- Email: [email protected]
Partnerships of the Future
Seminars in Oncology Nursing, Vol 32, No 2 (May), 2016: pp 164-171
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PARTNERSHIPS OF THE FUTURE BRENDA NEVIDJON OBJECTIVES: To explore how partnerships among private, nonprofit, and public organizations can be instrumental in addressing 21st century health care challenges.
DATA SOURCES: Peer-reviewed studies and guidelines, journal articles, books, websites, and personal communication.
CONCLUSION: Given the complexity of the health care environment and the need to transform the system, individuals and organizations will need to form partnerships that result in improved quality of care and decreased cost. Some recent initiatives have been successful and are included in this article.
IMPLICATIONS
FOR NURSING PRACTICE: In many communities and at the national level, there are agencies and organizations that are working independently, yet they have overlapping goals and the same intent. They compete for the same financial and human resources whether in academia, the care delivery sector, or non-profit associations. In the cancer care world, interprofessional teams are essential, yet much care is still delivered in silos. There are redundant patient advocacy organizations even for some of the less common cancers. Partnerships and collaboration will take new forms and require new skill sets in the future.
KEY WORDS: Interprofessional, collaboration, partnership, coalition, alliance, cancer care.
Coming together is a beginning. Keeping together is progress. Working together is success. Henry Ford
T
he 21st century has brought increased partnerships, collaborations, and integration of organizations in the health care ecosystem, domestically and internationally. Solo
Brenda Nevidjon, MSN, RN, FAAN: Chief Executive Officer, Oncology Nursing Society, Pittsburgh, PA. Address correspondence to Brenda Nevidjon, MSN, RN, FAAN, Oncology Nursing Society, 125 Enterprise Dr., Pittsburgh, PA 15275. e-mail: [email protected] © 2016 Elsevier Inc. All rights reserved. 0749-2081 http://dx.doi.org/10.1016/j.soncn.2016.02.010
health care providers are becoming increasingly rare as groups of providers now become the norm. Health care systems are expanding their reach not only within their geographic region but nationally and internationally through collaborative agreements and mergers and acquisitions. Research is not only team-based but now the team members may reside in different, and even competitive, organizations. The collaboration between academic settings and care delivery settings, long proposed in the literature, is taking place not only in discipline specific formats but across disciplines in some locations. Patient advocate groups, professional member associations, payers, and industry now more readily share health policy agenda priorities and lobby together. This scenario describes the world of cancer care today. The siloed approach of the past to solve societal challenges is not effective today and thus, partnerships
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among private, nonprofit, and public organizations are needed to solve 21st century problems.1 Competition among organizations has not disappeared. However, there is a greater recognition that the health care world is highly interrelated and achieving the triple aim of health care reform will require new skills and levels of collaboration. Given the 24 hours per day 7 days per week real-time connectivity, individuals and organizations can easily work together anytime and anywhere. This connectivity has also increased the opportunities for global partnerships. A number of key factors will continue to motivate organizations to collaborate, coordinate, and merge: the complexity of the health care environment, the pressures in the political and economic environment, knowledge specialization, technology, and declining resource availability.2 Yet, duplication and redundancy in the advocacy and professional member associations not only exists, but has continued to expand. Not only are coalitions often populated with the same agency or organization representatives, but there is overlap and redundancy of coalitions. A question for the future is how these relationships might change to mobilize and harness existing resources leading to better outcomes. Partnerships can have benefits for all parties but also can be challenging to formalize and operate. In the cancer care environment, there are many examples of successful team-based research and care delivery approaches. Yet several Institute of Medicine (IOM) reports identify that well-coordinated interprofessional teams are a needed solution to the complex clinical challenges ahead. These challenges include the future workforce and the pipeline of diagnosis and treatment discoveries coupled with the unrelenting financial burden on patients. Oncology nurses are central to finding solutions to complex issues in health care but oncology nurses may not currently exert as much influence on these collaborations as they should to shape the future. Collaborations begin at the individual level and expand to organizations and professions. Understanding the conditions/elements of effective collaboration and partnerships and exploring current examples in health care delivery, research, advocacy, and education/professional development are the focus of this article.
COLLABORATION AND PARTNERSHIP Although the words collaboration and partnership may be used interchangeably, the terms are
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not the same.3 Collaboration is the process of working together for a mutual goal. Partnership is also a process of working together but includes shared risk and reward. Another term commonly used to define a relationship between organizations is alliance. Further distinguished as strategic or social, like collaborations and partnerships, alliances serve the needs of both (or several) organizations. Strategic alliances advance economic or political agendas or priorities. Social alliances are characterized as having both for-profit and nonprofit organizations in the relationship and will have non-economic objectives.4 Whether a collaboration, partnership, or alliance, not all of them are alike. Some may be complex, long-term, or temporary. There may be differences in the assets that each organization brings to the relationship. Regardless of the complexity or longevity of the relationship, from the beginning the organizations must have a clear understanding of the purpose and why they want to work together. Building a relationship between and among organizations requires trust, respect, and commitment among the parties. A clearly defined statement of purpose is critical and must be endorsed by all parties. Based on that purpose statement, goals should be established that are obtainable and measurable. Acknowledgement and credit of all the participating groups should be consistent to avoid conflict and distrust. A clear outline of the assets or resources each group is expected to contribute and with what frequency should be decided early. Having an understanding of the advantages and disadvantages of collaborations and partnerships helps an organization’s leaders make decisions about these opportunities (Table 1). The bottom line is that transparency and mutual benefit must exist for collaborations and partnerships to be truly effective.
INTERPROFESSIONAL EDUCATION AND PROFESSIONAL DEVELOPMENT Collaboration, partnerships, and alliances each require interpersonal and interprofessional skills that can be learned and developed. Hasmiller and Goodman5 note that the committee that prepared the 2010 IOM report, The Future of Nursing: Leading Change, Advancing Health envisioned a future in which interprofessional collaboration and
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TABLE 1. Advantages and Disadvantages of Partnerships Advantages Shared resources Synergy of individual strengths/expertise of each organization New insights/solutions to complex problems because of diverse perspectives May give tax benefits to some participating organizations Enhanced access to funding Greater influence on policy Enriched organizational reputation
coordination is the norm. To create that future, strengthening the interprofessional education (IPE) model for all health professions students is essential and must become more robust than it is today. This topic of interprofessional development has been of interest to many organizations nationally and internationally, such as the IOM and the World Health Organization, both of which have proposed frameworks for IPE. These organizations do not advocate the elimination of profession-specific education, but rather support the positive outcomes of students learning together and being prepared for a care delivery system in which collaboration and coordination of care is essential for improving quality and decreasing cost. As a follow-up to its two reports on quality and safety, the IOM held a workshop and published the report, Health Professions Education: A Bridge to Quality.6 The workshop committee set the following vision for 21st century health professions education: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidencebased practice, quality improvement approaches, and informatics.” Noted in that report and still relevant today was the observation that the vision “. . . is not incorporated into the basic fabric of health professions education, nor is it supported by oversight processes or financing arrangements.” Action is needed to incorporate this vision into the fabric that covers all health professions education. The World Health Organization report, Framework for Action on Interprofessional Education and Collaborative Practice, views interprofessional collaboration as an important strategy in education and practice to deal with workforce shortages globally.7 They identify several factors needed to
Disadvantages Limited scope or compromise of purpose Time required to develop the relationship, build trust Ineffectiveness if all do not fulfill their responsibilities Constraint on business development due to conflict of interest agreements Strained resources between organizational priorities versus partnership priorities Loss of flexibility to take quick action that might be in one organization’s best interest Credit may not be given equitably
achieve effective IPE and collaboration: supportive management practices, identifying and supporting champions, the resolve to change the culture and attitudes of health workers, a willingness to update, renew and revise existing curricula, and appropriate legislation that eliminates barriers to collaborative practice. The literature has abundant articles and examples of IPE of health care professions students spanning several decades. There are journals dedicated to IPE and interprofessional care. Many interprofessional educational approaches, though successful, are elective and are not required fundamentals courses in which all the professions participate. Most students learn their profession in silos and may continue their professional development in similar silos also.8 The reasons that the silos continue are numerous: conflicting schedules, curricula focus, faculty preparedness to teach an interprofessional course, lack of clinical opportunities, and tuition models for the various schools. Speakman and Sicks8 offer students suggestions for developing their own interprofessional opportunities, such as inviting students from other programs to form a discussion group or taking the initiative to engage in rounds together on their clinical unit. Grapczynski et al.9 add two other possible barriers to IPE: learning style differences and loss of professional status. However, their Integrated Model for Interprofessional Education (IMIPE) overcame many of the barriers identified above and developed a program for students from five health care disciplines. Stout et al.10 described a nurse residency in an academic-practice partnership that resulted in positive outcomes, including increased number of BSN prepared nurses at the practice site, decreased cost compared with traditional orienta-
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TABLE 2. Resources for Interprofessional Education and Practice Team-Based Competencies: Building a Shared Foundation for Education and Clinical Practice (Josiah Macy Jr. Foundation, American Board of International Medicine [ABIM] Foundation and Robert Wood Johnson Foundation [RWJF]) Core Competencies for Interprofessional Collaborative Practice – (IPEC): http://www.aacn.nche.edu/education-resources/ IPECReport.pdf Interprofessional Education Collaborative (IPEC): https://ipecollaborative.org/ American Interprofessional Health Collaborative (AIHC): https://aihc-us.org/ Centre for the Advancement of Interprofessional Education (CAIPE): http://caipe.org.uk/ National Center for Interprofessional Practice and Education (NCIPE): https://nexusipe.org/ International Association for Interprofessional Education and Collaborative Practice (IAIECP): https://nexusipe.org/global-topiccategories/international-association-interprofessional-education-and-collaborative Journal of Interprofessional Care: http://www.tandfonline.com/toc/ijic20/current Journal of Interprofessional Education and Practice: http://www.journals.elsevier.com/journal-of-interprofessional-education -and-practice/ Journal of Research in Interprofessional Practice and Education: http://jripe.org/index.php/journal Health and Interprofessional Practice (journal): http://commons.pacificu.edu/hip/
tion, improved competencies, and overall high satisfaction with the program. Bull and colleagues11 in Australia also developed an academic-practice collaboration to support the nurse’s transition into employment that includes engagement in practice and higher education. Their program was designed to bridge the gap between the university theory-based content and the real world of practice. Faculty developed a course for new graduates that had a formal degree component and partnered with health care partners that employed these nurses. The program is a nationally recognized award achievable within the first year after graduation and enables participants to be engaged in both care delivery and education to bring about change in the workplace. Smith and colleagues12 summarized a successful collaboration among three competing medical schools in the UK and other key organizations to develop an innovative undergraduate medical e-portfolio. They attribute the success of the endeavor to their attention to key elements of collaboration: interpersonal relationships among team members, organizational support, and the clearly defining the project with all key stakeholders identified. Learning does not end with the completion of an academic program, but just as in the academic setting much of continuing education is also delivered in discipline specific silos. There are some professional development programs, such as TeamSTEPPS, that are designed to bring multiple disciplines together to learn and develop strong interprofessional skills. Some organizations have
instituted collaborative skills and competency renewal programs. Outside the work environment, professional member associations also provide ongoing education. More groups, such as the recently formed Advanced Practitioner Society for Hematology and Oncology, are emerging as model interprofessional member organizations. With this type of member organization, the disciplines are equal partners as opposed to many organizations that offer a secondary membership for those not in the dominant discipline. In the future, the competition for members and funding most likely will lead to more collaborative and innovative approaches to professional development. Use of technology can remove the geographic and schedule barriers that in-person education presents. The younger health care workforce is comfortable with technology-based approaches to education and will demand more innovative and flexible educational opportunities in the future. Table 2 lists several resources for developing IPE programs. The 2011 core competencies published by the Interprofessional Education Collaborative can guide the development of IPE programs in the academic and continuing education areas.13 To transform health care, the greatest strides will likely be achieved by individuals who have learned and exercised skills in collaborative projects and work.
INTERPROFESSIONAL CARE DELIVERY Given the complex needs of patients and communities, no one profession alone can redesign the
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health care system. Interprofessional collaboration is a fundamental concept embedded in the Affordable Care Act and various collaborative approaches are being implemented and evaluated, such as medical homes and accountable care organizations. In a 2011 issue brief, the Robert Wood Johnson Foundation advocated for more interprofessional collaboration in health care, noting that it is not the norm.14 Reeducation of professionals in collaboration and team-based practice with the patient at the center is one recommendation to support the new models of care that are being tested. Kara et al.15 developed the accountable care team model for an inpatient unit using eight interventions based on three specific domains: enhancing interprofessional collaboration, datadriven decisions, and leadership. Examples of the accountable care team model interventions are: collaborative bedside rounding, hospitalist and specialty co-management agreements, and monthly review of unit-based outcome data. Outcomes that were measured were length of stay, case-mix index adjusted variable direct costs, 30-day readmission rates, overall patient satisfaction score, and provider satisfaction. The accountable care team trial achieved statistically significant decreases in length of stay and case-mix index adjusted variable direct costs. The provider survey data showed overall agreement that the model had improved the quality and safety of care, improved communication, and improved their job satisfaction. Suggestions for future improvements included more emphasis on patient centeredness and greater bedside nursing engagement. Collaborations of multiple practitioners within a practice or setting can benefit patients and clinicians, yet they can be fraught with barriers to overcome. Two examples of such collaborations are integrating behavioral health into primary care and providing palliative care throughout the cancer care trajectory. Dickinson16 summarized key lessons derived from a series of articles on integrating behavioral health and primary care. Payment structures and other barriers make integration of these two disciplines complex and challenging. Primary care practices can be inundated with new programs requiring change and the practice may not have the infrastructure support for incorporating these new programs efficiently. There are multiple strategies to assist primary care practices with program adaptations but few studies have looked at integrating behavioral health. This group of studies summarized by Dickinson showed that a
highly functional interprofessional team was essential to successful integration of other disciplines.16 A major investment must be made in training and socialization of the clinicians to the new program. Interestingly, physical space can be either a facilitator or a barrier to collaboration since co-locating staff can support collaboration. At the Seattle Cancer Care Alliance, this model of co-locating all the professions facilitated communication and problemsolving effectively and efficiently (personal communication). In the past few years, evidence is building and several studies have documented the benefit of integrating palliative care throughout the cancer care continuum. For example, outcomes were improved for patients with non-small cell lung cancer that were randomized to the group receiving care concurrently from a palliative care team as well as their oncology team. 17,18 Bakitas et al. 19 conducted a study of the outcomes resulting from a nurse-led palliative care program. In these studies, the actual collaboration of palliative care and oncology care was not specifically discussed but such studies have resulted in advocates calling for greater inclusion of palliative care and more studies to demonstrate the positive outcomes of interprofessional collaboration.19 Fully integrating palliative care into oncology care is a model to develop for the future. Cancer care has always been provided to more patients in community-based centers than at National Cancer Institute (NCI) designated comprehensive cancer centers. In 2007, the NCI Community Cancer Centers Program (NCCCP) was launched as a pilot to explore ways to enhance the quality of cancer care and to increase access to clinical research in community-based cancer centers. Petrelli and Grusenmeyer20 describe the development of one NCCCP and noted the importance of collaboration among institutions of higher learning, community cancer organizations, and the state cancer control program. This collaborative model is one that uses existing resources and enhances what each program is able to do. Eventually the NCCCP program merged with another program and transitioned to become the NCI Community Oncology Research Program, which has a goal of bringing cancer clinical trials and cancer care delivery research to individuals in their own communities (http://ncorp.cancer.gov/). Concurrently, the NCI-designated comprehensive cancer centers are expanding their reach through partnerships, acquisitions, and mergers. In many situations, these organizations may have previ-
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ously had overlapping activity and recognized that partnering was a better alternative than competing for resources and patients. As there is more focus on value-based care, it is likely that further consolidation and partnerships will continue. Payers are a key stakeholder in transforming health care and many payers have developed partnerships with providers to demonstrate better outcomes. The Oncology Care Model designed by the Centers for Medicare and Medicaid Services brings together government, other payers, and providers to test and evaluate a model of care that could improve quality and reduce cost of care (https:// www.cms.gov/Newsroom/mediaReleaseDatabase/ Fact-sheets/). In this model, not only is the Medicare fee-for-service program included but the Centers for Medicare and Medicaid Services has invited other commercial payers to join. Nursing’s role in interprofessional collaboration has extraordinary range: from partnerships at the unit level to major national initiatives. In certain specialties, teamwork has been a cornerstone of care including creating safe work environments.21 This is certainly true in oncology, which has had multidisciplinary care planning and clinics for many years with nurses being active participants. As the complexity of cancer care has increased, strategies such as navigation and survivorship care planning have contributed to greater alignment of all individuals involved. Regardless of competency development, team practice strategies, and years of multidisciplinary focus, evidence suggests that professional power and status still significantly influence how people experience their roles on the team.22 Despite being the largest workforce in health care, nurses may have the numbers but not necessarily the voice and influence on teams in relation to other professions. Hart’s22 study showed that issues of power and status can positively or negatively affect interprofessional teamwork, an issue that nursing must continue to address through education and advocacy. Interprofessional teamwork takes place at the individual, organization, and profession levels. Education must not only concentrate on competencies but also address issues of power and status among the health professions.
COLLABORATIONS IN RESEARCH Cancer research has long been an endeavor that depended on collaborations within organizations, across organizations, with funders, and with
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industry. Reeve23 describes how silos are broken down and how discovery and development can be accelerated with cross-organization collaborations with representation from academic institutions, biopharmaceutical industry, venture capital companies, and disease foundations. Though some of the examples did not result in the scientific or business success anticipated this type of collaboration and experimentation is needed to solve complex problems today and in the future. Harris and colleagues24 evaluated the benefits and drawbacks of organizational collaboration across the discovery-development-delivery continuum using a cancer research network. One of their findings was that once organizations were working and collaborating together, geography was no longer an issue, although other studies have shown that distance was an issue. Conversely, there were drawbacks that teams faced: frustrations with each other, issues of credit (especially related to tenure systems), and resentment of colleagues within their own organization. The NCI Division of Cancer Control and Population Sciences has a mission of advancing implementation sciences through several objectives including the goal to: “Build partnerships for the development, dissemination and implementation of evidence-based measures, initiatives and programs” (http://cancercontrol.cancer.gov/IS/about.html#vision). There are many questions regarding the benefits and drawbacks of collaboration that are important to answer. Funders are one group in particular that may want to require collaboration in future initiatives they support to ensure adequate accrual and representative populations. For oncology nurse scientists and advanced practice nurses, developing collaborative relationships with other members of the cancer care team can potentiate collecting data that builds the evidence for oncology nursing practice.
CHARITIES, ADVOCACY GROUPS, COALITIONS AND ALLIANCES In the cancer care ecosystem, there are abundant and, in many cases, redundant charities, advocacy groups, coalitions, and alliances. It is important to note that the use of alliance and coalition in an organization’s name can be confusing. The entity may be a single organization and not necessarily several members that have united for a particular cause. The composition of the alliance or coalition can be determined by visiting the
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group’s web page. For purposes of this section, alliance describes an “organization of organizations” that share in a common initiative, but are independent organizations. In a Google search using the prompt “cancer foundation,” the first two pages listed 20 distinct foundations including one for canine cancer. This is the tip of endless list of foundations large and small, some with broad scopes and some very narrow. For example, the website, Charity Navigator (http://www.charitynavigator.org/index.cfm? bay=content.view&cpid=497#.Vm3pdF5Infc) lists more than 30 charities that each work to prevent and cure breast cancer. The need for donations and volunteers overlaps and creates competition among these organizations that have similar if not the same mission. Each organization must also sustain an operational infrastructure to remain viable. This redundancy in operational infrastructure could be reduced and result in more resources being directed to the mission if non-profit organizations were to merge in their communities. The scenario of merging organizations is a strategy that can benefit communities and the organizations alike and most likely will transpire in the years to come. Many foundations also have an advocacy role, as do professional member associations and industry groups. Although many organizations will promote their health policy priorities individually, the development of coalitions and alliances has become quite common and poses a challenge and a choice for Boards as many require a fee to belong as well as dedicated representation. Coalitions and alliances bring together patient advocacy groups, member associations, foundations, and industry in some combination. For example, the Metastatic Breast Cancer Alliance brings together patient advocacy groups, foundations, and industry (http://www.mbcalliance.org/about/members/). One distinct advantage to joining a coalition or alliance is the strength in numbers achieved when organizations combine. For example, the coalition of cancer organizations, facilitated by the Campaign for Tobacco-Free Kids, advocated for and supported stronger tobacco control and resulted in successful legislation in 2009. Also, by being a member of an alliance, a smaller organization can have visibility on issues for which they might have insufficient resources to do so alone. Deciding to join a coalition or alliance will be based on whether there is synergy of mission and values between the potential partners and whether the organization can commit the requisite
resources to the initiative. There are many coalitions and alliances to consider for partnership or alliance, particularly in the nursing and specialty specific domains. Not surprisingly, larger organizations with more resources have a greater opportunity to influence a coalition’s direction and may even serve as host to the coalition. For example, the American Nurses Association hosts an Organization Affiliate meeting twice per year. It serves as a forum for the American Nurses Association and specialty organizations that are members to share information and work on solutions to issues facing the nursing profession. Only a partial number of nursing specialty organizations are Organization Affiliate members, but more than double this number are members in another nursing specialty alliance. Redundancies like this example are prevalent throughout the health care environment, but how many entities can be sustained until the end of the 21st century will depend on availability of resources. Rethinking and reshaping organizations and their partnerships will require significant thought and collaborative skills of the leaders.
CONCLUSION As cancer care evolves in the 21st century, new ways for diverse organizations to work together will be needed. One way this may happen is exemplified by the World Orphan Drug Congress USA, that brings together speakers from academic medical centers, industry, advocacy groups, government, regulators, solution providers/consultants, payers, and associations. One track in the program is called Pitch and Partner for biotech companies seeking capital. One can imagine the various opportunities that might emerge from a meeting that is designed specifically to foster partnerships and promoted to multiple constituencies. Given the redundancy in the various domains in the cancer care ecosystem and competition for resources, relationships among professionals and organizations must change to fully benefit from those resources. Change begins with how students of health professions learn about each other and the skills needed to partner effectively. Solutions for improving quality and reducing cost in cancer care will not happen unless groups come together and focus on the patients rather than the specialty. Policy and funding decisions made in isolation will not create breakthrough solutions and
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thus groups that may have been on opposite sides of an issue will need to collaborate together. The examples of today’s successful collaborations provide
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a model that will continue to mobilize resources and achieve a more open system of caring for future patients with cancer.
REFERENCES 1. Rosenbaum L, VanBuren E, Mennel J. Partnerships for the future. Business Trends 2013. Available at: http://www2.deloitte .com/content/dam/Deloitte/ie/Documents/Finance/CFO/2013SO-Business-Trends_vFINAL.pdf. Accessed November 23, 2015. 2. O’Neil EH. Collaboration – for whose benefit? J Nurs Educ 2013;52:67-68. 3. Lucey PA, Fitzpatrick TA. Greater than the sum of the parts. Nurs Econ 2015;33:109-112, 116. 4. Weinstein L, Cook J. The benefits of collaboration between for-profit businesses and nonprofit arts- or culture-oriented organizations. SAM Adv Manage J 2011;76:4-9. 5. Hasmiller SB, Goodman DC. Interprofessional care and the future of nursing. J Interprof Care 2011;25:163-164. 6. Institute of Medicine. Health professions education: a bridge to quality. Washington, DC: National Academies Press; 2003. 7. World Health Organization. Framework for action on interprofessional education & collaborative practice. Geneva: WHO Press; 2010. 8. Speakman E, Sicks S. Nursing in the 21st century: find opportunities to practice in interprofessional healthcare teams. Imprint 2015;62:35-37. 9. Grapczynski CA, Schuurman S, Booth AD, Bambini D, Beel-Bates C. The integrated model for interprofessional education: a design for preparing health professions’ students to work in interprofessional teams. J Allied Health 2014;44:108114. 10. Stout C, Short N, Aldrich K, Cintron RJ, Provencio-Vsquez E. Meeting the future of nursing report™ recommendations: a successful practice-academic partnership. Nurs Econ 2015;33:161-166. 11. Bull R, Shearer T, Phillips M, Fallon A. Supporting graduate nurse transition: collaboration between practice and university. J Contin Educ Nurs 2015;46:409-415. 12. Smith LJ, Belcher R, Coppola W, et al. Successful collaboration in education: the UMeP. Clin Teach 2014;11:546550. 13. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative
practice: report of an expert panel. Washington, DC: Interprofessional Education Collaborative; 2011. 14. Robert Wood Johnson Foundation. What can be done to encourage more interprofessional collaboration in health care? Issue brief, September 2011. Available at: http://www.rwjf.org/ content/dam/farm/reports/issue_briefs/2011/rwjf72058. Accessed November 23, 2015. 15. Kara A, Johnson C, Nicley A, Niemeier MR, Hui SL. Redesigning inpatient care: testing the effectiveness of an accountable care team model. J Hosp Med 2015;10:773-779. 16. Dickinson WP. Strategies to support the integration of behavioral health care and primary care: what have we learned thus far? J Am Board Fam Med 2015;28:S773-S779. 17. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:773-779. 18. Von Roenn JH, Temel J. The integration of palliative care and oncology: the evidence. Oncology 2011;25:1258-1260, 1262. 19. Bakitas M, Lyons K, Hegel M, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the project ENABLE II randomized controlled trial. JAMA 2009;302:741-749. 20. Petrelli NJ, Grusenmeyer P. Collaboration with the community cancer center: benefit for all. Surg Oncol Clin North Am 2012;21:487-495. 21. Kear T, Ulrich B. Professional collaboration supports a culture of safety in dialysis clinics. Nephrology News and Issues. July 2015. Available at: http://www.nephrologynews.com/ interprofessional-collaboration-supports-a-culture-of-safety-indialysis-clinics/. Accessed November 23, 2015. 22. Hart C. The elephant in the room: nursing and nursing power on an interprofessional team. J Contin Educ Nurs 2015;46:349-355. 23. Reeve BC. Creative cross-organizational collaboration: coming to a project near you. Regen Med 2013;7:237-243. 24. Harris JK, Provan KG, Johnson KJ, Leischow SJ. Drawbacks and benefits associated with inter-organizational collaboration along the discovery-development-delivery continuum: a cancer research network case study. Implement Sci 2012;7:69.
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PARTNERSHIPS OF THE FUTURE BRENDA NEVIDJON OBJECTIVES: To explore how partnerships among private, nonprofit, and public organizations can be instrumental in addressing 21st century health care challenges.
DATA SOURCES: Peer-reviewed studies and guidelines, journal articles, books, websites, and personal communication.
CONCLUSION: Given the complexity of the health care environment and the need to transform the system, individuals and organizations will need to form partnerships that result in improved quality of care and decreased cost. Some recent initiatives have been successful and are included in this article.
IMPLICATIONS
FOR NURSING PRACTICE: In many communities and at the national level, there are agencies and organizations that are working independently, yet they have overlapping goals and the same intent. They compete for the same financial and human resources whether in academia, the care delivery sector, or non-profit associations. In the cancer care world, interprofessional teams are essential, yet much care is still delivered in silos. There are redundant patient advocacy organizations even for some of the less common cancers. Partnerships and collaboration will take new forms and require new skill sets in the future.
KEY WORDS: Interprofessional, collaboration, partnership, coalition, alliance, cancer care.
Coming together is a beginning. Keeping together is progress. Working together is success. Henry Ford
T
he 21st century has brought increased partnerships, collaborations, and integration of organizations in the health care ecosystem, domestically and internationally. Solo
Brenda Nevidjon, MSN, RN, FAAN: Chief Executive Officer, Oncology Nursing Society, Pittsburgh, PA. Address correspondence to Brenda Nevidjon, MSN, RN, FAAN, Oncology Nursing Society, 125 Enterprise Dr., Pittsburgh, PA 15275. e-mail: [email protected] © 2016 Elsevier Inc. All rights reserved. 0749-2081 http://dx.doi.org/10.1016/j.soncn.2016.02.010
health care providers are becoming increasingly rare as groups of providers now become the norm. Health care systems are expanding their reach not only within their geographic region but nationally and internationally through collaborative agreements and mergers and acquisitions. Research is not only team-based but now the team members may reside in different, and even competitive, organizations. The collaboration between academic settings and care delivery settings, long proposed in the literature, is taking place not only in discipline specific formats but across disciplines in some locations. Patient advocate groups, professional member associations, payers, and industry now more readily share health policy agenda priorities and lobby together. This scenario describes the world of cancer care today. The siloed approach of the past to solve societal challenges is not effective today and thus, partnerships
PARTNERSHIPS OF THE FUTURE
among private, nonprofit, and public organizations are needed to solve 21st century problems.1 Competition among organizations has not disappeared. However, there is a greater recognition that the health care world is highly interrelated and achieving the triple aim of health care reform will require new skills and levels of collaboration. Given the 24 hours per day 7 days per week real-time connectivity, individuals and organizations can easily work together anytime and anywhere. This connectivity has also increased the opportunities for global partnerships. A number of key factors will continue to motivate organizations to collaborate, coordinate, and merge: the complexity of the health care environment, the pressures in the political and economic environment, knowledge specialization, technology, and declining resource availability.2 Yet, duplication and redundancy in the advocacy and professional member associations not only exists, but has continued to expand. Not only are coalitions often populated with the same agency or organization representatives, but there is overlap and redundancy of coalitions. A question for the future is how these relationships might change to mobilize and harness existing resources leading to better outcomes. Partnerships can have benefits for all parties but also can be challenging to formalize and operate. In the cancer care environment, there are many examples of successful team-based research and care delivery approaches. Yet several Institute of Medicine (IOM) reports identify that well-coordinated interprofessional teams are a needed solution to the complex clinical challenges ahead. These challenges include the future workforce and the pipeline of diagnosis and treatment discoveries coupled with the unrelenting financial burden on patients. Oncology nurses are central to finding solutions to complex issues in health care but oncology nurses may not currently exert as much influence on these collaborations as they should to shape the future. Collaborations begin at the individual level and expand to organizations and professions. Understanding the conditions/elements of effective collaboration and partnerships and exploring current examples in health care delivery, research, advocacy, and education/professional development are the focus of this article.
COLLABORATION AND PARTNERSHIP Although the words collaboration and partnership may be used interchangeably, the terms are
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not the same.3 Collaboration is the process of working together for a mutual goal. Partnership is also a process of working together but includes shared risk and reward. Another term commonly used to define a relationship between organizations is alliance. Further distinguished as strategic or social, like collaborations and partnerships, alliances serve the needs of both (or several) organizations. Strategic alliances advance economic or political agendas or priorities. Social alliances are characterized as having both for-profit and nonprofit organizations in the relationship and will have non-economic objectives.4 Whether a collaboration, partnership, or alliance, not all of them are alike. Some may be complex, long-term, or temporary. There may be differences in the assets that each organization brings to the relationship. Regardless of the complexity or longevity of the relationship, from the beginning the organizations must have a clear understanding of the purpose and why they want to work together. Building a relationship between and among organizations requires trust, respect, and commitment among the parties. A clearly defined statement of purpose is critical and must be endorsed by all parties. Based on that purpose statement, goals should be established that are obtainable and measurable. Acknowledgement and credit of all the participating groups should be consistent to avoid conflict and distrust. A clear outline of the assets or resources each group is expected to contribute and with what frequency should be decided early. Having an understanding of the advantages and disadvantages of collaborations and partnerships helps an organization’s leaders make decisions about these opportunities (Table 1). The bottom line is that transparency and mutual benefit must exist for collaborations and partnerships to be truly effective.
INTERPROFESSIONAL EDUCATION AND PROFESSIONAL DEVELOPMENT Collaboration, partnerships, and alliances each require interpersonal and interprofessional skills that can be learned and developed. Hasmiller and Goodman5 note that the committee that prepared the 2010 IOM report, The Future of Nursing: Leading Change, Advancing Health envisioned a future in which interprofessional collaboration and
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TABLE 1. Advantages and Disadvantages of Partnerships Advantages Shared resources Synergy of individual strengths/expertise of each organization New insights/solutions to complex problems because of diverse perspectives May give tax benefits to some participating organizations Enhanced access to funding Greater influence on policy Enriched organizational reputation
coordination is the norm. To create that future, strengthening the interprofessional education (IPE) model for all health professions students is essential and must become more robust than it is today. This topic of interprofessional development has been of interest to many organizations nationally and internationally, such as the IOM and the World Health Organization, both of which have proposed frameworks for IPE. These organizations do not advocate the elimination of profession-specific education, but rather support the positive outcomes of students learning together and being prepared for a care delivery system in which collaboration and coordination of care is essential for improving quality and decreasing cost. As a follow-up to its two reports on quality and safety, the IOM held a workshop and published the report, Health Professions Education: A Bridge to Quality.6 The workshop committee set the following vision for 21st century health professions education: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidencebased practice, quality improvement approaches, and informatics.” Noted in that report and still relevant today was the observation that the vision “. . . is not incorporated into the basic fabric of health professions education, nor is it supported by oversight processes or financing arrangements.” Action is needed to incorporate this vision into the fabric that covers all health professions education. The World Health Organization report, Framework for Action on Interprofessional Education and Collaborative Practice, views interprofessional collaboration as an important strategy in education and practice to deal with workforce shortages globally.7 They identify several factors needed to
Disadvantages Limited scope or compromise of purpose Time required to develop the relationship, build trust Ineffectiveness if all do not fulfill their responsibilities Constraint on business development due to conflict of interest agreements Strained resources between organizational priorities versus partnership priorities Loss of flexibility to take quick action that might be in one organization’s best interest Credit may not be given equitably
achieve effective IPE and collaboration: supportive management practices, identifying and supporting champions, the resolve to change the culture and attitudes of health workers, a willingness to update, renew and revise existing curricula, and appropriate legislation that eliminates barriers to collaborative practice. The literature has abundant articles and examples of IPE of health care professions students spanning several decades. There are journals dedicated to IPE and interprofessional care. Many interprofessional educational approaches, though successful, are elective and are not required fundamentals courses in which all the professions participate. Most students learn their profession in silos and may continue their professional development in similar silos also.8 The reasons that the silos continue are numerous: conflicting schedules, curricula focus, faculty preparedness to teach an interprofessional course, lack of clinical opportunities, and tuition models for the various schools. Speakman and Sicks8 offer students suggestions for developing their own interprofessional opportunities, such as inviting students from other programs to form a discussion group or taking the initiative to engage in rounds together on their clinical unit. Grapczynski et al.9 add two other possible barriers to IPE: learning style differences and loss of professional status. However, their Integrated Model for Interprofessional Education (IMIPE) overcame many of the barriers identified above and developed a program for students from five health care disciplines. Stout et al.10 described a nurse residency in an academic-practice partnership that resulted in positive outcomes, including increased number of BSN prepared nurses at the practice site, decreased cost compared with traditional orienta-
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TABLE 2. Resources for Interprofessional Education and Practice Team-Based Competencies: Building a Shared Foundation for Education and Clinical Practice (Josiah Macy Jr. Foundation, American Board of International Medicine [ABIM] Foundation and Robert Wood Johnson Foundation [RWJF]) Core Competencies for Interprofessional Collaborative Practice – (IPEC): http://www.aacn.nche.edu/education-resources/ IPECReport.pdf Interprofessional Education Collaborative (IPEC): https://ipecollaborative.org/ American Interprofessional Health Collaborative (AIHC): https://aihc-us.org/ Centre for the Advancement of Interprofessional Education (CAIPE): http://caipe.org.uk/ National Center for Interprofessional Practice and Education (NCIPE): https://nexusipe.org/ International Association for Interprofessional Education and Collaborative Practice (IAIECP): https://nexusipe.org/global-topiccategories/international-association-interprofessional-education-and-collaborative Journal of Interprofessional Care: http://www.tandfonline.com/toc/ijic20/current Journal of Interprofessional Education and Practice: http://www.journals.elsevier.com/journal-of-interprofessional-education -and-practice/ Journal of Research in Interprofessional Practice and Education: http://jripe.org/index.php/journal Health and Interprofessional Practice (journal): http://commons.pacificu.edu/hip/
tion, improved competencies, and overall high satisfaction with the program. Bull and colleagues11 in Australia also developed an academic-practice collaboration to support the nurse’s transition into employment that includes engagement in practice and higher education. Their program was designed to bridge the gap between the university theory-based content and the real world of practice. Faculty developed a course for new graduates that had a formal degree component and partnered with health care partners that employed these nurses. The program is a nationally recognized award achievable within the first year after graduation and enables participants to be engaged in both care delivery and education to bring about change in the workplace. Smith and colleagues12 summarized a successful collaboration among three competing medical schools in the UK and other key organizations to develop an innovative undergraduate medical e-portfolio. They attribute the success of the endeavor to their attention to key elements of collaboration: interpersonal relationships among team members, organizational support, and the clearly defining the project with all key stakeholders identified. Learning does not end with the completion of an academic program, but just as in the academic setting much of continuing education is also delivered in discipline specific silos. There are some professional development programs, such as TeamSTEPPS, that are designed to bring multiple disciplines together to learn and develop strong interprofessional skills. Some organizations have
instituted collaborative skills and competency renewal programs. Outside the work environment, professional member associations also provide ongoing education. More groups, such as the recently formed Advanced Practitioner Society for Hematology and Oncology, are emerging as model interprofessional member organizations. With this type of member organization, the disciplines are equal partners as opposed to many organizations that offer a secondary membership for those not in the dominant discipline. In the future, the competition for members and funding most likely will lead to more collaborative and innovative approaches to professional development. Use of technology can remove the geographic and schedule barriers that in-person education presents. The younger health care workforce is comfortable with technology-based approaches to education and will demand more innovative and flexible educational opportunities in the future. Table 2 lists several resources for developing IPE programs. The 2011 core competencies published by the Interprofessional Education Collaborative can guide the development of IPE programs in the academic and continuing education areas.13 To transform health care, the greatest strides will likely be achieved by individuals who have learned and exercised skills in collaborative projects and work.
INTERPROFESSIONAL CARE DELIVERY Given the complex needs of patients and communities, no one profession alone can redesign the
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health care system. Interprofessional collaboration is a fundamental concept embedded in the Affordable Care Act and various collaborative approaches are being implemented and evaluated, such as medical homes and accountable care organizations. In a 2011 issue brief, the Robert Wood Johnson Foundation advocated for more interprofessional collaboration in health care, noting that it is not the norm.14 Reeducation of professionals in collaboration and team-based practice with the patient at the center is one recommendation to support the new models of care that are being tested. Kara et al.15 developed the accountable care team model for an inpatient unit using eight interventions based on three specific domains: enhancing interprofessional collaboration, datadriven decisions, and leadership. Examples of the accountable care team model interventions are: collaborative bedside rounding, hospitalist and specialty co-management agreements, and monthly review of unit-based outcome data. Outcomes that were measured were length of stay, case-mix index adjusted variable direct costs, 30-day readmission rates, overall patient satisfaction score, and provider satisfaction. The accountable care team trial achieved statistically significant decreases in length of stay and case-mix index adjusted variable direct costs. The provider survey data showed overall agreement that the model had improved the quality and safety of care, improved communication, and improved their job satisfaction. Suggestions for future improvements included more emphasis on patient centeredness and greater bedside nursing engagement. Collaborations of multiple practitioners within a practice or setting can benefit patients and clinicians, yet they can be fraught with barriers to overcome. Two examples of such collaborations are integrating behavioral health into primary care and providing palliative care throughout the cancer care trajectory. Dickinson16 summarized key lessons derived from a series of articles on integrating behavioral health and primary care. Payment structures and other barriers make integration of these two disciplines complex and challenging. Primary care practices can be inundated with new programs requiring change and the practice may not have the infrastructure support for incorporating these new programs efficiently. There are multiple strategies to assist primary care practices with program adaptations but few studies have looked at integrating behavioral health. This group of studies summarized by Dickinson showed that a
highly functional interprofessional team was essential to successful integration of other disciplines.16 A major investment must be made in training and socialization of the clinicians to the new program. Interestingly, physical space can be either a facilitator or a barrier to collaboration since co-locating staff can support collaboration. At the Seattle Cancer Care Alliance, this model of co-locating all the professions facilitated communication and problemsolving effectively and efficiently (personal communication). In the past few years, evidence is building and several studies have documented the benefit of integrating palliative care throughout the cancer care continuum. For example, outcomes were improved for patients with non-small cell lung cancer that were randomized to the group receiving care concurrently from a palliative care team as well as their oncology team. 17,18 Bakitas et al. 19 conducted a study of the outcomes resulting from a nurse-led palliative care program. In these studies, the actual collaboration of palliative care and oncology care was not specifically discussed but such studies have resulted in advocates calling for greater inclusion of palliative care and more studies to demonstrate the positive outcomes of interprofessional collaboration.19 Fully integrating palliative care into oncology care is a model to develop for the future. Cancer care has always been provided to more patients in community-based centers than at National Cancer Institute (NCI) designated comprehensive cancer centers. In 2007, the NCI Community Cancer Centers Program (NCCCP) was launched as a pilot to explore ways to enhance the quality of cancer care and to increase access to clinical research in community-based cancer centers. Petrelli and Grusenmeyer20 describe the development of one NCCCP and noted the importance of collaboration among institutions of higher learning, community cancer organizations, and the state cancer control program. This collaborative model is one that uses existing resources and enhances what each program is able to do. Eventually the NCCCP program merged with another program and transitioned to become the NCI Community Oncology Research Program, which has a goal of bringing cancer clinical trials and cancer care delivery research to individuals in their own communities (http://ncorp.cancer.gov/). Concurrently, the NCI-designated comprehensive cancer centers are expanding their reach through partnerships, acquisitions, and mergers. In many situations, these organizations may have previ-
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ously had overlapping activity and recognized that partnering was a better alternative than competing for resources and patients. As there is more focus on value-based care, it is likely that further consolidation and partnerships will continue. Payers are a key stakeholder in transforming health care and many payers have developed partnerships with providers to demonstrate better outcomes. The Oncology Care Model designed by the Centers for Medicare and Medicaid Services brings together government, other payers, and providers to test and evaluate a model of care that could improve quality and reduce cost of care (https:// www.cms.gov/Newsroom/mediaReleaseDatabase/ Fact-sheets/). In this model, not only is the Medicare fee-for-service program included but the Centers for Medicare and Medicaid Services has invited other commercial payers to join. Nursing’s role in interprofessional collaboration has extraordinary range: from partnerships at the unit level to major national initiatives. In certain specialties, teamwork has been a cornerstone of care including creating safe work environments.21 This is certainly true in oncology, which has had multidisciplinary care planning and clinics for many years with nurses being active participants. As the complexity of cancer care has increased, strategies such as navigation and survivorship care planning have contributed to greater alignment of all individuals involved. Regardless of competency development, team practice strategies, and years of multidisciplinary focus, evidence suggests that professional power and status still significantly influence how people experience their roles on the team.22 Despite being the largest workforce in health care, nurses may have the numbers but not necessarily the voice and influence on teams in relation to other professions. Hart’s22 study showed that issues of power and status can positively or negatively affect interprofessional teamwork, an issue that nursing must continue to address through education and advocacy. Interprofessional teamwork takes place at the individual, organization, and profession levels. Education must not only concentrate on competencies but also address issues of power and status among the health professions.
COLLABORATIONS IN RESEARCH Cancer research has long been an endeavor that depended on collaborations within organizations, across organizations, with funders, and with
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industry. Reeve23 describes how silos are broken down and how discovery and development can be accelerated with cross-organization collaborations with representation from academic institutions, biopharmaceutical industry, venture capital companies, and disease foundations. Though some of the examples did not result in the scientific or business success anticipated this type of collaboration and experimentation is needed to solve complex problems today and in the future. Harris and colleagues24 evaluated the benefits and drawbacks of organizational collaboration across the discovery-development-delivery continuum using a cancer research network. One of their findings was that once organizations were working and collaborating together, geography was no longer an issue, although other studies have shown that distance was an issue. Conversely, there were drawbacks that teams faced: frustrations with each other, issues of credit (especially related to tenure systems), and resentment of colleagues within their own organization. The NCI Division of Cancer Control and Population Sciences has a mission of advancing implementation sciences through several objectives including the goal to: “Build partnerships for the development, dissemination and implementation of evidence-based measures, initiatives and programs” (http://cancercontrol.cancer.gov/IS/about.html#vision). There are many questions regarding the benefits and drawbacks of collaboration that are important to answer. Funders are one group in particular that may want to require collaboration in future initiatives they support to ensure adequate accrual and representative populations. For oncology nurse scientists and advanced practice nurses, developing collaborative relationships with other members of the cancer care team can potentiate collecting data that builds the evidence for oncology nursing practice.
CHARITIES, ADVOCACY GROUPS, COALITIONS AND ALLIANCES In the cancer care ecosystem, there are abundant and, in many cases, redundant charities, advocacy groups, coalitions, and alliances. It is important to note that the use of alliance and coalition in an organization’s name can be confusing. The entity may be a single organization and not necessarily several members that have united for a particular cause. The composition of the alliance or coalition can be determined by visiting the
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group’s web page. For purposes of this section, alliance describes an “organization of organizations” that share in a common initiative, but are independent organizations. In a Google search using the prompt “cancer foundation,” the first two pages listed 20 distinct foundations including one for canine cancer. This is the tip of endless list of foundations large and small, some with broad scopes and some very narrow. For example, the website, Charity Navigator (http://www.charitynavigator.org/index.cfm? bay=content.view&cpid=497#.Vm3pdF5Infc) lists more than 30 charities that each work to prevent and cure breast cancer. The need for donations and volunteers overlaps and creates competition among these organizations that have similar if not the same mission. Each organization must also sustain an operational infrastructure to remain viable. This redundancy in operational infrastructure could be reduced and result in more resources being directed to the mission if non-profit organizations were to merge in their communities. The scenario of merging organizations is a strategy that can benefit communities and the organizations alike and most likely will transpire in the years to come. Many foundations also have an advocacy role, as do professional member associations and industry groups. Although many organizations will promote their health policy priorities individually, the development of coalitions and alliances has become quite common and poses a challenge and a choice for Boards as many require a fee to belong as well as dedicated representation. Coalitions and alliances bring together patient advocacy groups, member associations, foundations, and industry in some combination. For example, the Metastatic Breast Cancer Alliance brings together patient advocacy groups, foundations, and industry (http://www.mbcalliance.org/about/members/). One distinct advantage to joining a coalition or alliance is the strength in numbers achieved when organizations combine. For example, the coalition of cancer organizations, facilitated by the Campaign for Tobacco-Free Kids, advocated for and supported stronger tobacco control and resulted in successful legislation in 2009. Also, by being a member of an alliance, a smaller organization can have visibility on issues for which they might have insufficient resources to do so alone. Deciding to join a coalition or alliance will be based on whether there is synergy of mission and values between the potential partners and whether the organization can commit the requisite
resources to the initiative. There are many coalitions and alliances to consider for partnership or alliance, particularly in the nursing and specialty specific domains. Not surprisingly, larger organizations with more resources have a greater opportunity to influence a coalition’s direction and may even serve as host to the coalition. For example, the American Nurses Association hosts an Organization Affiliate meeting twice per year. It serves as a forum for the American Nurses Association and specialty organizations that are members to share information and work on solutions to issues facing the nursing profession. Only a partial number of nursing specialty organizations are Organization Affiliate members, but more than double this number are members in another nursing specialty alliance. Redundancies like this example are prevalent throughout the health care environment, but how many entities can be sustained until the end of the 21st century will depend on availability of resources. Rethinking and reshaping organizations and their partnerships will require significant thought and collaborative skills of the leaders.
CONCLUSION As cancer care evolves in the 21st century, new ways for diverse organizations to work together will be needed. One way this may happen is exemplified by the World Orphan Drug Congress USA, that brings together speakers from academic medical centers, industry, advocacy groups, government, regulators, solution providers/consultants, payers, and associations. One track in the program is called Pitch and Partner for biotech companies seeking capital. One can imagine the various opportunities that might emerge from a meeting that is designed specifically to foster partnerships and promoted to multiple constituencies. Given the redundancy in the various domains in the cancer care ecosystem and competition for resources, relationships among professionals and organizations must change to fully benefit from those resources. Change begins with how students of health professions learn about each other and the skills needed to partner effectively. Solutions for improving quality and reducing cost in cancer care will not happen unless groups come together and focus on the patients rather than the specialty. Policy and funding decisions made in isolation will not create breakthrough solutions and
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thus groups that may have been on opposite sides of an issue will need to collaborate together. The examples of today’s successful collaborations provide
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a model that will continue to mobilize resources and achieve a more open system of caring for future patients with cancer.
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