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Widening the Circle: ACCAHC Report from the 1st IOM Global Forum on Interprofessional Education PDF Print E-mail
Written by John Weeks   

Widening the Circle: ACCAHC Report from the 1st IOM Global Forum on Interprofessional Education and Care

Note: The report is based on a similar report from the Academic Consortium for Complementary and Alternative Health Care (ACCAHC) to its members and participants following a two-day workshop on August 28-29, 2012 that was called the most inclusive and diverse dialogue in Institute of Medicine (IOM) history. It is the first of six such workshops which will be convened as part of the IOM Global Forum on Innovation in Health Professional Education. ACCAHC is one of over 30 academic and professional organizations sponsoring the forum. I produced this report as one of ACCAHC's "ambassadors" to the Global Forum and the workshop.

Report on breakthrough IOM Global Forum

-First an Outcome: IPE Leader Calls for a Need to "Rethink Who is in Our Circle"
-Context: The Most Inclusive "Horizontal" Dialogue in IOM History
-ACCAHC is One of 30 Forum Sponsors, Goldblatt a Member, Weeks an Alternate
-To "Fundamentally Change" - Objectives of the Two 2012 IOM Forum Workshops
#1: Employer to Academics - "What Happened to You Guys?"
#2: Strategy, Culture, Economics, Accountability: What Trumps What in Making Change?
#3: Aetna Leader Urges Academics to Link IPE/C with Care Coordination Movement
#4: Whose Team is This? Kaiser Leader References ACCAHC's Goldblatt in Comment about the Patient's Role
#5: Perfect Teamwork, but for What Purpose: Co-Chair Meleis Asks Who Decides the Focus of the Team?
#6: Goldblatt Suggests Teams Should (also) Focus on Health and Healing 
#7: Money Trumps: Canadian System Leads via $20-Million Government Investment
#8: A $200-Million Coordinated Campaign to Get the U.S. to Invest in IPE/C?
#9: Widening the Circle and Focusing on Health Outcomes: A Public Health View
#10: Vermont Blueprint for Health Leader in Revelation about Role of Naturopathic Doctors
#11: Concluding Remarks from Schmitt, Others: Importance of Holism, Political-Economics, Culture
-Postlude : ACCAHC's 3-Level Mission as "Ambassador" in the Global Forum

George Thibault: Macy CEO and the engine driving IPE/C
First an Outcome: IPE Leader Calls for a Need to "Rethink Who is in Our Circle"

"The issues of who's on the team and who's at the table have been important here. We don't want to create a new elitism, leave others out of the circle. We need to rethink who is in our circle, both in terms of clinical and community resources. We need to be more explicit in our competency to be able to go outside our teams. We need more partnerships and funding partnerships." The speaker was George Thibault, MD, CEO of the Josiah Macy Jr. Foundation. Macy is the leading backer and organizer of the Forum, of recent efforts to create competencies in interprofessional education/care (IPE/C) and of the new National Coordinating Center for IPE/C to be funded through HRSA. He was reflecting on an intense 1.5 days of "horizontal" dialogue focusing in IPE/C as a tool in improving health care. These were packed hours of formal and informal exchange. The work led Thibault's close colleague in this work, the "godmother" of IPE/C in the United States, nurse-sociologist Madeline (Maddie) Schmitt, PhD, RN, FAAN, to urge a "more holistic, person-centered approach." She called the two day workshop "a resounding success."

Global Forum convenor
Context: The Most Inclusive "Horizontal" Dialogue in IOM History

It is with great excitement that I report the experience ACCAHC chair Elizabeth (Liza) Goldblatt, PhD, MPA/HA and I had August 29-30, 2012 as ACCAHC ambassadors to a tremendously powerful dialogue on the future of health care. More specifically, the workshop focused on the character of the optimal health professional education that will be a tool to enhance optimal delivery. The setting was the Keck Center of the National Academy of Sciences, in Washington, D.C. The convener was the IOM. This is the first of six, 2-day forums created through the IOM Global Forum on Innovation in Health Professional Education. This includes some particular focus on ACCAHC contributions. Please understand that we were happily ensconced with 50-60 others at perhaps the most equitable discussion table ever on the need to enhance interprofessional respect, community involvement and social accountability in team care. 

ACCAHC is One of 30 Forum Sponsors, Goldblatt a Member, Weeks an Alternate

ACCAHC is one of 30 organizational sponsors of the Forum. ACCAHC's participation is thanks in part to the visionary support of a North American foundation. This is the most diverse, horizontally-inclusive, interprofessional gathering the IOM has ever hosted. Liza is at the table as the ACCAHC member of the IOM forum. As the ACCAHC alternate, I fully participated in the dialogue as well. The IOM also graciously included me in the dinner for members on Wednesday evening. A major focus of this meeting, and of the November 30-31, 2012 follow-up, is IPE/C as a tool of healthcare enhancement. Here is a partial list of sponsors. ACCAHC is the only formal voice for integrative health care, though many are supportive. A key participant told Goldblatt in a post-meeting note: "You and John are an important part of the conversation we are trying to stimulate."

IOM Global Forum Sponsors

Academic Consortium for Complementary and Alternative Health Care
Academy of Nutrition and Dietetics
American Academy of Nursing
American Association of Colleges of Pharmacy
American Association of Nurse Anesthetists
American Board of Family Medicine
American Board of Internal Medicine
American Board of Pediatrics
American Dental Education Association
American Medical Association
American Psychological Association
American Society for Nutrition
American Association of Colleges of Nursing
American Association of Colleges of Osteopathic Medicine
Association of American Medical Colleges

  Association of American Veterinary Medical Colleges
Association of Schools of Public Health
Association of Schools of the Allied Health Professions
Atlantic Philanthropies
Bill and Melinda Gates Foundation
China Medical Board
Department of Veterans Affairs Office of Academic Affiliations
Josiah Macy, Jr. Foundation
Kaiser Permanente
The National Academies of Practice
National League for Nursing
National Organization for Associate Degree Nursing
National Social Workers Association
The Society for Simulation in Healthcare
Uniformed Services University of the Health Sciences

Scott Reeves: workshop co-chair
To "Fundamentally Change" - Objectives of the Two 2012 IOM Forum Workshops

A subgroup of 7 members of the IOM Committee, led by UCSF IPE/C educator (and ICECIM keynoter) Scott Reeves, PhD. MSc and Lucinda Maine, DPharm, director of the academic consortium for pharmacy schools, developed the following workshop objectives. These will also shape the May 2013 workshop:

  • Engage in forward-looking dialogue around the importance of aligning health professional education with the needs of clinical practice, consumers and the health care delivery system.
  • Explore the opportunity for shared decision making, distributed leadership and team-based care, amongst other interprofessional education (IPE) and practice innovations, to fundamentally change health professions curricula, pedagogy, culture, human resources, and assessment and evaluation metrics.
  • Discuss how innovations in IPE will impact patient and population health as identified through the "triple aim" of better health, higher quality and lower cost.

Picture a large u-shaped room at the Keck Center with all the 40 committee members in managed dialogues and other members of the public arrayed outside the big table. Below is a sampler from the dialogue.

Paul Grundy: IBM's health transformation leader
#1: Employer to Academics - "What Happened to You Guys?"

One theme of the IOM Global Forum is to create better responsiveness in academic health care to meet real world needs. In an opening panel on August 29, Paul Grundy, MD, MPH head of IBM's Healthcare Transformation team, took aim at the assembled academics: "It takes 3 years to retrain the (healthcare) workforce after they've been trained by you. The VA says it's 3 years. Kaiser says it's 3-4 years. What happened to you guys? Health reform is happening in spite of you, not because of you." Grundy then took aim at the procedure and profit orientation in the large, hospital-based academic systems that have led creation of a $2.8-trillion system about which IOM has estimated that 30%-50% is waste. "You are a milking machine," Grundy bluntly asserted. Then he warned them: "You are going to see a remorseless campaign in the press about how bad you are." Later: "You are the lobster in water. Slowly we will change payment away from the [procedure and] episode of care ..." Credit the IOM team for letting these harsh perspectives on the business of medicine kick off the forum. Given the so-called "perverse incentives" shaping our system, blunt talk is needed.

Sarita Verma: Canadian project leader
#2:  Strategy, Culture, Economics, Accountability: What Trumps What in Making Change?

The procedure-based payment and education system favors work in silos. What strategies can help academics foster team care, given the evidence favoring better respect and collaboration between the disciplines? One participant said: "Culture (of the silos favored in academic health system and by payment practices) trumps strategy" (to change toward interprofessional education). IBM's Grundy added: "Money trumps culture." That perspective seemed to meet agreement. (One example in the integrative health space is that many academic health centers became interested in integrative medicine when the NIH began to dispense scores of millions of dollars each year in research funds.) In later discussion, Canadian IPE leader Sarita Verma, MD offered: "Accountability trumps money." This is an argument for data. Those at the table know IPE/C improves care people receive, yet the hard data are still scarce, while at the same time best practices are emerging that address virtually every challenge in pockets of activity throughout North America. These need to be surfaced and yet, will data trump money? 

Gillian Barclay: Aetna Foundation
#3: Aetna Leader Urges Academics to Link IPE/C with Care Coordination Movement 

Gillian Barclay, DDS, DrPH from the Aetna Foundation spoke to the low visibility yet of education in IPE/C even in an area of care delivery where alignment would seem natural: "No one (out in the delivery world) is talking about interprofessional education even when they are talking about coordinated care. People think that coordinated care can be done without educating people for teams. You [in academic health] need to jump into the movement for coordinated teams. Care coordination will look different with IPE, with team training. This is a clear opportunity."  Barclay was pointing out that, given the financial obstacles that support maintenance of silos, opportunism is key. Go where there is a broader, parallel movement that shows openness. (Note that the ACCAHC involvement with the IOM Forum followed this principle. The ACCAHC Board of Directors saw in the values of the IPE/C dialogue a clear framework for more broadly inclusive integration that reflects the patterns of patient usage.)

Marilyn Chow: Kaiser
#4: Whose Team is This? Kaiser Leader References ACCAHC's Goldblatt in Comment about the Patient's Role 

Marilyn Chow, RN, DNSc, FAAN of Kaiser Permanente was part of a reflection panel the second day. She stated that "we can't design interprofessional care without first knowing the family and community needs." She referenced former CMS director Don Berwick, MD stating that we need "to leverage the people and their teams." (Kaiser Northern California has many acupuncturists on staff, offers yoga and also contracts with ND's and DC's.) Chow then referred to a dinner conversation the prior evening with ACCAHC chair Liza Goldblatt. The exchange stimulated her to make the point that "it is the patient and family that determine the team." After Chow's remark, Goldblatt added that the patient's choices are not necessarily sought out or known by the conventional medicine provider team. She shared: "Some of those whom patients choose for their teams could be from the disciplines I represent here or from others." Then: "What are the problems that come up if the providers who are the patient's choices are not communicating with the system's team?" Goldblatt concluded her comment with referencing the application of this principal to the global nature of the forum: "People are accessing practices that may be 1000 or more years old." Aetna's Barclay then suggested that "systems might be designed so people can effectively choose their teams."

Afaf Meleis: Forum co-chair
#5: Perfect Teamwork, but for What Purpose - Co-Chair
Meleis Asks: Who Decides the Focus of the Team? 

The co-chair of the Global Forum, Afaf Meleis, PhD, DrPS (Hon), FAAN, a nurse educator with global health experience, posed a tough question: "If we get everyone in the room but then the only focus is on the biomedical model, is that IPE? How about having all the perspectives in the room, in the curriculum, in the IPE curriculum?" Another speaker Jan De Maeseneer, MD, PhD, from the European Forum for Primary Care later said "interprofessional education to do what?" I caught up with Meleis afterward and joked with her that my own way of saying this is to ask what do we get if we have a perfect team that perfectly carries out a surgery that is unnecessarily being performed? Meleis urges that IPE/C teams focus on what the content of care is, and on who gets to determine it. Notably, Meleis and others nurses present suggested that another way for more inclusiveness in content would be "to look at what other professions are doing." For instance, it might be useful for educators of medical doctors to consider nursing models of education in which practitioners are already training in both community and hospital settings. An acknowledged challenge for moving academic medicine is the way federal payments for education and residency direct resources and students into tertiary care. Meleis again: "We must begin with a framework of equity and justice between all the professions."

Liza Goldblatt: ACCAHC'S Forum Member
#6: Goldblatt Urges Teams to Also Focus on Health, Healing and Optimal Treatment of Chronic Conditions 

Goldblatt, the ACCAHC member of the IOM Global Forum, spoke to the issue of the substance of what the team is doing: "We tend to be leaning toward a disease-based model" in the discussions and practice. She added that this is of course important in many situations then added: "Wouldn't it be an excellent opportunity to also focus IPE/C on health and healing and the treatment of difficult chronic conditions?" In elevating this orientation, Goldblatt carried the charge of the ACCAHC Board of Directors in January 2012 when they discussed ACCAHC priorities. In the Board's discussions of the optimal "innovation in health professional education" for the 21st century, members focused on urging that we need to develop a workforce that isn't merely reactive but focuses on creating health and healing in the patients and populations served. Who wants to enter the 22nd century bemoaning a reactive medical system?

Marie Tassone: Canadian project team
#7: Money Trumps: Canadian System Leads via $20-Million Government Investment 

Sarita Verma, LLB, MB, CCFP, and Maria Tassone, BS (PT), MS, two leaders of a cross-Canada IPE/C collaboration that funded via the Global Forum, reported the remarkable Canadian experience in interprofessional education/care (IPE/C) since 2004.  Work there began in earnest with $20-million of Health Canada funds. (See "money trumps culture," above.) The Canadian project, led by John Gilbert, PhD, director of the Canadian Interprofessional Health Collaborative, and others, imbedded interprofessional education and team care throughout Canada. (Gilbert is a member of the ACCAHC Council of Advisers.) Eight years later, 16 quality IPE/C programs exist in Canadian academic institutions, compared to a handful in the U.S. This level of Canadian investment is roughly comparable to $200-million of US government investment here. Yet in the U.S., all we have is $8.6-million, pooled by 4 foundations (led by Thibault's Macy Foundation), and announced only a few months ago in April 2012, to start a National Coordinating Center for IPE under patronage of the Health Resources Services Administration. How much will these funds move a nation with some 120 academic health centers?

John Weeks: ACCAHC's Forum alternate
#8: A $200-Million Coordinated Campaign to Get the U.S. to Invest in IPE/C?

In an open reflection session, I suggested to the group that maybe what we need is a coordinated campaign in the US. What if all of the organizations assembled in the room jointly signed on to get the US government to back this movement with $200-million? Since we're talking about an industry in which much of the 30% to 50% that is waste -$900-billion-$1.4 trillion each year - is both harmful and a key portion connected to disrespect between the disciplines, $200-million to kick-start team care and horizontal respect is not so much. Informal conversation after this comment taught me that some view it as a non-starter because too many of the more powerful players are still bought into the present payment system. Another agreed with the direction of a coordinated campaign for resources but believed the focus should be on outcomes rather than IPE per se.

Core Competencies booklet
#9: ACCAHC Competency Additions Speak to Key Workshop Innovation Themes 

At one point, the core domains on the Competencies for Interprofessional Collaborative Practice, developed by the Big 6 disciplines (medicine, nursing, pharmacy, public health, dentistry, osteopathy) were elucidated. Ensuing dialogue touched on physician and practitioner empathy, and whether that can be trained or must be reflected in medical school entrance decisions. Discussion also reflected the issues, noted by Meleis (#5, above) that teams need to consider diverse views of what evidence suggests. And multiple participants, speaking to the need for new leaders, urged health professional education with more education in systems, policies, power structures, mechanisms for change in health systems and how to leverage change. The themes gave me an opportunity to note the tremendous work of the ACCAHC Education Working Group (led by Mike Wiles, DC, MEd and Jan Schwartz, MA) in redrafting the ACCAHC competencies to align with the Competencies declared by the Big 6. Notably, ACCAHC'S Competencies for Optimal Practice in Integrated Environments included 3 additions: one regarding self care - definitely linked to one's ability to have empathy; section 5 on skills in applying evidence; and section 6 on knowing the culture and practices of mainstream systems in order to be better at making change. The ACCAHC competencies seemed prescient.

Harrison Spencer: Public health educator
#10: Widening the Circle and Focusing on Health Outcomes: A Public Health View 

Before second-day panel comments of Harrison Spencer, MD, MPH, DTM&H, the CEO of the Association of Schools of Public Health, a speaker suggested that public health people were perfect leaders of interprofessional teams. That position was underscored by data presented early Thursday. Clinical advances represent just 16% of the increase in life expectancy in the US. The remainder is associated with public health advances linked to the determinants of health. Spencer: "If you're going to think about health outcomes and population health, there is a lot more to it (than clinical teams). You need to involve a much wider circle." He suggested that IPE/C look at "the population-level competencies" across all disciplines. He agreed that "public health is a good convener, particularly with chronic disease," adding "with chronic disease we have to have a hefty dose of public health." Aetna's Barclay noted the importance of a movement to place community gardens next to community clinics in places like Detroit as a health initiative. A speaker from the community noted that good nutrition may be the core requirement for advancing health. Co-chair of the workshop (and keynoter) Scott Reeves, PhD, MSc chimed in: "It is not just 'team' - it is 'network' and coordination."

Craig Jones: Vermont Blueprint
#11: Vermont Blueprint for Health Leader in Revelation about Role of Naturopathic Doctors 

Primary Care doctor Craig Jones, MD, runs the Vermont Blueprint for Health. In a panel, he surprised many in the crowd when he shared how his state's move toward patient centered medical homes (PCMHs) allows Vermont's licensed naturopathic physicians to apply to become the point people in PCMHs. NDs have been recognized as primary care, and covered under Medicaid, for a few years now. Unfortunately, time did not allow for a broader exchange on the other types of practitioners that are anticipated to be in the PCMH teams - whether led by MDs, DOs, NDs or advanced practice nurses in the Vermont model. In a small group session later, I responded to a call for examples of innovations in medical education that are shifting outcomes by sharing data from a Group Health Research Institute study led by Ryan Bradley, ND, MPH that found positive outcomes from integrative medicine for people with diabetes receiving care from naturopathic doctors. Perhaps allowing MDs or advanced practice nurses or other primary providers to have more time to work with patients on habit change, engagement, lifestyle issues and in building self-efficacy may be a good innovation in education, payment and delivery - if they are trained, as the NDs are, in a philosophy that supports empowerment and in skill sets to use the additional time.

MaryJoan Ladden: RWJF
#12: Concluding Remarks from Schmitt, Others: Importance of Holism, Political-Economics, Culture

These comments reflect only a fraction of the exchange. Not included are exceptional comments from patients who were brought into the room (Patients Like Me), from a medical student (Sandeep Kishore, from TEDMED 2012) and from the Global Forum pilot projects in Uganda, South Africa and India. Schmitt captured some of what is here, and what is missing, in concluding remarks. Her first point: "The importance of a holistic, person-centered approach." She noted support for "service-learning" models of IPE training. Much discussion focused on the need for new, more collaborative leadership. Political-economic and cultural contexts each need to be addressed. Social accountability in students must be elevated in all health professional education. She believes that the group "needs each other" and asks: "What is it going to take?" Maryjoan Ladden, PhD, RN, FAAN from the Robert Wood Johnson Foundation reframed the question: "What is it going to take to put ourselves out of business? We need to figure out our messages. What evidence do CEOs and health systems need? I challenge us to look for stakeholders who will push the needle who aren't here." Then she referenced a hero, Bud Baldwin, who began promoting inter-professionalism in the 1960s. "How do we move the needle?"

Postlude : ACCAHC's 3-Level Mission as "Ambassador" in the Global Forum

In the work underway on the ACCAHC Ambassador training, the ACCAHC Task Force on Leadership Development identified three levels of healthcare leadership with which we are interested. 
  1. Contribute substantively and positively to the core content of the initiative.
  2. Represent the shared values of integrative health care (e.g. whole person care, inclusiveness, balance and health-orientation).
  3. Ensure that that the ACCAHC disciplines themselves are seen as parts of the optimal teams that will best support health in the humans we serve.
Goldblatt and I are ACCAHC's formal Ambassadors at the Global Forum. We are seeking to have impact across these three levels of mission. We are happy to report that through direct and indirect feedback from various parties, this commitment from the ACCAHC Board of Directors to take a risk and become sponsors of the Global Forum - and the foundation support - are proving useful across all three domains. We will work to have it grow in time as the other 5 workshops between now and 2014 are planned and unfold. Thanks for this opportunity to, as my 20-year old son puts it, "represent."

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