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Meeting the Challenges of Training for Interdisciplinary Care
Archives of Psychiatric Nursing 28 (2014) 355–356
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu
Guest Editorial
Meeting the Challenges of Training for Interdisciplinary Care
Nearly all health care professionals and health policy experts accept the value of interdisciplinary and integrated care, which is one of the hallmarks of President Obama's Patient Protection and Affordable Care Act (ACA) [P.L. 111-148]. There is agreement at the highest levels of national professional associations. In 2009, six national education associations of schools of the health professions established the Interprofessional Education Collaborative (IPEC) to advance substantive interprofessional learning experiences to prepare clinicians for the team-based care of patients, including the development of core educational competencies. IPEC members include allopathic and osteopathic medicine, dentistry, nursing, pharmacy, and public health. Psychology, physical therapy, optometry, and podiatry are also active partners in this visionary effort. Interdisciplinary training is not a new concept. Rusnack's (1977) astute observation holds true today: “The difficulties appear to lie in the actual implementation of interdisciplinary practice and education” (p.104). Within mental health, there had been a concerted effort in California to develop a new doctor of mental health degree, which ultimately was unable to overcome resistance from the state's medical licensing board (Wallerstein, 1991). Change always takes time, often far longer than one might initially expect. There can be no question that from a quality of care frame of reference, as well as from a cost–benefit orientation, interdisciplinary care improves patient outcomes, reduces costs, and improves clinician and patient satisfaction. Today, our nation spends more on health care than any other industrialized nation, with disappointing, if not unacceptable, results (The Commonwealth Fund, 2013). Serious mental illness is estimated to cost the United States economy nearly $200 billion in lost earning annually (DeLeon, Convoy, & Rychnovsky, 2013; Insel, 2008). Chronic mentally ill patients and those who require substance abuse treatment are often treated using a team approach, thereby providing an excellent venue for interdisciplinary training. Within the military and veterans' health care systems, there is clear leadership support for collegially utilizing the clinical expertise of every discipline to focus upon patient-centered and preventative-oriented care—historical private sector reimbursement restraints, notwithstanding. Interdisciplinary training is not meant to replace or “over load” an already heavy mental health curriculum. Rather, the underlying objective is for the various disciplines to integrate selected elements of their expertise into existing courses, thereby enriching and expanding the options for patients and providers. Some might well perceive this approach as challenging the historical “medical hierarchy” of mental health, raising the fundamental question regarding the appropriateness of any particular discipline automatically serving as “captain of the ship,” The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the United States Government. http://dx.doi.org/10.1016/j.apnu.2014.08.001 0883-9417/Published by Elsevier Inc.
instead of focusing upon the competency of individual clinicians. The overarching philosophy is encouraging all providers to expand their awareness to create greater value for their patients. By enriching the curriculum with each discipline's unique knowledge and expertise, an integrated and truly holistic approach to patient care should evolve. Tomorrow's providers must cease functioning like the fable's “blind men who only see and treat their part of the elephant,” rather than seeing the whole patient. Throughout mental health professional programs, interdisciplinary training is often referred to as two or more disciplines sharing a required class at the same time in the same room. This classroom interaction should yield a culture of civility and respect among the participating professionals. Although civility and respect are important, they do not fully embrace interdisciplinary training. Our vision at USUHS is several disciplines collaborating to teach through a shared curriculum, shared decision making, and similar goals. In mental health, this would result in an amazing curriculum where the world view from other health care fields—as well as from the humanities, anthropology, and sociology—would be integrated to target the common goal of fostering prevention and, where necessary to treat patients with mental illness. How, for example, should one conceptualize and treat the clinical phenomena of auditory hallucinations, which often possess a cultural and situational component? What would be the value-add of an audiologist's expertise? Our USUHS course on trauma in the military context was jointly developed by faculty from the graduate school of nursing and the medical and clinical psychology doctoral programs. This highlights the importance of interdisciplinary collaboration in considering the multiple aspects of military trauma and its physical, psychosocial, cultural, and psychological sequelae on wounded warriors and their families. Students from each discipline learned and worked collaboratively. They brought their unique perspectives to discussions about patient care and potential research, while developing an understanding and appreciation for one another's perspectives. During the course, it was striking that students from one discipline would hone in on aspects of the case presentation or research design consistent with their training, and then, those same students would be surprised and intrigued by the different aspects highlighted by students from the other discipline. The challenge one faces in implementing interdisciplinary training starts with the need for a fundamental shift in philosophy regarding the development of health care professionals. Are we collectively prepared to move from an approach where each discipline feels it must guard its own turf by training students primarily within its confines to one in which collaboration and cooperation are seen as the primary mechanisms through which excellent patient care occurs? Are, for example, psychiatric mental health nurse educators willing to develop psychotropic medication training modules that are crafted to reflect the
356
Guest Editorial
background and experience of psychology graduate students? In addition, are psychology's educators willing to design assessment and diagnostic tools/courses specifically targeting the skills of future doctors of nursing practice (DNP)? Until comfortable professional silos are torn down in both the didactic and clinical arenas, change will be difficult to achieve. The Patient Protection and Affordable Care Act is steadily moving our nation towards developing systems of integrated health care with the laudable objective of utilizing the advances occurring within the computer and communication fields to ensure that all Americans will have timely access to gold-standard, outcomes-oriented, quality care (2010). How will the mental health community respond to these unprecedented and transformational changes?
Teresa Combs Daniel K. Inouye Graduate School of Nursing Uniformed Services University of the Health Sciences Jeanette M. Witter Department of Medical and Clinical Psychology Uniformed Services University of the Health Sciences
Eric Pauli Daniel K. Inouye Graduate School of Nursing Uniformed Services University of the Health Sciences Patrick H. DeLeon Daniel K. Inouye Graduate School of Nursing Department of Medical and Clinical Psychology Uniformed Services University of the Health Sciences
References DeLeon, P. H., Convoy, S. P., & Rychnovsky, J. D. (2013). Guest editorial – Unprecedented challenges. Archives of Psychiatric Nursing, 27, 63–64. Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165(6), 663–665. Rusnack, B. (1977). Planned change: Interdisciplinary education for health care. Journal of Education for Social Work, 13(1), 104–111. The Commonwealth Fund (2013). Confronting costs: Stabilizing U.S. health spending while moving toward a high performance health care system. Publication # 1653. New York: New York. The Patient Protection and Affordable Care Act (ACA) (2010). (P.L. 111-148, HR 3590). Wallerstein, R. S. (Ed.). (1991). The doctorate in mental health: An experiment in mental health professional education. Lanham: University Press of America.
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing journal homepage: www.elsevier.com/locate/apnu
Guest Editorial
Meeting the Challenges of Training for Interdisciplinary Care
Nearly all health care professionals and health policy experts accept the value of interdisciplinary and integrated care, which is one of the hallmarks of President Obama's Patient Protection and Affordable Care Act (ACA) [P.L. 111-148]. There is agreement at the highest levels of national professional associations. In 2009, six national education associations of schools of the health professions established the Interprofessional Education Collaborative (IPEC) to advance substantive interprofessional learning experiences to prepare clinicians for the team-based care of patients, including the development of core educational competencies. IPEC members include allopathic and osteopathic medicine, dentistry, nursing, pharmacy, and public health. Psychology, physical therapy, optometry, and podiatry are also active partners in this visionary effort. Interdisciplinary training is not a new concept. Rusnack's (1977) astute observation holds true today: “The difficulties appear to lie in the actual implementation of interdisciplinary practice and education” (p.104). Within mental health, there had been a concerted effort in California to develop a new doctor of mental health degree, which ultimately was unable to overcome resistance from the state's medical licensing board (Wallerstein, 1991). Change always takes time, often far longer than one might initially expect. There can be no question that from a quality of care frame of reference, as well as from a cost–benefit orientation, interdisciplinary care improves patient outcomes, reduces costs, and improves clinician and patient satisfaction. Today, our nation spends more on health care than any other industrialized nation, with disappointing, if not unacceptable, results (The Commonwealth Fund, 2013). Serious mental illness is estimated to cost the United States economy nearly $200 billion in lost earning annually (DeLeon, Convoy, & Rychnovsky, 2013; Insel, 2008). Chronic mentally ill patients and those who require substance abuse treatment are often treated using a team approach, thereby providing an excellent venue for interdisciplinary training. Within the military and veterans' health care systems, there is clear leadership support for collegially utilizing the clinical expertise of every discipline to focus upon patient-centered and preventative-oriented care—historical private sector reimbursement restraints, notwithstanding. Interdisciplinary training is not meant to replace or “over load” an already heavy mental health curriculum. Rather, the underlying objective is for the various disciplines to integrate selected elements of their expertise into existing courses, thereby enriching and expanding the options for patients and providers. Some might well perceive this approach as challenging the historical “medical hierarchy” of mental health, raising the fundamental question regarding the appropriateness of any particular discipline automatically serving as “captain of the ship,” The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the United States Government. http://dx.doi.org/10.1016/j.apnu.2014.08.001 0883-9417/Published by Elsevier Inc.
instead of focusing upon the competency of individual clinicians. The overarching philosophy is encouraging all providers to expand their awareness to create greater value for their patients. By enriching the curriculum with each discipline's unique knowledge and expertise, an integrated and truly holistic approach to patient care should evolve. Tomorrow's providers must cease functioning like the fable's “blind men who only see and treat their part of the elephant,” rather than seeing the whole patient. Throughout mental health professional programs, interdisciplinary training is often referred to as two or more disciplines sharing a required class at the same time in the same room. This classroom interaction should yield a culture of civility and respect among the participating professionals. Although civility and respect are important, they do not fully embrace interdisciplinary training. Our vision at USUHS is several disciplines collaborating to teach through a shared curriculum, shared decision making, and similar goals. In mental health, this would result in an amazing curriculum where the world view from other health care fields—as well as from the humanities, anthropology, and sociology—would be integrated to target the common goal of fostering prevention and, where necessary to treat patients with mental illness. How, for example, should one conceptualize and treat the clinical phenomena of auditory hallucinations, which often possess a cultural and situational component? What would be the value-add of an audiologist's expertise? Our USUHS course on trauma in the military context was jointly developed by faculty from the graduate school of nursing and the medical and clinical psychology doctoral programs. This highlights the importance of interdisciplinary collaboration in considering the multiple aspects of military trauma and its physical, psychosocial, cultural, and psychological sequelae on wounded warriors and their families. Students from each discipline learned and worked collaboratively. They brought their unique perspectives to discussions about patient care and potential research, while developing an understanding and appreciation for one another's perspectives. During the course, it was striking that students from one discipline would hone in on aspects of the case presentation or research design consistent with their training, and then, those same students would be surprised and intrigued by the different aspects highlighted by students from the other discipline. The challenge one faces in implementing interdisciplinary training starts with the need for a fundamental shift in philosophy regarding the development of health care professionals. Are we collectively prepared to move from an approach where each discipline feels it must guard its own turf by training students primarily within its confines to one in which collaboration and cooperation are seen as the primary mechanisms through which excellent patient care occurs? Are, for example, psychiatric mental health nurse educators willing to develop psychotropic medication training modules that are crafted to reflect the
356
Guest Editorial
background and experience of psychology graduate students? In addition, are psychology's educators willing to design assessment and diagnostic tools/courses specifically targeting the skills of future doctors of nursing practice (DNP)? Until comfortable professional silos are torn down in both the didactic and clinical arenas, change will be difficult to achieve. The Patient Protection and Affordable Care Act is steadily moving our nation towards developing systems of integrated health care with the laudable objective of utilizing the advances occurring within the computer and communication fields to ensure that all Americans will have timely access to gold-standard, outcomes-oriented, quality care (2010). How will the mental health community respond to these unprecedented and transformational changes?
Teresa Combs Daniel K. Inouye Graduate School of Nursing Uniformed Services University of the Health Sciences Jeanette M. Witter Department of Medical and Clinical Psychology Uniformed Services University of the Health Sciences
Eric Pauli Daniel K. Inouye Graduate School of Nursing Uniformed Services University of the Health Sciences Patrick H. DeLeon Daniel K. Inouye Graduate School of Nursing Department of Medical and Clinical Psychology Uniformed Services University of the Health Sciences
References DeLeon, P. H., Convoy, S. P., & Rychnovsky, J. D. (2013). Guest editorial – Unprecedented challenges. Archives of Psychiatric Nursing, 27, 63–64. Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165(6), 663–665. Rusnack, B. (1977). Planned change: Interdisciplinary education for health care. Journal of Education for Social Work, 13(1), 104–111. The Commonwealth Fund (2013). Confronting costs: Stabilizing U.S. health spending while moving toward a high performance health care system. Publication # 1653. New York: New York. The Patient Protection and Affordable Care Act (ACA) (2010). (P.L. 111-148, HR 3590). Wallerstein, R. S. (Ed.). (1991). The doctorate in mental health: An experiment in mental health professional education. Lanham: University Press of America.