well as possibly K-12.

Evans: This will all be online, I assume.

Maine: All up in the cloud. All you need is an Internet connection.

Evans: Wow. That’s intriguing. Any idea how soon this will be available for everyone?

Maine: Yeah, Alpha and Beta testing in the second half of 2014, and to market sometime in the first quarter of 2015.

Evans: That train has left the station!

Maine: Yes, we are seriously engaged. We reached out to a content expert panel and to our colleagues across the health professions space. We have had all those brands of players involved in some of the earliest conceptual work. Then we are in dialog with all of our partners, IPEC, FASHP, about marketing opportunities, and potentially even opportunities to invest in the company itself. Those are early conversations.

Evans: This is really outside-the-box thinking. You know Google might want to “acquire” you at some point.

Maine: Yes, but for how many billions of dollars? (laughing)

Evans: A moment ago you made a distinction between practice and education.Could you say a little more about how you see the difference, the connection, or the overlap between interprofessional education and collaborative practice?

Maine: I think that the most direct connection comes from answering the question: “why are we even worried about IPE in the first place?” It is because of our collective belief that much care in the future will be delivered in a team-based, collaborative practice model. So if collaborative practice were not rising in prominence and importance, there would be virtually no reason for us to invest anything like our current level of energy in trying to incorporate IPE meaningfully to the curriculum. Similarly, I would have to say that all efforts to expand collaborative practice models will be less successful if we are not producing the right kinds of young clinicians ready and eager to practice in those models. We are desperate to have access to authentic care delivery systems or collaborative practices that are in play, because it’s just vitally important to the rigor and effectiveness of our education.

Evans: I’m going to paraphrase what you just said and you tell me if I’ve gone too far. “It’s not that IPE is worth doing in and of itself, it’s more like IPE is a means to an end, with that end being our conviction that collaborative practice is where we want to be.”

Maine: I will even go a step further: it’s our conviction that collaborative practice is the model best in line with our aspiration for patient safety and quality of the healthcare delivery system.

Evans: Which takes us right back to the IOM report, doesn’t it?

Maine: Yes it does.

Evans: It’s really gratifying to see that over these 10+ years the substance of that report has really gotten into the thinking of all of us and our colleagues.

Maine: In our DNA.

Evans: Especially for the students who are coming up now. Their professional DNA is just getting created–unlike some of us older ones who had to be “born again” to see the light. This collaborative way of practice is what today’s students hopefully are learning from Day 1.

I’m going to change the subject a bit now. You will be speaking at AAL’s Chairs and Academic Administrators Management Program (July 17-19, 2014). As you know, these participants are mostly mid-level managers like department chairs, academic administrators, etc. What does that group need to know about IPE—assuming they will not be the front-line faculty teaching IPE courses or advising students?

Maine: Depending on how the university or the institution has elected to organize its work in this area, a department chair could be thrust into the main stream, at least in planning for where the resources for IPE come from and where the institution is most likely to succeed in integrating IPE into the curriculum map. At a minimum, I will characterize the department chairs as essential to the culture and even the sense of urgency that IPE is the “right thing to do”. They may play an even more meaningful role Department chairs could find themselves on the academic health center-wide planning group–although this role is more likely to be filled by the associate dean for education or academic affairs. Department chairs have a key role to play in encouraging faculty development and in creating the rewards and recognitions that are so important to changing faculty into willing collaborators–when the incentives are lined up right. So I see a number of very strategic roles for department chairs to play. Even basic sciences department chairs can be important in appreciating the relevance of IPE to the clinical career of their students.

Evans: Suppose some of the CAAMP participants come from universities where there really is very little, if anything, going on with IPE. If those participants “get the bug” and want to see IPE advanced at their institution, what advice would you have for them about getting started?

Maine: It’s a really good question. First of all, if they are starting from scratch, they need not feel lonely. There really are now some excellent repositories of resources including MedEd Portal, which includes the iCollaborative collection of organizational tools and strategies for enhancing the culture of quality across both clinical care and education; the Directory and Repository of Educational Assessment Measures (DREAM); and the National Center for Interprofessional Practice and Education’s Resource Exchange and Literature Compendium. So there are meaningful resources that describe different types of activities and evaluations of those activities. So newcomers don’t have to feel like they are out there on an iceberg, all alone. Second, I would certainly encourage them to consider the faculty development opportunities of the IPEC Institute. There will be at least two institutes per year for the foreseeable future. There have been six institutes so far and the evaluations (including the longitudinal evaluations) suggest that for teams that are really ripe and ready, the Institute can really accelerate their progress. You saw that same phenomenon when you did the two IPE Institutes for teams (with a focus on the Healthy People objectives) sponsored by the Association for Prevention Teaching and Research. These team-based institutes are a powerful model for change.

But recently those of us within IPEC have been asking a different question: “what leadership did it take to make successful programs successful? What was the leadership component to that success model?” And it became pretty clear to us that there is an essential “top-down” component to IPE leadership. At the same time, a “bottom-up” leadership component is also necessary. That means you not only need one (or more) institutional leaders to promote IPE; you also need a set of willing faculty across all the health sciences disciplines present, to become a set of collaborators ready and willing to make IPE a reality. In order to do that, those faculty will need certain resources, including release time that only institutional leaders can provide.

So I would advise a person just starting out to sit down with some of the institutional leaders and also with some of their peers across the spectrum of health professions learners. Finally, I would tell them to think outside their own institution.  It turns out that only about 40% of pharmacy programs are in academic health centers—which means there are many places where pharmacy is the only health science. (The comparable figure for baccalaureate nursing programs is around 20 %.)Thus we sometimes have to be creative in finding partners for IPE activities—often outside our own institution.  One of my AACP programs is the St. Louis College of Pharmacy, celebrating 150 years. But Pharmacy is the only discipline they educate. It happens that they have a huge commitment to IPE, and have pursued that interest not only with Washington University (which surrounds them physically), but also St. Louis University. Neither institution has a pharmacy program but both were eager to incorporate pharmacy students into their own IPE efforts. So there are opportunities to create inter-university collaborations as well as intra-university. Does that increase the level of difficulty? Probably, though I’m not certain.

Evans: As I listened to your thoughts about IPE institutional leadership, I visualized a “pincer” movement, coming from two different directions, in which there is support from the top and support from the bottom. Either one without the other has a much smaller chance of success. I hope that’s not too great an over-simplification. It is vital to have people at the ground level willing to devote themselves to these activities because they are passionate about it; it is also vital to have someone at the top who can set the vision and direction and direct resources as needed.  Is there anything else from the current dialog and discussion about IPE on which you think we haven’t yet “seen the light” or just haven’t gotten around to addressing?

Maine: There is one big area.  I think we’re getting around to addressing it, and it certainly hasn’t been ignored, but the area where we may be most lagging behind–apart from healthcare payment reform–is the tools for assessment: formative and summative assessments, learner assessment and program assessment. Some assessments exist and more are coming. I’m sure you are aware of the Interprofessional-Professionalism work that has been chugging along now for nearly 10 years. Part of their chugging is that they are really trying to do some validation right now, which is so critically important for certainly anything that is high stakes. So while we are eager to make progress, we also recognize that it takes time and resources to develop and validate really good, useful, meaningful tools.

Evans: I know that the key leaders in the field share your concern and agree that this is a gap we need to fill. I am confident that in time we will get there, but for so long our “evidence” has been mostly anecdotal, customer satisfaction feedback from students and faculty who like IPE.  That is wonderful, but we have to get to that next level. Any other things about interprofessional education or collaborative practice we haven’t talked about that you think are really important?

Maine: I haven’t mentioned this yet, but you probably know that every Monday at 8am our six IPEC colleagues are on the phone talking about IPE and collaborative practice. To me that shows that we are modeling precisely the interprofessional and collaborative values and behaviors that we’re hoping our colleagues will emulate.

Evans: That kind of commitment, from six very busy people, is really impressive.

Maine: We just love it so much.

Evans: One last question: what is the take-home message about IPE that you’d like CAAMP participants to walk away with?

Maine: I would tell them to “damn the torpedoes; full speed ahead”.

Evans: What are the torpedoes?

Maine: Embracing the fact that IPE is real, is sustainable, is not going away, and will need to be manifest in didactic, laboratory, experiential, and extra-curricular components that are meaningfully integrated into our curricula to touch all of our learners and not just a few who elect to participate.

Evans: Thank you.

Maine: It’s been my pleasure.

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Dr. Tandra Atkins

NYU Lutheran Medical Center

"The AAL team has enhanced my knowledge and decision making tools, objective analysis, and creativity in a radically changing health care environment."