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Providing Care across Settings

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The patient case begins with a referral from a dentist: Patient "Gregory" is a 31-year-old male seen in the Dental Urgent Care Clinic at the UW School of Dentistry. Gregory presented for treatment of tooth pain in one of his upper right teeth that has obvious decay. Dental and medical histories were taken and all vital signs. We were unable to provide dental treatment to "Gregory" today due to his elevated blood pressure. He was prescribed Amoxicillin for treatment of abscess and asked to return once his hypertension is controlled. Please evaluate Gregory for hypertension. We will provide the necessary dental treatment after his blood pressure has been reduced.

With this hypothetical patient before them, teams of health sciences students huddled to develop the best course of care for their patient, Gregory. The exercise, titled Providing Care across Settings, was the second in the new Foundations of Interprofessional Practice curriculum, a seven-session, year-long series. Students from across the health professions schools work together in the same teams solving real health challenges throughout the series.

The curriculum is part of the Interprofessional Education Initiative: Vision for a Collaborative Future, launched last year by the UW Board of Health Sciences Deans. The initiative aims to promote progressive integration of collaborative learning across the UW’s six schools of health sciences—dentistry, medicine, nursing, pharmacy, public health and social work. In the first session, held Sept. 24, students were introduced to the process of team development, roles and responsibilities of team members, the practices of effective teams, and building a culture of positive interprofessional working relationships. (Read about the first session in UW Today.)

In the second session, held Oct. 10, nearly 600 health sciences students and more than 50 faculty members participated in the "Gregory" exercise, in locations across the entire UW campus. The exercise was designed to help students communicate and practice as a team in guiding the patient to appropriate healthcare professionals to meet his needs. The goal was to use the knowledge, skills and abilities of team members to provide safe, timely, efficient, effective and equitable care.

Jennifer Danielson, assistant professor of pharmacy, led the interdisciplinary team of faculty in developing the case. Other case development team members included Kimberly Huggins, affiliate instructor of oral medicine in the School of Dentistry; Megan Moore, assistant professor of social work; Elizabeth Kaplan, attending physician in medicine; Karen McDonough, associate professor of medicine; and Brenda Zierler, professor of biobehavioral nursing and health systems in the School of Nursing.

"This was the first time we’ve developed such a case with both the dental and social work faculty--a groundbreaking project for health sciences at UW," Danielson said. "Our purpose was to engage dental, social work, and dietetics students in a case with the team [physicians, physician assistants, nurses, and pharmacy] usually found in a medical home clinic. We purposefully highlighted the expertise of dentists, social workers, pharmacists, nurses, and dietitians in this exercise so that everyone could 'see themselves.' We want to give our students the skills to reach out to each other in practice."

Together, student groups representing diverse health disciplines discussed Gregory's medical history, including his vital signs, lifestyle, and socioeconomic and psychosocial issues. Gregory is unemployed and doesn’t know the date of his last physical exam. He rates his health as fair and his oral health as poor. He eats lots of fast foods. His family has no history of hypertension. He does have a history of drug use (meth, but has been clean for the past two years.) He has smoked 5 to 10 cigarettes per day for a decade. Danielson asked the students to consider and discuss the patient’s needs, which professionals are most appropriate to meet those needs and barriers to medication adherence and better health that Gregory faced. Working in teams of eight to nine, the students enthusiastically discussed Gregory’s needs and the healthcare professionals who could best serve him. Collectively, the teams developed varying care plans for Gregory.

One group determined that Gregory needed many services and designated the most appropriate healthcare professionals to provide or facilitate care, as outlined below:

  • Thorough physical exam (physician, physician assistant, nurse)
  • Hypertension control (physician, physician assistant, pharmacist)
  • A primary care medical home, with dental care included (physician, dentist, physician assistant, pharmacist, nurse, social worker)
  • Full dental work-up with X-rays (dentist) • Smoking cessation (dentist, physician , physician assistant, nurse, pharmacist, social worker, hotline)
  • Toxicology screening to stay sober (physician, physician assistant)
  • Stability evaluation for housing, employment, insurance, drug use (social worker)
  • A more thorough social history (dentist, physician, physician assistant, pharmacist, nurse, registered dietician, social worker)
  • Patient education (all health care professionals)
  • Dietary counseling (registered dietician)

In the scenario, Gregory missed his follow-up appointment and did not pick up his medications. The teams were tasked with understanding why this occurred. The groups also discussed possible barriers to Gregory’s healthcare: unemployment, drug use, and lack of money, transportation, and understanding of his disease.

"He has no motivation," a nursing student contributed, "Hypertension is silent. He may not have symptoms and thinks he only needs to take meds if he’s feeling bad."

A faculty expert from pharmacy, Shanna O’Connor, interjected: "Physicians often don’t know what other physicians are prescribing. Pharmacists are often in the best position of seeing all of the prescription drugs because they are usually billed to the same insurance company." Danielson queried the class, "In dealing with barriers, how will you maximize outcomes? Who else can help?”

Students piped up:

"A social worker could help the patient explore affordable healthcare coverage resources and transportation options."

"Gregory needs education about the medication, side-effects and how to minimize the side effects. We need to talk to him about his long-term quality of life."

A nursing student suggested using a nursing care model to help with care compliance: "We explain, these are your meds; this is what it’s for; and these are the side-effects. Can you tell me what I told you? Do you understand what I said? Do you think this is something you can do?"

Elizabeth Kaplan, a faculty member from medicine, offered one of her methods for communicating with her patients: "I often say, 'I want to make sure I explained this well. Can you tell me what I told you?'"

At the end of the session, students were asked to consider how they would provide continuity of care for the patient. Suggestions included having the healthcare professional provide follow-up care recommendations to the dentist via note, medical chart or phone call.

A dental student summarized her team’s conclusion: "If the hypertension is resolved or controlled, the patient would return to the dentist for follow-up and be treated as a normal patient. Otherwise, the dentist would need a medical consult if the hypertension remains high."

Danielson concluded the session with one final request: "Name one thing from this session that you will take into practice." Comments included:

"Use your resources well."

"I have a better feel for the different professional roles that can come into play."

"Keep the lines of communication open."

"Be more assertive in how I participate."

"Give everyone the space to talk."

Gregory’s case was officially closed, but the interprofessional teamwork had formally begun.

This article courtesy of Marsha Rule, UW Medicine Strategic Marketing & Communications. Photo of IPE students by Ashley Wiggin, School of Nursing.