SGIM Forum

Medical Education: Part II

Reimagining the Virtual Interprofessional Team Care During the COVID-19 Pandemic

Ms. Achonjei (jachuonjei@northwell.edu) is medical student at Zucker School of Medicine at Hofstra/Northwell. Dr. Coletti (dcoletti@northwell.edu) is assistant professor of psychiatry and medicine at Zucker School of Medicine at Hofstra/Northwell. Ms. Alexandri (malexandri1@pride.hofstra.edu) is medical student at Zucker School of Medicine at Hofstra/Northwell. Dr. LaVine (nlavine@northwell.edu) is assistant professor of medicine at Zucker School of Medicine at Hofstra/Northwell. Dr. Block (lblock2@northwell.edu) is associate professor of medicine and science education at Zucker School of Medicine at Hofstra/Northwell.

Introduction

The COVID-19 pandemic forced healthcare systems worldwide to reinvent medical education and healthcare delivery using telehealth technology. Social distancing disrupted traditional educational models and teams had to improvise to establish workflows for patient care and education in the online space.1 We describe in this piece the implementation and initial evaluation of a reimagined interprofessional training practice functioning remotely and collaborating through technology.

An interprofessional team structure is associated with improved patient quality measures and decreased clinician burnout.2, 3 Integrated primary care teams have been associated with improved chronic disease management, positive patient satisfaction scores, and higher ratings of individual effectiveness.4 U.S. federal policy changes enacted through the Cares Act and other policies expanded reimbursement for telehealth modalities.

Collaboration in interprofessional (IP) teams through huddles and rounds is associated with improved patient outcomes.2, 3, 5 Recreating this collaboration and transitioning co-located ambulatory teams online remains a challenge in virtual patient care. We developed and studied an innovative approach to virtual IP ambulatory training and practice.

Methods

This was a pilot study of communication within an IP ambulatory training program operating remotely over a period of five weeks starting in May 2020. The Improving Patient Access Care and cost through Training (IMPACcT) team includes residents, graduate-level students in medicine, pharmacy, physician assistant (PA) training, and clinical health psychology, a medical assistant, and patient access coordinator. Faculty preceptors include physicians, pharmacists, and a psychologist.

Patient sessions began with huddles held via videoconference. Huddles included introductions, mini-didactic sessions led by faculty or trainees, and a discussion about which team members would see each patient. Continuous team communication occurred throughout the clinical session using the secure chat feature of Microsoft Teams. Pharmacy students called patients prior to their scheduled appointment to perform medication reconciliation and counseling, then communicated their findings and recommendations to the team. Psychology students were available to assist with behavioral health care management and treatment adherence. Medical visits were conducted via video or telephonic platforms (e.g., Doximity, Avizia). Residents supervised PA students or medical students on the telehealth visits. The resident and student then communicated with faculty by phone about the case. Finally, the resident (or resident with faculty) reconnected with the patient as needed.

At the end of the five-week period, team members participating in the virtual clinic were emailed a link to an online questionnaire to examine benefits and drawbacks of the virtual model. All IMPACcT residents and students were surveyed. The project was deemed exempt by the Northwell IRB.

Results

Surveys were emailed to 26 team members—six trainees and seven faculty responded (response rate 13/26, 50%). The accompanying table summarizes highlighted benefits and drawbacks of participating in an IP telehealth care model. Additionally, one trainee felt that telehealth emphasized history taking, “It really is so much about the story.” Trainees and faculty noted that interprofessional communication was maintained, as “the rest of the IP team is still heard.” Team members also appreciated the insights into patients’ daily lives through virtual visits conducted in patients’ homes.

Respondents described several drawbacks as well, including communication technology glitches. As one trainee stated, the “ease of transition between providers in person is not available online.” Trainees and faculty noted that maintaining the transparency of interprofessional care for the patient was more challenging on telehealth, as “usually the members of the IP team accompany the provider during the actual visit, which was not available online.” Faculty noted that without being present for the actual visit, it was hard to see the learner’s individual needs. Additionally, performing physical examination was challenging to perform via telehealth and some supportive services, such as ASL interpretation, were difficult to obtain. Finally, respondents noted that team building afforded through a shared space, “fostering close, collaborative IP relationships,” was less feasible in a remote environment.

Respondents provided suggestions for model improvement. Faculty recommended compiling a set of “best practices for a hybrid model.” For example, having one telehealth resident and another resident providing in-person care might optimize workflow in a hybrid model. Trainees requested communication skills training specific to telehealth and access to the telehealth platform for all team members as well as patient “tech checks” to limit delays in care. To assist patients with technology problems, one learner recommended a training visit with a standardized patient. Respondents recommended using multi-participant capabilities of the telehealth platform to accommodate team visits where needed.

Discussion

Our interprofessional training practice recreated an interprofessional team structure in a virtual environment during the Spring 2020 phase of the COVID-19 pandemic. Interprofessional huddles, teaching sessions, team discussions, and patient care moved online and included all team members. The team used a variety of technology including videoconference huddles, secure chat, telephone, and telehealth patient visits. We were able to maintain a facile IP team with opportunities for teachable moments for trainees intact during the pandemic lockdown.

During evaluation of our pilot project, survey respondents, including a diversity of trainees from different health professions and faculty, indicated that the virtual approach did maintain aspects critical to interprofessional practice. Specifically, these included team communication, IP perspective, patient communication, and patient safety. Pilot participants stated that maintaining clear and frequent communication between team members working remotely is critical to maintaining the quality of training and the patient experience.

Several difficulties noted by respondents are common to telehealth models, including technological problems, limited physical examination, and barriers to observing trainee-patient interactions.

This pilot study had several limitations, including a small sample size, limited response rate, and a single practice studied. Analysis by profession was not performed, which may limit understanding of different health professions’ experiences. Staff or patient experiences were also not performed. Future work includes improving the model to address drawbacks, implementing suggestions raised by participants and expanding evaluation to include insights from patients and staff.

References

  1. Almarzooq Z, Lopes M, Kochar A. Virtual learning during the COVID-19 pandemic: A disruptive technology in graduate medical education. J Amer Coll Cardiol. 2020; 75(20):2635-8.

  2. Block L, LaVine NA, Martinez J, et al. A novel longitudinal interprofessional ambulatory training practice: The improving patient access care and cost through training (IMPACcT) clinic. J Interprof Care. 2020 May 7;1-4. doi:10.1080/13561820.2020.1751595. Online ahead of print.

  3. Reiss-Brennan B, Brunisholz KD, Dredge C, et al. Association of integrated team-based care with health care quality, utilization, and cost. JAMA. 2016;316(8): 826-34.

  4. Bower P, Campbell S, Bojke C, et al. Team structure, team climate and the quality of care in primary care: An observational study. BMJ Quality & Safety. 12(4), 273-79

  5. Reeves S, Pelone F, Harrison R, et al. Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017 Jun 22;6(6):CD000072. doi: 10.1002/14651858.CD000072.pub3.


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