London Journal of Primary Care 2013;5:52–5
# 2013 Royal College of General Practitioners
Published 7 April 2013
Refereed paper
Educating for integrated care Elisabeth Paice OBE MA FRCP HonFAcadMEd Chair North West London Integrated Care Pilots
Samia Hasan MBBS MRCGP DFFP GP Lead, Imperial College Healthcare Trust; GP and GP Training Programme Director, NHS Hammersmith and Fulham
Key messages If integrated care is to be implemented and sustained, we will need a culture change among the people delivering and managing health and social care at every level. To achieve this will require a large-scale educational effort. To get the ball rolling we held a conference of educators from a range of healthcare professions across north west London. The aim of the conference was first to support clinical educators in understanding what integrated care means and how it is different from existing models of multidisciplinary working, and second to explore how to educate a workforce for integrated care. Participants agreed that the three main capabilities required were: . . .
engaging patients, carers and service users; collaborating with other health and social care professionals; leading improvements in systems of care.
Participants agreed that educational interventions should focus on helping learners to apply existing skills while working as part of a multidisciplinary team across organisational boundaries. The learning should wherever possible be interprofessional, team-based and experiential. Participants felt that assessment should be workbased, reviewing the individual’s real-life, real-world behaviour.
Why this matters to us Both the authors are advocates of integrated care and passionate about education as a means of changing a culture. EP was until recently a dean of postgraduate medical education and now chairs the two integrated care pilots in north west London. SH is a GP, GP training programme director and the chair of a multidisciplinary group (MDG) within north west London. The event we describe was sponsored by the North West London Health Innovation and Education Cluster.
ABSTRACT In September 2012 the North West London Integrated Care Plot held a conference for clinical educators. The aim was to reach a consensus about what learning clinical staff needed in order to contribute to an integrated care system. The conference was attended by 81 clinical educators from a range of backgrounds. The participants decided that competence in the following three domains was essential: 1. Patient and user engagement and empowerment. 2. Collaboration with other health and social care professionals. 3. Leading improvement in the system of care. Educational interven-
tions to facilitate learning should wherever possible be interprofessional, team based and experiential. The views of patients, carers and users should inform the education. Assessment should take into account real-life performance through multi-source feedback and observed practice. Evaluation of the educational intervention should take into account any impact on the patient and user experience as well as clinical outcome measures. Keywords: integrated care, collaborative care, education, learning, professional
Educating for integrated care
53
Background
Setting
In June 2011, the Inner North West London Integrated Care Pilot was launched and a year later a similar pilot was launched in outer north west London. Together, the two pilots cover a potential population of just under two million patients. As Andrew Steeden made clear1 in this Journal, integrated care is all about collaboration – among the people who care for an individual patient or service user, among the services that provide care to a population, and among the organisations that manage those services. While there is no doubt that a more joined-up approach to care would reduce frustration and duplication of effort for patients and professionals alike, there are a number of obstacles to achieving it. These include financial incentives that do not encourage collaboration, lack of shared data and lack of shared accountability. To overcome these obstacles we need to develop a culture in which people are comfortable and competent in working across organisational boundaries to serve the needs of patients more effectively, and strive continuously to improve the quality of care. Previous educational initiatives designed to prepare staff for working in integrated care systems have emphasised the importance of developing clinicians competent in teamworking, communication, role awareness, personal and professional development and practice development.2 The importance of learning in context,3 with other professionals4 and about the systems of care5 has been strongly emphasised. Educational interventions that included simulation and role-play have been successful in providing new perspectives.6 Sir Nigel Crisp recently reviewed the education and training of primary care and public health professionals from a global perspective, recognising the problems arising from shrinking resources and a growing burden of chronic disease.7 He emphasised the importance of changing both the content and the system for delivering healthcare education. Understanding the system of care has become a necessity.8 In order to consider the ways in which education could support integrated care in north west London, we decided to hold a meeting of clinical educators. The aim was to reach a common understanding of what integrated care means and how it is different from existing models of multidisciplinary working. We planned to draw upon the expertise of the participants to explore how to educate for and in an integrated care system.
The North West London Integrated Care Pilot has recently been described in this Journal.1 The education event took place in September 2012 at the Royal College of Obstetricians and Gynaecologists.
Question We wanted to find out what clinical educators felt healthcare professionals needed to learn in order to perform effectively within an integrated care system. We also wanted to find out what educational interventions were considered most likely to be effective, and how learning could be assessed. And we wanted to find out whether getting a multiprofessional group of educators in a room together would generate answers to these questions.
Methods The conference opened with presentations about integrated care, internationally and in the UK. This ensured that participants had a shared understanding of what integrated care implied and how it had been implemented in north west London. Participants then had the opportunity to attend workshops showcasing a range of educational interventions that had already been developed. These included: . . .
.
using coaching skills to empower patients; roles for drama and simulation; interprofessional learning initiatives involving primary and secondary care, clinicians and managers; and case conferences as an educational tool.
Participants were then asked to work in small groups to describe what it was that staff needed to learn in order to work well within an integrated care system, and what educational interventions were best suited to encourage that learning. They were also asked to consider how the learning might be assessed and the interventions evaluated.
Results The event was attended by 81 clinical educators, mostly doctors and nurses with a few pharmacists and allied health professionals.
54
E Paice and S Hasan
General points Participants felt that integrated care was sufficiently different as to require the planning, selection and development of a workforce with the right attitudes as well as skills and knowledge to do this sort of work well. Nurses in particular should have access to postregistration training and a career structure within integrated care systems as they could play a key role. More social workers were also required as many problems that were dealt with by medical teams could be avoided with better staffed and funded social care.
. .
Lead improvement in the system of care .
. .
Competences Participants felt that staff working within integrated care must have (or develop) emotional intelligence and empathy in dealing with patients and users, be willing to work in teams with shared accountability, and be prepared to take on a leadership role in improving the system of care. To do this, they needed the following competences.
Engage and empower patients and users .
. . . . .
. .
Listen to their views and concerns, showing respect for their resourcefulness, giving them the information they need to make the choices that will work best for them, and maintaining a non-judgemental attitude. Communicate well with patients, users and carers. Adopt a coaching or motivational interviewing style in consultations. Provide holistic care, taking into account the priorities of the patient or user. Assess the risk status of patients and users and plan proactive care taking this into account. Act as an advocate for patients and users where necessary, negotiating, influencing and securing resources to meet their needs. Apply the ‘recovery model’ of care in dealing with mental health and long-term conditions. Share accountability for the care of patients and users with other professionals.
Collaborate with other health and social care professionals . . . . . .
Recognise the roles and responsibilities of each profession, avoiding stereotypes. Communicate well with colleagues in other professions. Manage conflict effectively, ensuring that all perspectives are heard. Challenge and be willing to be challenged. Supervise junior colleagues from different professional groups, respectfully and knowledgeably. Recognise the problems posed by professional barriers and stereotypes, and work successfully in a variety of settings with a variety of professionals.
Understand the role of the third sector and work effectively with charities. Recognise the importance of shared data in optimising care and reviewing performance, and participate fully in the collection and use of these data.
. . . . .
Engage colleagues, patients and users, and the public in ways that help them understand the purpose, principles and benefits of an integrated care system. Ensure that representatives of patients and users are engaged in co-design of plans to improve their care. Give patients, users and staff at all levels a voice to express satisfaction and concerns with the system. Organise services in a way that best meets the needs of patients and users. Understand the impact of financial incentives on different providers. Recognise the role of competition and choice in the system. Encourage and harness innovation and creativity at all levels. Champion change in the interest of quality improvement.
Educational interventions None of the capabilities described above are new or unique to integrated care. It is the context in which they are applied that is new. Educational interventions should focus on helping learners to apply existing skills while working as part of a multidisciplinary team across organisational boundaries. The learning should wherever possible be interprofessional, team-based and experiential. Where possible, the views of patients, users and carers should inform the education. Examples of appropriate interventions suggested were: .
.
. .
.
. .
blearning – combining reading and e-learning resources with team-based seminars or group work; sequential patient pathway simulation – as a way of experiencing the patient’s journey through the system; drama and role-play – experiencing care from diverse viewpoints; secondments – to work within different settings or paired with a colleague from another profession within an integrated care system; coaching and motivational interviewing techniques – to use in consultations with patients and users; problem-based learning – to explore issues in depth; multidisciplinary case conferences – to participate in discussions among different professionals sharing in the care of an individual;
Educating for integrated care
.
. .
‘mini-case conferences’ – at which learners replicate or observe the roles of professionals, under expert supervision; action learning sets – for those working in new ways; leadership development – in all professions and at all levels.
Perry, Prof Tim Swanwick, Dr Andrew Steeden, Dr Jonathan Vilabhji, Dr Rebecca Viney, Paul Gilmore, Dr Caroline Bradbeer, Dr Robert Klaber, Dr Sara Hamilton, Nuttan Tanna, Rachel Abraham. And finally, our thanks to all the clinical educators who participated so enthusiastically in the event.
Assessment
CONFLICTS OF INTEREST
Participants felt that assessment should be workbased, reviewing the individual’s real-life, real-world behaviour. Suggested methods included:
None.
. . . . .
feedback from patients and users, colleagues and employers; portfolio of activities and achievements; recordings or videos of behaviour in meetings or consultations; metrics related to the process or outcomes of care; ‘mystery shopper’ evaluations.
Evaluation Participants felt that the effectiveness of a programme of educating for integrated care could only be evaluated by looking at success factors for integrated care in that locality. Suggested measures were: . . . . .
patient experience – satisfaction surveys, qualitative research; clinical outcomes – patient data; professional experience – staff satisfaction surveys, qualitative research; cost savings – through reduced error, duplication, unnecessary admissions; flexibility of workforce – evidence of work across professional boundaries.
Conclusions/discussion The event exceeded our expectations in delivering the ideas we were looking for about education for integrated care. It was clear that many of the skills required were those of good professional practice, but that they needed to be learned in the difficult context of cross-boundary working, whether real or simulated. The new skills identified related mainly to the issues raised by interprofessional collaboration and collaboration with patients, users and carers. ACKNOWLEDGEMENTS
Our thanks to the North West London Health Innovation and Education Cluster who provided the funding and Yvonne Robertson and Nicole Bannister who managed the event. Our thanks to colleagues who presented or ran the workshops, Dr Fiona Moss, Claire
55
ETHICAL APPROVAL
Not needed. REFERENCES 1 Steeden A. The Integrated Care Pilot in North West London. London Journal of Primary Care 2012;5:8–11. www.londonjournalofprimarycare.org.uk/articles/ 5872852.pdf 2 Howarth M, Holland K and Grant MJ. Education needs for integrated care: a literature review. Journal of Advanced Nursing 2006;56:144–56. 3 Hodgins G, Judd F, Davis J and Fahey A. An integrated approach to general practice mental health training: the importance of context. Australasian Psychiatry 2007; 15:52–7. 4 Lennox A and Anderson ES. Delivering quality improvements in patient care: the application of the Leicester Model of interprofessional education. Quality in Primary Care 2012;20:219–26. 5 Power TJ, Shapiro ES and DuPaul GJ. Preparing psychologists to link systems of care in managing and preventing children’s health problems. Journal of Pediatric Psychology 2003;28:147–55. 6 Tang TS, Funnell MM, Gillard M, Nwankwo R and Heisler M. The development of a pilot training program for peer leaders in diabetes: process and content. Diabetes Educator 2011;37:67–77. 7 Crisp N. Structures to support integrated working between public health and primary care. A global perspective on the education and training of primary care and public health professionals. London Journal of Primary Care 2012;4:116–19. www.londonjournalofprimarycare. org.uk/articles/5248793.pdf 8 Frenk J, Chen L, Bhutta ZA et al. Health professionals for a new century – transforming education to strengthen health systems in an interdependent world. The Lancet Nov 2010; doi:10.1016/S0140–6736(10)61854–5. ADDRESS FOR CORRESPONDENCE
Professor Elisabeth Paice 142 Cromwell Tower Barbican London EC2Y 8DD, UK Email: [email protected] Submitted 20/12/12; comments to authors 11/1/13; revised 15/1/13
# 2013 Royal College of General Practitioners
Published 7 April 2013
Refereed paper
Educating for integrated care Elisabeth Paice OBE MA FRCP HonFAcadMEd Chair North West London Integrated Care Pilots
Samia Hasan MBBS MRCGP DFFP GP Lead, Imperial College Healthcare Trust; GP and GP Training Programme Director, NHS Hammersmith and Fulham
Key messages If integrated care is to be implemented and sustained, we will need a culture change among the people delivering and managing health and social care at every level. To achieve this will require a large-scale educational effort. To get the ball rolling we held a conference of educators from a range of healthcare professions across north west London. The aim of the conference was first to support clinical educators in understanding what integrated care means and how it is different from existing models of multidisciplinary working, and second to explore how to educate a workforce for integrated care. Participants agreed that the three main capabilities required were: . . .
engaging patients, carers and service users; collaborating with other health and social care professionals; leading improvements in systems of care.
Participants agreed that educational interventions should focus on helping learners to apply existing skills while working as part of a multidisciplinary team across organisational boundaries. The learning should wherever possible be interprofessional, team-based and experiential. Participants felt that assessment should be workbased, reviewing the individual’s real-life, real-world behaviour.
Why this matters to us Both the authors are advocates of integrated care and passionate about education as a means of changing a culture. EP was until recently a dean of postgraduate medical education and now chairs the two integrated care pilots in north west London. SH is a GP, GP training programme director and the chair of a multidisciplinary group (MDG) within north west London. The event we describe was sponsored by the North West London Health Innovation and Education Cluster.
ABSTRACT In September 2012 the North West London Integrated Care Plot held a conference for clinical educators. The aim was to reach a consensus about what learning clinical staff needed in order to contribute to an integrated care system. The conference was attended by 81 clinical educators from a range of backgrounds. The participants decided that competence in the following three domains was essential: 1. Patient and user engagement and empowerment. 2. Collaboration with other health and social care professionals. 3. Leading improvement in the system of care. Educational interven-
tions to facilitate learning should wherever possible be interprofessional, team based and experiential. The views of patients, carers and users should inform the education. Assessment should take into account real-life performance through multi-source feedback and observed practice. Evaluation of the educational intervention should take into account any impact on the patient and user experience as well as clinical outcome measures. Keywords: integrated care, collaborative care, education, learning, professional
Educating for integrated care
53
Background
Setting
In June 2011, the Inner North West London Integrated Care Pilot was launched and a year later a similar pilot was launched in outer north west London. Together, the two pilots cover a potential population of just under two million patients. As Andrew Steeden made clear1 in this Journal, integrated care is all about collaboration – among the people who care for an individual patient or service user, among the services that provide care to a population, and among the organisations that manage those services. While there is no doubt that a more joined-up approach to care would reduce frustration and duplication of effort for patients and professionals alike, there are a number of obstacles to achieving it. These include financial incentives that do not encourage collaboration, lack of shared data and lack of shared accountability. To overcome these obstacles we need to develop a culture in which people are comfortable and competent in working across organisational boundaries to serve the needs of patients more effectively, and strive continuously to improve the quality of care. Previous educational initiatives designed to prepare staff for working in integrated care systems have emphasised the importance of developing clinicians competent in teamworking, communication, role awareness, personal and professional development and practice development.2 The importance of learning in context,3 with other professionals4 and about the systems of care5 has been strongly emphasised. Educational interventions that included simulation and role-play have been successful in providing new perspectives.6 Sir Nigel Crisp recently reviewed the education and training of primary care and public health professionals from a global perspective, recognising the problems arising from shrinking resources and a growing burden of chronic disease.7 He emphasised the importance of changing both the content and the system for delivering healthcare education. Understanding the system of care has become a necessity.8 In order to consider the ways in which education could support integrated care in north west London, we decided to hold a meeting of clinical educators. The aim was to reach a common understanding of what integrated care means and how it is different from existing models of multidisciplinary working. We planned to draw upon the expertise of the participants to explore how to educate for and in an integrated care system.
The North West London Integrated Care Pilot has recently been described in this Journal.1 The education event took place in September 2012 at the Royal College of Obstetricians and Gynaecologists.
Question We wanted to find out what clinical educators felt healthcare professionals needed to learn in order to perform effectively within an integrated care system. We also wanted to find out what educational interventions were considered most likely to be effective, and how learning could be assessed. And we wanted to find out whether getting a multiprofessional group of educators in a room together would generate answers to these questions.
Methods The conference opened with presentations about integrated care, internationally and in the UK. This ensured that participants had a shared understanding of what integrated care implied and how it had been implemented in north west London. Participants then had the opportunity to attend workshops showcasing a range of educational interventions that had already been developed. These included: . . .
.
using coaching skills to empower patients; roles for drama and simulation; interprofessional learning initiatives involving primary and secondary care, clinicians and managers; and case conferences as an educational tool.
Participants were then asked to work in small groups to describe what it was that staff needed to learn in order to work well within an integrated care system, and what educational interventions were best suited to encourage that learning. They were also asked to consider how the learning might be assessed and the interventions evaluated.
Results The event was attended by 81 clinical educators, mostly doctors and nurses with a few pharmacists and allied health professionals.
54
E Paice and S Hasan
General points Participants felt that integrated care was sufficiently different as to require the planning, selection and development of a workforce with the right attitudes as well as skills and knowledge to do this sort of work well. Nurses in particular should have access to postregistration training and a career structure within integrated care systems as they could play a key role. More social workers were also required as many problems that were dealt with by medical teams could be avoided with better staffed and funded social care.
. .
Lead improvement in the system of care .
. .
Competences Participants felt that staff working within integrated care must have (or develop) emotional intelligence and empathy in dealing with patients and users, be willing to work in teams with shared accountability, and be prepared to take on a leadership role in improving the system of care. To do this, they needed the following competences.
Engage and empower patients and users .
. . . . .
. .
Listen to their views and concerns, showing respect for their resourcefulness, giving them the information they need to make the choices that will work best for them, and maintaining a non-judgemental attitude. Communicate well with patients, users and carers. Adopt a coaching or motivational interviewing style in consultations. Provide holistic care, taking into account the priorities of the patient or user. Assess the risk status of patients and users and plan proactive care taking this into account. Act as an advocate for patients and users where necessary, negotiating, influencing and securing resources to meet their needs. Apply the ‘recovery model’ of care in dealing with mental health and long-term conditions. Share accountability for the care of patients and users with other professionals.
Collaborate with other health and social care professionals . . . . . .
Recognise the roles and responsibilities of each profession, avoiding stereotypes. Communicate well with colleagues in other professions. Manage conflict effectively, ensuring that all perspectives are heard. Challenge and be willing to be challenged. Supervise junior colleagues from different professional groups, respectfully and knowledgeably. Recognise the problems posed by professional barriers and stereotypes, and work successfully in a variety of settings with a variety of professionals.
Understand the role of the third sector and work effectively with charities. Recognise the importance of shared data in optimising care and reviewing performance, and participate fully in the collection and use of these data.
. . . . .
Engage colleagues, patients and users, and the public in ways that help them understand the purpose, principles and benefits of an integrated care system. Ensure that representatives of patients and users are engaged in co-design of plans to improve their care. Give patients, users and staff at all levels a voice to express satisfaction and concerns with the system. Organise services in a way that best meets the needs of patients and users. Understand the impact of financial incentives on different providers. Recognise the role of competition and choice in the system. Encourage and harness innovation and creativity at all levels. Champion change in the interest of quality improvement.
Educational interventions None of the capabilities described above are new or unique to integrated care. It is the context in which they are applied that is new. Educational interventions should focus on helping learners to apply existing skills while working as part of a multidisciplinary team across organisational boundaries. The learning should wherever possible be interprofessional, team-based and experiential. Where possible, the views of patients, users and carers should inform the education. Examples of appropriate interventions suggested were: .
.
. .
.
. .
blearning – combining reading and e-learning resources with team-based seminars or group work; sequential patient pathway simulation – as a way of experiencing the patient’s journey through the system; drama and role-play – experiencing care from diverse viewpoints; secondments – to work within different settings or paired with a colleague from another profession within an integrated care system; coaching and motivational interviewing techniques – to use in consultations with patients and users; problem-based learning – to explore issues in depth; multidisciplinary case conferences – to participate in discussions among different professionals sharing in the care of an individual;
Educating for integrated care
.
. .
‘mini-case conferences’ – at which learners replicate or observe the roles of professionals, under expert supervision; action learning sets – for those working in new ways; leadership development – in all professions and at all levels.
Perry, Prof Tim Swanwick, Dr Andrew Steeden, Dr Jonathan Vilabhji, Dr Rebecca Viney, Paul Gilmore, Dr Caroline Bradbeer, Dr Robert Klaber, Dr Sara Hamilton, Nuttan Tanna, Rachel Abraham. And finally, our thanks to all the clinical educators who participated so enthusiastically in the event.
Assessment
CONFLICTS OF INTEREST
Participants felt that assessment should be workbased, reviewing the individual’s real-life, real-world behaviour. Suggested methods included:
None.
. . . . .
feedback from patients and users, colleagues and employers; portfolio of activities and achievements; recordings or videos of behaviour in meetings or consultations; metrics related to the process or outcomes of care; ‘mystery shopper’ evaluations.
Evaluation Participants felt that the effectiveness of a programme of educating for integrated care could only be evaluated by looking at success factors for integrated care in that locality. Suggested measures were: . . . . .
patient experience – satisfaction surveys, qualitative research; clinical outcomes – patient data; professional experience – staff satisfaction surveys, qualitative research; cost savings – through reduced error, duplication, unnecessary admissions; flexibility of workforce – evidence of work across professional boundaries.
Conclusions/discussion The event exceeded our expectations in delivering the ideas we were looking for about education for integrated care. It was clear that many of the skills required were those of good professional practice, but that they needed to be learned in the difficult context of cross-boundary working, whether real or simulated. The new skills identified related mainly to the issues raised by interprofessional collaboration and collaboration with patients, users and carers. ACKNOWLEDGEMENTS
Our thanks to the North West London Health Innovation and Education Cluster who provided the funding and Yvonne Robertson and Nicole Bannister who managed the event. Our thanks to colleagues who presented or ran the workshops, Dr Fiona Moss, Claire
55
ETHICAL APPROVAL
Not needed. REFERENCES 1 Steeden A. The Integrated Care Pilot in North West London. London Journal of Primary Care 2012;5:8–11. www.londonjournalofprimarycare.org.uk/articles/ 5872852.pdf 2 Howarth M, Holland K and Grant MJ. Education needs for integrated care: a literature review. Journal of Advanced Nursing 2006;56:144–56. 3 Hodgins G, Judd F, Davis J and Fahey A. An integrated approach to general practice mental health training: the importance of context. Australasian Psychiatry 2007; 15:52–7. 4 Lennox A and Anderson ES. Delivering quality improvements in patient care: the application of the Leicester Model of interprofessional education. Quality in Primary Care 2012;20:219–26. 5 Power TJ, Shapiro ES and DuPaul GJ. Preparing psychologists to link systems of care in managing and preventing children’s health problems. Journal of Pediatric Psychology 2003;28:147–55. 6 Tang TS, Funnell MM, Gillard M, Nwankwo R and Heisler M. The development of a pilot training program for peer leaders in diabetes: process and content. Diabetes Educator 2011;37:67–77. 7 Crisp N. Structures to support integrated working between public health and primary care. A global perspective on the education and training of primary care and public health professionals. London Journal of Primary Care 2012;4:116–19. www.londonjournalofprimarycare. org.uk/articles/5248793.pdf 8 Frenk J, Chen L, Bhutta ZA et al. Health professionals for a new century – transforming education to strengthen health systems in an interdependent world. The Lancet Nov 2010; doi:10.1016/S0140–6736(10)61854–5. ADDRESS FOR CORRESPONDENCE
Professor Elisabeth Paice 142 Cromwell Tower Barbican London EC2Y 8DD, UK Email: [email protected] Submitted 20/12/12; comments to authors 11/1/13; revised 15/1/13
