What Makes High IMPACT Interprofessional Teams Effective?

As baby boomers age, meeting their primary care needs will become increasingly difficult due to a diminishing number of physicians entering primary care practice, the increasing complexity of available diagnostic tools and treatments, and expanded access to care under the Patient Protection and Affordable Care Act. This perfect storm has led to calls for changes in the way primary care is delivered including the adoption of interprofessional collaboration (IPC) practice models.¹ According to the World Health Organization, IPC is care provided by “multiple health workers from different professional backgrounds working together with patients, families, carers [sic], and communities to deliver the highest quality care.”²

Although many have advocated for the IPC approach, high-quality studies showing concrete evidence of improved patient outcomes is still lacking.^2,3,4 The recently reported Interprofessional Model of Practice for Aging and Complex Treatments (IMPACT) study was a two-year project designed to evaluate an interprofessional team-based model of care delivered to community-dwelling seniors with complex health care needs.¹

The IMPACT IPC model was implemented in three family health centers in Ontario, Canada. This study’s population (N=42) had a mean age of 83.9 years and participants had multiple chronic conditions and medications resulting in a high disease complexity score.  The mean (SD) complexity score for participants in this study was 19.74 (5.56). The IMPACT clinic’s interprofessional team was composed of family physicians, community nurse, pharmacist, physiotherapist, occupational therapist, dietician, and social worker. Each team member assumed three roles in the project: 1) a clinician that provided care directly to patients and their families; 2) an educator that provided information and guidance to staff; and 3) an innovator that contributed to the ongoing refinement and evaluation of the practice model.

The interprofessional team met weekly.  Comprehensive assessments of each patient included medical, functional, and psychosocial conducted by the team during an extended initial visit (1.5-2 hours). During this visit, the patient and their family met the family physician and a family medicine resident. After introductions, the resident conducted a 20-minute quality-of-life interview with the patient and family. This was designed to “unpack” the patient’s concerns. The interview was observed by the entire interprofessional team via closed-circuit television.

After completing the interview, the resident debriefed with the team. Each team member identified and discussed patient- and family- centered concerns. The team developed an initial patient evaluation plan after discussing the patient and family priorities.

Two or three members of the team then met with the patient to perform additional assessments, while the rest of the team observed via closed-circuit television. Collaborative discussions were continuously happening during this period. After the initial patient evaluation was completed, the team drafted the interprofessional care plan during a second formal discussion. The family physician and resident returned to the patient and family to discuss and finalize the care plan with their input.

Finally, during a third formal meeting, the team debriefed and developed a follow-up plan of care for the family physician, who was responsible for providing continued care to the patient.  This plan was intended to assist the family physician address areas of mutual concern at subsequent follow-up appointments.

Perhaps the greatest benefit of the IPC practice model is the opportunity for all health care professionals to learn together in real-time. The authors reported an increase in respect among the interprofessional team members over time and saw continuous improvement in discipline-specific assessments and treatment plans.  An average of 10.5 issues were identified per patient with a corresponding 10.48 recommended interventions.  Not surprisingly, 41.3% of the interventions were medication related (mean of 4.3 per patient) and the pharmacist played a significant role in the shared decision-making regarding the management of the patient’s medications.

Surveys of the IMPACT participants indicate that the model is a feasible, effective, well received, and portable. However, the cost-effectiveness of the model was not addressed in this study.  Moreover, the study did not clearly report patient-related outcomes.  There would be significant challenges to implementing this practice model including extended visits that exhausted elderly patients, space to conduct team meetings, and payment structures.

Not all teams are created equal and team dynamics are likely a critical factor. While the results of the IMPACT study are positive, we do not yet know which components are essential to successful teamwork and improved patient outcomes.  While several manuscripts regarding interprofessional team-based care have been published in recent years, none of these studies provided any insights regarding the association of patient health outcomes and team functionality.^5-8  One would hope that a functional team could outperform a dysfunctional one … or a group of professionals who work in proximity to one another but in silos … but who knows!

Possible essential factors for a high-functioning interprofessional team likely include mutual respect and trust, common goals, shared decision-making, clear roles and responsibilities, and a willingness to collaborate.^4,9  Leadership that focuses on interprofessional collaboration appears to be an important factor with regard to the sustainability of interprofessional practices. Interprofessional teams that do not have a strong leader who is passionate about the effectiveness of the collaboration are more likely to loose their cohesiveness and structure over time.^6,7  Other factors that promote high-performing teams may include the structures that support the clinical program (e.g. professions represented, technology available, physical layout and facilities), the treatment protocols or pathways used by the team, and the presence of a care coordinator or navigator.^10,11,12  How long a team has been together may also be important.  As the IMPACT investigators observed, teams can improve functionally and become more efficient over time.¹

What does all this information mean and how should it impact our practices? I believe that before we can claim that IPC is the best model to provide primary care, we need to determine what makes an interprofessional team functional and accumulate more evidence about which components of the model lead to improved health care outcomes.  Many questions remain.  Should we adopt a standardized nomenclature and coding for team-based interventions?  How should team functionality be reported? How do we describe the components of the IPC practice model so that readers clearly know what was done?