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Feasibility Study: A Proposed Model of a ‘Healthy Ageing Clinic’ and Team Based Curricular for Clinical Placement of Healthcare Students

Faculty of Health and MedicineUniversity of Newcastle

Prepared by:Associate Professor Chris KewleyDr Sharyn HunterMr Wayne Jeffree, Project Officer

Acknowledgement

The study has been supported through funding received from the NSW Health Education and Training Institute (HETI), NSW Interdisciplinary Clinical Training Network (ICTN) and Health Workforce Australia (HWA).

Project Team

Professor Kichu Nair, Clinical Professor of Medicine and Director of Continuing Medical Education and Professional Development.

Dr Sharyn Hunter, Senior Lecturer, School of Nursing and Midwifery, UoN

Ms Marie Larkings, Faculty Director Health and Community Services Hunter TAFE

Professor Michael Hazelton Head, of School/Professor of Mental Health Nursing

Professor Darren Rivett, Head of School, Health Sciences

Dr Mark Foster, CEO Hunter Medicare Local

Professor Dimity Pond, School of Medicine and Public Health

Associate Professor Chris Kewley, Director of Post Graduate Studies Course Work School of Nursing and Midwifery UoN, and Health Systems Leadership

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Executive Summary

While we strive to promote a positive view of ageing the reality is that the majority of health services and training institutions remain locked in a disease model. As with all aspects of health care, promotion of wellness in ageing requires a well-qualified inter-professional team-based approach and yet we continue to train our future health professionals in discipline specific programs, devoid of authentic inter-professional education or team-based training.

The intention of this project was to consider the feasibility of developing the concept of a ‘healthy ageing clinic’ based within a primary healthcare model, and supported through a team-based inter-professional practice curriculum. Promotion of wellness requires a multisectoral approach to address the complexity of social determinants and social engagement across the life-span. Social determinants for wellness touch on all aspects of life including housing, welfare, education, community connectivity and rights of citizenship. Broad community consultation across public and private organisations critical to the promotion of wellness in ageing, endorsed their support and willingness to participate in an authentic primary health model. These agencies covered all aspects required to address the social determinants vital to healthy living including city councils, Medicare Locals, aged care providers, faith based and multicultural organisations, Aboriginal health providers, and other training institutions.

Health professionals work in teams and yet we continue to train within single discipline curricular. A comprehensive review of national and international literature on the subject of inter-professional education and team-based training revealed a plethora of literature, and a number of exemplar models albeit nothing directly related to wellness in ageing. From an international perspective there are some excellent examples lead by the University of Southampton in the United Kingdom, Canadian Inter-professional Health Collaborative, World Health Organisation and a significant number of medical schools in the United States. Outside of Health Workforce Australia’s beginning dialogue on the subject of inter-professional education and team-based training, Curtin University appears to be the only Australian University or health education provider that has strategically consolidated inter-professional education into its undergraduate curriculum.

On the policy front there is evidence of a convergence if not yet a nexus between health reform and education reform awareness, and direction to change the way health professionals are educated as a key to building effective health care teams, and improving the experience and outcomes for patients.

From the broad community consultation and international literature search, there is no doubt that the concept of a healthy ageing clinical supported through an inter-professional team-based curricular is not only feasible, but strategically fits with the changes in global demographics, policy reform and therefore is a perfect vehicle for introducing authentic inter-professional team-based training.

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Table of Content

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1 Introduction.............................................................................................................................................. 52 Background.............................................................................................................................................. 53 Project Process........................................................................................................................................ 74 Literature Review..................................................................................................................................... 8

4.1 Wellness in Ageing................................................................................................................................... 84.2 Health Service Reform, Model of Care and Health Workforce Capacity................................................114.3 Inter-professional Education, Practice & Health Workforce Competency...............................................164.4 Student Inter-professional Practice Initiatives Relevant to Healthy Ageing Clinics.................................254.5 Health and Education Policy Nexus.......................................................................................................29

5 Examples of Inter-professional Education in Practice in Australasia...............................................326 Stakeholder Consultation...................................................................................................................... 337 Project Outcomes.................................................................................................................................. 35

7.1 Specific Project Outcomes..................................................................................................................... 357.2 Strategic Outcomes................................................................................................................................ 37

8 Bibliography........................................................................................................................................... 399 Appendix................................................................................................................................................. 45

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1 Introduction

The Healthy Ageing Clinic Feasibility Project commenced late last year through funding from the N.S.W. Health Education Training Institute (HETI) and Health Workforce Australia (HWA). The project was facilitated through the Faculty of Health and Medicine in partnership with the Hunter Medicare Local and Hunter Institute of TAFE. The project addressed the feasibility of establishing a community based, inter-professional, student managed Healthy Ageing Clinic.

The project examined contemporary health services and policies, health professional education and operational considerations, which underpin a model of wellness in ageing for the community. Experts and other relevant stakeholders were consulted and field trips to institutions where inter-professional practice was being conducted also occurred.

2 Background

The current aged care system is primarily focused on disease management and ageing is often associated with disease and disability. Accumulating evidence about ageing enables age-related changes to be differentiated from disease and illness. Although many problems affecting older people are caused by diseases, it is often the combination of aged-related changes and diseases that produce ill health and negative functional consequences. Importantly, ageing changes can be delayed or even prevented (Watson, 2008).

There is increasing awareness of the importance of maintaining the health of older people. To support an older person’s health, they require information about the ageing process, diseases and risk factors for ill health and how they can maintain or improve their health. World Health Organisation (2002) recommends global community health care programs focusing on measures to assist older people to remain healthy. Despite this level of knowledge and understanding, translation into health care has not occurred. One reason is that healthy ageing requires a level of health literacy. Maintenance of health and wellness requires functional literacy and awareness in three related areas including health promotion, disease prevention, and health system navigation. A study which examined health literacy in Australian older people found that most were below average (<3) on the health literacy scale (Australian Bureau of Statistics, 2008).Another is the lack of accessible health care about healthy ageing. There are very few healthy ageing clinics and the clinics that do exist tend to be issue-focused and not multi-disciplinary (Kong, 2007; Helping Hand Aged Care, 2012).

The above reasons and the experience of an initiative at the University of Newcastle where undergraduate nursing students interact with older persons living in the community using a healthy ageing approach (Hunter, 2012), led to the idea of a ‘healthy ageing clinic’ for

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healthcare students. A model was developed for a community based, inter-professional, student managed Healthy Ageing Clinic (see Figure 1) (Hunter & Kewley, 2012). The model had seven strategic intents: Older person health (core intent) Community promotion of healthy ageing Provision of quality and innovative clinical student placement Student managed Inter-professional and team based training and team readiness testing Community based within an integrated primary health care model Curricular delivered within an experiential learning and reflective model that allows for

seamless translation of learning to action.

Figure 1: The Model of the Healthy Ageing Clinic

A submission was accepted in late 2012 by HETI to fund a project to explore the feasibility of this innovative clinical placement model to increase quantity and quality of clinical placement experiences for healthcare students. It was anticipated that this project would provide a strategic road map aligned to contemporary pedagogy and clinical thinking through:

1. Establishment of an innovative approach to expanding clinical placement and supervision within a model of care that is aligned to international trends, changes in clinical demographics, and the national health reform agenda.

2. Addressing the need for educators, clinical providers and students to integrate undergraduate training into an inter-professional and team-based model.

3. Expanding training in care for older persons beyond secondary and tertiary levels into a ‘wellness model’ that provides life-scripts for healthy ageing in partnership with other primary health care providers.

4. Introduction of healthy ageing into the curricular through expanding primary health care placements designed to move student thinking beyond the traditional profiling of older persons care – demography, morbidity and mortality; to

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considering the socioeconomic determinants of health and wellness such as income, social position, housing, environment healthy life choices and behaviour.

5. Creating a value-proposition that focusses on authentic inter-professional team-based clinical placements, training and supervision.

6. Inter-agency collaborative approach to clinical placement that brings together undergraduate level nursing, medicine, physiotherapy, occupational therapy, nutrition and dietetics, podiatry and vocational students into one integrated training model.

3 Project Process

This project addressed “a community based inter-professional student managed Healthy Ageing Clinic” by asking the following questions:

1. What is the evidence base to support the capability of the proposed model to achieve the following outcomes:

Wellness in Ageing Inter-professional and inter-sectoral collaboration between Health, Education,

relevant agencies and consumers Develop service/workforce capacity to address emerging health concerns.

1. These are the outcomes which together underpin a paradigm for the advancement of health and against which the feasibility of the proposed model is measured.

2. How does the policy environment align with and enable the implementation of the proposed model?

3. What are the systemic enablers/challengers of the proposed model?4. What is the cost/benefit of implementation? What would be required for

sustainability?

The approaches undertaken to address these questions were: A comprehensive literature review of demographic and epidemiological information;

relevant Australian and international policy directions; and published evidenced-based exemplars.

The development and implementation of a methodology which could adequately assess the feasibility of a healthy ageing clinic and team-based curricular for clinical placement of healthcare students

Consultation and engagement of expert sponsors, local project partners and community stakeholders.

Field trips to Curtin University of Technology and Auckland University of Technology to confer with academic and field staff who are actively engaged in developing and implementing a number of inter-professional, student led health initiatives.

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4 Literature Review

A review of international and national published research and contemporary strategic policies was conducted and occurred in the areas of:

o the advancement of the health of individuals and the ageing population;o health service models, initiatives and provision; o strategic directions for the education and health sectors to enable increased

health workforce and service capacity particularly inter-professional education theory and practice

o student inter-professional practice initiatives relevant to healthy ageing clinics.

4.1 Wellness in Ageing

The concept of “wellness in ageing” as a vehicle for inter-professional education is at the heart of this study and while no-one could argue against the concept as a value statement; community perceptions of ageing along with illness based health service models perpetuate a conflict with both the vision and advancement of wellness in the ageing population. The inevitability and association of ageing with a reduction in individual capability and capacity does not easily reconcile with an optimal notion such as wellness. Some fundamental questions and precepts need to be examined in order to reconceptualise wellness in ageing:

Why is wellness in ageing a priority? What constitutes wellness in ageing? Is wellness in ageing achievable? What determines wellness in ageing? How can wellness in ageing be advanced and promoted?

In most countries of the world the population is ageing in terms of the absolute numbers of and relative proportion of older people. This has resulted from economic, scientific and medical progress. However, it poses challenges for health and social services (Watson, 2008). Already, advances in treating conditions commonly associated with old age have changed our demography (Institute of Medicine, 2001; Wagner et al., 2001). In most of the developed world, population ageing was a gradual process following steady socio-economic growth over several decades and generations. In developing countries, the process is being compressed into two or three decades (WHO, 2002).

Australia’s population is growing. Increasing fertility rates and numbers of migrants has led to a significant increase in the Australian Bureau of Statistics (ABS) population projection, which has grown from 28.2 million people in 2051 (2004 estimates) to 34.2 million people (2006 estimates). This, together with demographic trends, suggests that while there will be a growing need for primary health care services targeted at children, teenagers and young

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families, the predominant influence will remain ageing, which will cause most change in the use of primary health care services (National Primary Health Care Strategy (NPHCS), 2009).

The prevalence and burden of chronic disease is significant and will increase with the ageing of the population. Chronic diseases, including cancers, are estimated to be responsible for more than 80% of the burden of disease and injury. The World Health Organisation (WHO) warns that the global burden of chronic disease is increasing rapidly and predicts by the year 2020 that chronic disease will account for almost three quarters of all deaths (WHO, 2002).

While we strive to promote a positive view of ageing, it is simply a reality that, for many, it is associated with greater degrees of disability and illness. Traditionally, old age has been associated with retirement, illness and dependency. Policies and programmes that are stuck in this out-dated paradigm do not reflect reality. Indeed, most people remain independent into very old age (WHO, 2001). With regard to rising public expenditures for medical care, available data increasingly indicate that old age itself is not associated with increased medical spending. Rather, it is disability and poor health associated with old age that are costly (National Chronic Disease Strategy(NCDS), 2006).

The ageing of Australia’s population is a profound social shift which requires an equally profound shift in society’s mind set about ageing. This is neither a problem nor an inconvenience; it’s an historic achievement that human society has strived for over centuries and presents a range of economic and social opportunities. More people live longer, although lifespan is not increasing. In addition, as some of the more intractable physical aspects of ageing become amenable to intervention, if not treatment, then the advice to promote a positive image of ageing and to encourage health promotion in ageing move from being abstract, almost ideological propositions, to being practical realities (Commonwealth of Australia (CoA), 2012).

As individuals age, non-communicable diseases (NCDs) become the leading causes of morbidity, disability and mortality in all regions of the world, including in developing countries. NCDs, which are essentially diseases of later life, are costly to individuals, families and the public purse. But many NCDs are preventable or can be postponed (WHO, 2002).

Ultimately, the worldwide shift in the global burden of disease toward chronic diseases requires a shift from a model which relies on diagnosis and responds to episodes of illness, to a coordinated and comprehensive continuum of care model which addresses the complexities of risk factors is grounded in the promotion and advancement of health. This will require a reorientation in health systems that are currently organized around acute, episodic experiences of disease. The present acute care models of health service delivery are inadequate to address the health needs of rapidly ageing populations

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Healthy ageing is influenced by a variety of interacting determinants within and outside the health sector. According to Dahlgren & Whitehead (2006), these determinants are: individual lifestyle factors, social and community networks, living and working conditions, and general socioeconomic, cultural and environmental factors. These determinants apply to the health of all age groups, although the emphasis here is on the health and quality of life of older persons. At this point, it is not possible to attribute direct causation to any one determinant; however, the substantial body of evidence on what determines health suggests that all of these factors (and the interplay between them) are good predictors of how well both individuals and populations age. Because no one agency can tackle all these determinants, the promotion of healthy ageing requires an inter-sectoral approach (Yach, 1996).

The term “active ageing” was adopted by the World Health Organization in the late 1990s. It is meant to convey a more inclusive message than “healthy ageing” and to recognize the factors in addition to health care that affect how individuals and populations age (Kalache and Kickbusch, 1997). It shifts strategic planning away from a “needs-based” approach (which assumes that older people are passive targets) to a “rights- based” approach that recognizes the rights of people to equality of opportunity and treatment in all aspects of life as they grow older.

If ageing is to be a positive experience, longer life must be accompanied by continuing opportunities for health, participation and security (WHO, 2002). Active ageing is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. It allows people to realize their potential for physical, social, and mental wellbeing throughout the life course and to participate in society according to their needs, desires and capacities, while providing them with adequate protection, security and care when they require assistance (WHO, 2002).

The word “active” refers to continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or to participate in the labour force. Older people who retire from work and those who are ill or live with disabilities can remain active contributors to their families, peers, communities and nations.

Whereas in the past the emphasis was on disease and disease prevention (Hansen-Kyle 2005, Nygren et al. 2005, Lindstrom & Eriksson, 2006) nowadays, health promotion is oriented more often to more positive processes, like for example healthy ageing (Eriksson & Lindstrom, 2008). Such a positive approach is based on the theory of salutogenesis, in which the focus is on the causes of health, instead of on the causes of disease (pathogenesis).

Active ageing aims to extend healthy life expectancy and quality of life for all people as they age, including those who are frail, disabled and in need of care. “Health” refers to physical, mental and social wellbeing as expressed in the WHO definition of health. Thus, in an

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active ageing framework, policies and programmes that promote mental health and social connections are as important as those that improve physical health status (WHO, 2002).

Active ageing policies and programmes are needed to enable people to continue to work and participate according to their capacities and preferences as they grow older, and although ageing per se cannot be prevented, the prevention or delay of disabilities and chronic diseases that are costly to individuals, families and the health care system is within our grasp.

To promote active ageing, health systems need to take a life course perspective that focuses on health promotion, disease prevention and equitable access to quality primary health care and long-term care. When the risk factors (both environmental and behavioural) for chronic diseases and functional decline are kept low while the protective factors are kept high, people will enjoy both a longer quantity and quality of life; they will remain healthy and able to manage their own lives as they grow older; fewer older adults will need costly medical treatment and care services (WHO, 2002).

Increasingly, both in Australia and overseas, there is recognition that strengthening and improving the way in which primary health care is provided is vital in determining how well the health system responds to current and emerging pressures. Research shows that those health systems with strong primary health care are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes including lower mortality, than those that do not (NPHCS, 2009).

The recently released World Health Organization (WHO) Report, Primary Health Care: now more than ever, calls for a return to primary health care to help align health systems to deliver better performance and equity. The WHO Report found that where countries at the same level of economic development are compared, those that were organised around the tenets of primary health care produced a higher level of health for the same investment.

Around the globe, many nations are grappling with how best to address similar issues. In response, many industrialised countries including Australia, New Zealand, the United Kingdom and Canada have undertaken significant investment and reform processes directed at strengthening the primary health care sector (WHO, 2012). These reform processes have predominantly focussed on encouraging a population health focus, greater use of multi-disciplinary teams, increased accountability for performance, and improved access to services.

4.2 Health Service Reform, Model of Care and Health Workforce Capacity

The World Health Organisation, international and national health policy environment is in substantial agreement around the following considerations with respect to health service reform and propose:

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A people-centred primary health care model, with a strong focus on addressing inequities, prevention of chronic disease, a population health focus, greater use of multi-disciplinary teams, increased accountability for performance, and improved access to services.

The health sector needs to refocus on wellness, prevention and primary health care if it is to be sustainable in the future (Health Workforce Australia (HWA), 2011).

Sustainability will require re-balancing many aspects of the current system: making decisions based on consumer and community need and focusing on the most cost-effective and efficient workforce arrangements to provide care (HWA, 2011).

This will mean re-configuring the workforce and the education and training programs that prepare and support them (HWA, 2011).

Inter-professional education and collaborative patient-centred practice are key to building effective health care teams and improving the experience and outcomes of patients (Canadian Inter-professional Health Collaborative (CIHC), 2007).

As outlined previously, evidence that risk factors (both environmental and behavioural) for chronic diseases and functional decline occur throughout the life-course, and can be prevented or postponed, has influenced a reorientation of health systems from a model based on treatment of resultant illness to a strengthened primary health care model. The increasing incidences of chronic illness and life-style diseases have placed even greater demands on already stretched health services. These changes have necessitated a shift in focus from acute service delivery to a chronic care model that emphasises among other system changes, interactions between practice team and patient, and support for self-management (Bodenheimer, Wagner & Brumbach, 2002).

In response, many industrialised countries including Australia, New Zealand (NZ), the United Kingdom (UK) and Canada have undertaken significant investment and reform processes directed at strengthening the primary health care sector. These reform processes have predominantly focussed on encouraging a client centred population health focus, health promotion, greater use of multi-disciplinary teams, and improved access to services.

While the primary health care sector delivers services that meet the needs of most people requiring treatment for isolated episodes of ill-health, it is less successful at dealing with the needs of people with more complex conditions or in enabling access to specific population groups that are ‘hard to reach’. Increasingly, both in Australia and overseas, there is recognition that strengthening and improving the way in which primary health care is provided is vital in determining how well the health system responds to current and emerging pressures. Research shows that those health systems with strong primary health care are more efficient, have lower rates of hospitalisation, fewer health inequalities and better health outcomes including lower mortality, than those that do not.

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The health sector needs to focus on wellness, prevention and primary health care if it is to be sustainable in the future. Sustainability will require re-balancing many aspects of the current system: making decisions based on consumer and community need and focusing on the most cost-effective and efficient workforce arrangements to provide care (HWA, 2011).

The recently released World Health Organization (WHO) Report, Primary Health Care: now more than ever (2008), calls for a return to primary health care to help align health systems to deliver better performance and equity. The WHO Report found that where countries at the same level of economic development are compared, those that were organised around the tenets of primary health care produced a higher level of health for the same investment.

To cope with the increasing complexity of health, organisations are recognising the need for effective teamwork between the health professions (Institute of Medicine, 2001).There is greater awareness that one profession alone can no longer meet the needs and expectations of the patient, nor can professions continue to work in silos, being reliant on the complementary skills of their colleagues to provide optimal care. There is also growing patient and community expectation of greater partnership and inclusion in the healthcare process. There is increasing emphasis on new ways of visualising the patient-professional relationship, where patients are recognised for their expertise and health care practitioner and patient roles are negotiated within the patient-professional relationship. There is growing recognition that the task of the health practitioner is to help patients manage their own health (NPHCS, 2009)

In recognition of the growing burden of chronic disease on individuals, communities, organisations and governments, a national policy approach has been adopted to improve chronic disease prevention and care across Australia (National Health Priority Action Council (NHPAC), 2006). The National Chronic Disease Strategy report (2006) incorporated an inter-professional approach to care, not only between individual practitioners but also in promoting collaboration between the various health care sectors, as evident in Principle 5:

Health care practitioners operating in effective primary health care networks are best placed to provide a team based approach (NHPAC), 2006. p10). Integrated care means that health services work collaboratively with each other, and with patients and their families and carers, to provide person centred optimal care (NHPAC), 2006. p11).

National health care reform is a strategic priority for the Council of Australian Governments (COAG). In 2007 the National Health Workforce Taskforce was established to progress health care reform with an aim of addressing priority issues identified in the National Workforce Strategic Framework. A key strategic action suggested is the development of ‘workplace, professional and education and training practices that facilitate team approaches and multidisciplinary care’ (Australian Health Ministers’ Conference, 2004).

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The National Health Agreement (2008) affirms the agreement of all governments that Australia’s health system should:

be shaped around the health needs of individual patients, families and their communities;

focus on prevention of disease and the maintenance of health, not simply the treatment of illness;

support an integrated approach to the promotion of healthy lifestyles, prevention of injury and diagnosis and treatment of illness across the continuum of care; and

provide all Australians with timely access to quality health services based on their needs, not ability to pay, regardless of where they live in the country.

The health sector needs to focus on wellness, prevention and primary health care if it is to be sustainable in the future. Sustainability will require re-balancing many aspects of the current system, making decisions based on consumer and community need and focusing on the most cost-effective and efficient workforce arrangements to provide care. It will mean re-configuring the workforce and the education and training programs that prepare and support them (HWA, 2011).

The National Primary Health Care (Draft) Strategy 2012 identified the following key priority areas:

improving access and reducing inequity; better management of chronic conditions; increasing the focus on prevention; improving quality, safety, performance and accountability.

Underpinning these key priority areas is the recognition that a patient-centred focus, and well educated and distributed workforce are key to all future reforms in primary health care.

In meeting the ongoing and future needs of the Australian population, the Draft National Primary Health Care Strategy aims to build on the undertakings agreed through the National Healthcare Agreement to improve the level of cooperation, coordination and integration of service delivery across Commonwealth and state and territory governments and to refocus the primary health care system on meeting the needs of individual patients, being responsive to changing population needs, and operating effectively in a broader social system.

In response to these challenges, health systems in general, and health services in particular, are increasingly emphasising the critical importance of improved and increased levels of inter-professional practice: that is, health professionals working together, often in teams, to manage complex practice situations. Changing the way health professionals are educated is a critical step to achieving broader system change and ensuring that health practitioners have the necessary knowledge and training to work effectively within a complex and evolving health care system

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Recognising the association between education and health reform, education and training was one of the key portfolios of the National Health Workforce Taskforce Objectives for this portfolio focused on maximising capacity of health and education systems to meet the projected workforce demands, and ensuring that education and training was appropriate, responsive and relevant to the changing health system needs.

What is required is a paradigm shift in ways of thinking about workforce design and planning, one that works backwards from outcomes for communities, consumers and population need, versus the current thinking that is generally focused on working forward from the base of existing professions and their interests and skills, demarcations and responsibilities (The National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015).

One of the key recommendations of the Australia’s Health Workforce report was to call for a national and systematic dialogue on health education and training to: facilitate consideration of education and training issues on an integrated rather than profession-by-profession basis. Amongst other things, this could provide greater scope to identify common education and training requirements across particular professions, and consequent opportunities to further develop inter/multi-disciplinary training approaches (Productivity Commission, 2005).

In recent years, there has been a continuous shift in the healthcare system towards collaboration and patient-centred care. Patient-centred care demands that healthcare professionals work together in an effective manner. The evidence suggests, however, that often these professionals do not collaborate well. Inter-professional education (IPE) offers a possible way to improve this through the education of healthcare students in multidisciplinary settings during their professional training. The goal of IPE is to cultivate knowledge of and establish collaboration with other professionals early on in the career of healthcare providers in order to enhance future practices.

The service/workforce capacity to address emerging health concerns links a multidisciplinary primary health service with an inter-professional health workforce education strategy in order to promote the health of populations throughout their life-course.

The WHO Framework for Action on Interprofessional Education and Collaborative Practice report (World Health Organisation, 2010) emphasises the role of inter-professional education in underpinning the development of a collaborative practice-ready health workforce, where health workers work together and rely on one another in delivering quality healthcare. The report summarised the evidence regarding the positive impact of inter-professional education on collaborative practice, and the impact of collaborative practice in addressing local health needs and improving healthcare delivery and patient outcomes.

This report noted that a high level of synergy between the health workforce planningsector and health education systems was critical, particularly for supporting thetransition of learners from the classroom to the workplace and enhancing the

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sustainability of inter-professional education and collaborative practice initiatives generally.

The National Health Workforce Innovation and Reform Strategic Framework for Action 2011-2015 is a national call to action for workforce reform that will involve and link the health and education sectors. The Framework has been designed to provide an overarching, national platform that will guide future health workforce policy and planning in Australia. It sets out key priority areas and five essential domains that create the foundation for an integrated, high performing workforce fit to meet Australia’s health care needs. A key finding of the strategy is that a major shift is required towards inter-professional education and practice to improve collaborative team-based practice and the quality of care delivered.

4.3 Inter-professional Education, Practice & Health Workforce Competency

In as much as the international and national health strategic directions have called for health system reform with respect to emerging health needs, models of care and workforce capability, the health workforce education sector is undergoing considerable change with respect to the organisation of health professional education and learning models required to support and ensure the work readiness of health professionals for client centred inter-professional practice.

Globally, policy drivers for inter-professional education (IPE) reflect the increasing pressures on the healthcare system. Within the Australian context, the need for new forms of educational thinking and practice aimed at addressing the above health issues and challenges through inter-professional learning have been increasingly articulated within the policy and practice literature.

Inter-professional education seeks to encourage different health professions to interact and learn together during their training process which will eventually lead to collaborative healthcare practices and improved care for patients. Inter-professional education (IPE), a process whereby health professionals learn from, with and about each other is advocated as a response to widespread calls for improved communication and collaboration between healthcare professionals (WHO, 2010).

A report commissioned by the US Institute of Medicine highlighted the anomaly between healthcare practice and education settings in that, although health professionals are expected to engage in collaborative practice in teams, they are not trained together or trained in team-based skills (Institute of Medicine, 2003). As such, this report identified: that all health professionals should be educated to deliver patient-centred care as part of an interdisciplinary team.

The first documented Australian IPE initiatives in the education of health professionals dates back to the late 1960s with Piggott (1975) describing a community-focused program

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developed and implemented through the Community Care Teaching Unit of Royal Prince Alfred Hospital, Sydney. This program was based within a community setting, allowing students the opportunity to become part of a student multidisciplinary team in planning the health care of community based patients. The focus on primary health care in the 1970s and the Declaration of Alma Ata (World Health Organisation, 1978) had a major impact on policy in Scandinavian countries, and provided the foundations for IPE in many ways. Linköping University in Sweden first implemented an inter-professional curriculum in 1986 (Areskog, 1988) when it launched its new Faculty of Health Sciences, two years before the WHO Learning Together to Work Together for Health report was released.

Linköping University is widely acknowledged as one of the forerunners for embedding IPE within curricula. Following its lead, other universities within the region responded with their own IPE initiatives. For example, the Karolinska Institute has implemented similar ward-based IPE training programs (Ponzer et al., 2004).

The University of Alberta in Canada has a relatively long history of IPE, first offering an interdisciplinary course in 1992 (Philippon, Pimlott, King, Day, & Cox, 2005). Initially an elective, this course is now embedded within curricula as a mandatory and assessed component for all healthcare students.

Davidson and Lucas (1995) also described two programs at the University of Adelaide, which included students from several different health professions. This Working in Health Care program focused on concepts of primary health care and the potential contributions of the different professions to the health system, and was mandatory for second year students; and the Community Practice Workshop was an elective for final year students and focused on translating community health principles into practice. State funding for these programs continued up until the mid-nineties, but these initiatives ceased once grant funding was withdrawn.

The United Kingdom Department of Health publication Working Together – Learning Together: a framework for lifelong learning for the NHS(2001) emphasised pthat core skills, particularly communication skills, undertaken on a shared basis with other professions, should be included from the earliest stages in professional preparation in both theory and practice settings

In 2003 in Canada, the First Ministers Health Accord identified that changing the way health professionals are educated was a key requisite for an integrated and interdisciplinary approach to care (Health Canada, 2003). Health Canada committed to a program of inter-professional research and service delivery and allocated funding of over nineteen million Canadian dollars. The Canadian Inter-professional Health Collaborative (CIHC) was established to facilitate the coordination and dissemination of information from funded projects. CIHC views that: inter-professional education and collaborative patient-centred

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practice are key to building effective health care teams and improving the experience and outcomes of patients (CIHC, 2007).

4.3.1 Education Sector ReformsWithin the context of economic globalisation, national systems of higher education are being brought more closely into alignment with international standards and modes of provision (Marginson, 2007; 2010). In Australia, reforms collapsed the binary system of tertiary education (with its division into universities that were discipline-based and the vocationally oriented colleges and institutes of technology), and established a ‘unified national system’ that eventually produced thirty-eight public universities (Dawkins, 1988). One significant turning point was the arrival of a variety of health professions hitherto located in colleges of advanced education and institutes of technology into the newly configured universities. Notable among these were the nursing and various allied health professions, such as occupational therapy and speech pathology. This created a new environment for a wider conception of health professional education than that provided by the earlier binary system in which only medicine, dentistry, physiotherapy and pharmacy were typically located in universities. It is within this environment that IPE developments within Australian higher education need to be situated and understood.

4.3.2 Student Learning TheoriesUniversity teaching has been substantially reshaped, and a field of research and development has emerged that has focused attention emphatically on student learning. Most notably, the concepts of ‘deep’ and ‘surface’ learning approaches in higher education that influence implicit or explicit approaches to teaching were widely established within a new field of educational development (Lee, 2005).

A similarly influential development has been the work of Biggs and colleagues on ‘constructive’ alignment (Biggs, 1999; Biggs & Tang, 2007). Constructivism comprises a family of theories that have in common the centrality of the learner’s activities in creating meaning. Biggs made a further distinction between ‘declarative knowledge’ and ‘functioning knowledge’ with the latter providing a means of conceptualising education for professional practice, and leading to the development of educational pedagogies and practices such as problem-based learning, case-based learning, lifelong learning and work-based learning, which foster collaborative and team learning.

More recently, an emphasis on what are called ‘threshold concepts’, has seen a more collaborative process of discipline scholars and educational developers working together to determine concepts critical for the development of understanding within disciplines and professional fields (Meyer & Land, 2003). A growing emphasis on aligning curriculum to outcomes, as shaped by a range of changing pressures from governments, the economy, and accrediting bodies, has meant that the ideas of constructive alignment and threshold concepts have become more systematically linked to policy agendas in the last five years. This has led to a concern within curriculum design for defining the capabilities that

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graduates are required to have upon completing their courses and entering the workforce and taking up social responsibilities. Recent research and development in what have become known as ‘graduate attributes’ (Barrie, Hughes, & Smith, 2009) has built on a prior focus in the vocational sector on skills, competencies and capabilities.

In a paper generated for WHO, Thistlethwaite & Moran (2010) reported on the learning objectives, learning outcomes, competencies or capabilities most frequently associated with IPE. The key words found within the literature most commonly associated with IPE learning outcomes were:

teamwork, roles and responsibilities, communication, learning/ reflection, the patient, and ethical/attitudes.

Development of evidenced-based assessments of inter-professional learning outcomes remains a major challenge for inter-professional educators. Health professional students are almost always assessed for individual achievement and their registration depends on meeting defined standards in knowledge and skills. While it is possible to assess knowledge of teamwork, roles and responsibilities, teamwork skills should at some point be assessed in the context of students working in teams. Some writers have drawn attention to the difficulty of assessing team attitudes regarding the values of inter-professional practice’ (Hammick & Anderson, 2009).

Consistent with the core definition of IPE teaching strategies utilised for inter-professional learning must include interactive methods. Small group formats and interactive sessions have the potential to encourage students to learn with, from, and about one another as students are dependent upon each other for at least part of their learning (Freeth et al., 2005).

A core underpinning assumption of adult learning theory is that learning experiences need to be relevant to the student (Knowles, 1980). In the context of IPE, Oandasan and Reeves (2005) suggested that, by incorporating some form of clinical exposure, relevance is enhanced, and hence motivation of learners to engage in IPE activities is also increased.

There is considerable debate and little consensus concerning the stage at which pre-qualification healthcare students should be introduced to inter-professional learning. Some have argued that it should begin early in the training programs of individual professions before any misconceptions are formed or stereotyping occurs (Anvaripour, Jacobson, Schweiger, & Weissman, 1991; Horak, O’Leary, & Carlson, 1998). Others have proposed that students must first gain knowledge and confidence within their chosen field before interacting effectively with other professions (Mariano, 1989; Petrie, 1976). Harden (1998) has suggested that “when” is not as important as ensuring that the learning activities are appropriate for the level of experience and stage at which the student is at within their

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program. For example, IPE clinical placements involving students exchanging and applying profession specific clinical knowledge, are best suited for senior students.

The New Generation Program at Southampton University incorporates three pedagogical approaches:

guided discovery learning; inter-professional learning; and collaborative learning within their IPE model (O’Halloran et al., 2006).

The first of these approaches enables students to develop their self-directed learning skills, while the second requires that students have the opportunity to learn not only with each other, but also from each other. This links with the third approach of collaborative learning. Learning activities are designed to promote authentic interdependence and equal contributions from all group members (Craddock et al., 2006).Increasingly, literature related to health service delivery and health workforce planning focuses on the need for collaborative inter-professional work practices.

For example, the National Patient Safety Education Framework Report (2005) identified that the development of IPE and inter-professional practice (IPP) capabilities across all sections of the Australian health workforce was essential for enabling effective collaboration, effective team work, and increased levels of quality and safety (Australian Council for Safety and Quality in Health Care, 2005, p.6).

Until recently, IPE curriculum initiatives have been piecemeal and have existed on the margins of mainstream curriculum in different professional fields. While there is now an array of IPE-related publications, and a rapidly increasing number of IPE initiatives underway within pre-qualification education programs, what is less common is a ‘whole of curriculum’ approach where IPL is part of the vision for the future, and is practically integrated and embedded within mainstream curricula as a mandatory, assessed component.

The WHO Framework for Action (2010) also identified an important number of mechanisms shaping and supporting how inter-professional education is developed and delivered. These include elements related to the training of personnel involved in developing and delivering curricula, institutional and environmental support mechanisms such as a working culture that is conducive to practicing collaboratively, and governance mechanisms which emphasise patient safety.

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4.3.3 Inter-professional Health Workforce CompetencyCompetence can be defined as the ability to handle a complex professional situation by combining relevant knowledge, skills and attitudes (Miller, 1990). Inter-professional competence, according to this view, refers to students’ ability to function effectively as a member of an inter-professional health care team.

One task undertaken by the Canadian Inter-professional Health Collaborative (CIHC) was to consolidate and reach consensus across the nation on a competency framework. An initial review of the literature identified a number of common terms used in these core competencies related to IPE including problem solving; decision making; respect; communication; shared knowledge and skills, and patient centred practice (Canadian Inter-professional Health Collaborative, 2007).

Linköping University has developed a framework defining a common set of professional values, which underpin a common set of inter-professional competencies include knowing roles and capabilities of other professionals, cooperation with other professionals, and awareness of skills and competence of other professions (Areskog, 2009; Fallsberg & Hammar, 2000; Wilhelmsson, et al., 2009). From the initial review, the CIHC (2010) have developed a national inter-professional competency framework detailing core knowledge, skills, attitudes and behaviours required for collaborative practice applicable to all health professions and clinical settings. Six competency domains which are thought to be developmentally incremental are identified, including two underpinning domains of inter-professional communication and patient/ client/family/community-centred care which influence four other competency domains of role clarification, team functioning, collaborative leadership, and inter-professional conflict resolution.

These competencies are similar to those listed in the WHO (2010) framework for action on inter-professional education and collaborative practice. The CIHC report also identifies that the complexity of the practice situation, the context of local practice, and the need for quality improvement are elements which need to be taken into account when applying the framework (Canadian Inter-professional Health Collaborative, 2010).

What is less clear from the CIHC report, however, is the differentiation between core competencies that could be related to,

learning in common (e.g. evidence-based practice; quality improvement practice; and information), and

Collaborative capabilities- those that add value by being addressed using inter-professional approaches.

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This differentiation underpins and proposes a content area of core competencies for learning in common along with the development of collaborative competencies which translate to patients, communities and other sectors as well as inter-professionally.

The National Chronic Disease Strategy Report (2006) also specified in one of its key direction statements, the development of core chronic disease prevention and care competencies within undergraduate and postgraduate health professional education. Included in this skill set are:

communication skills, which enable service providers to collaborateeffectively at three levels: not only with patients and their families andcarers, but also to be able to work closely with other service providers,and to join with communities to improve outcomes for people with chronic disease (National Health Priority Action Council (NHPAC) 2006) p36.

A major objective of the recommendations made in the Garling (2008) report on Acute Care Services in New South Wales Public Hospitals is the creation of an effective hospital workforce. The report recommended that health professional ‘clinical education and training should be undertaken in a multi-disciplinary environment which emphasises inter disciplinary team based patient centred care’ and that a central body such as an Institute of Clinical Education and Training be established to design, deliver, assess and evaluate clinical training across the professions. This report also sent a strong message about developing the capacity of the health workforce to work within a multidisciplinary environment as a member of, or as a contributor to an interdisciplinary team.

Similarly, the recent National Health and Hospitals Reform Commission (2009) report recommended the development of a new framework for the education and training of our health professionals which moves towards a flexible, multi-disciplinary approach, and incorporates an agreed competency-based framework as part of a broad teaching and learning curriculum for all health professionals.

The updated Tomorrow’s Doctors report (General Medical Council, 2009) has outlined that medical graduates will need to demonstrate the capacity to:

learn effectively within a multi-professional team understand and respect the roles and expertise of health and social care

professionals in the context of working and learning as a multi-professional team; understand the contribution that effective interdisciplinary team working makes to the

delivery of safe and high-quality care; work with colleagues in ways that best serve the interests of patients, including

passing on information and handing over care, demonstrating flexibility, adaptability and a problem solving approach;

build team capacity and positive working relationships and undertake various team roles including leadership and the ability to accept leadership by others.

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Despite the various IPE activities documented in the literature, its integration within healthcare education curricula is not occurring in a systematic fashion within Australia. Inter-professional education presents many challenges for educational organisations, health care providers and professional associations and these are summarised in the next section (Gardner, Chamberlin, Heestand, & Stowe, 2002; Headrick, Wilcock, & Batalden, 1998).

The need remains to identify, agree on, and strengthen core competencies for inter-professional collaborative practice across the professions. Competency domains and specific competencies should remain general in nature and function as guidelines, allowing flexibility within the professions and at the institutional level.

Principles of inter-professional competencies include: Patient/family centred (hereafter termed “patient centred”) Community/population oriented Relationship focused Process oriented Linked to learning activities, educational strategies, and behavioural assessments

that are developmentally appropriate for the learner Able to be integrated across the learning continuum Sensitive to the systems context/applicable across practice settings Applicable across professions Stated in language common and meaningful across the professions Outcome driven

Core competencies are needed in order to: create a coordinated effort across the health professions to embed essential content

in all health professions education curricula, guide professional and institutional curricular development of learning approaches

and assessment strategies to achieve productive outcomes, provide the foundation for a learning continuum in inter-professional competency

development across the professions and the lifelong learning trajectory, acknowledge that evaluation and research work will strengthen the scholarship in

this area, prompt dialogue to evaluate the “fit” between educationally identified core competencies for inter-professional collaborative practice and practice needs/ demands, find opportunities to integrate essential inter-professional education content

consistent with current accreditation expectations for each health professions education program (see University of Minnesota, Academic Health Center, Office of Education, 2009),

develop a common set of accreditation standards for inter-professional education (see Accreditation of Inter-professional Health Education: Principles and practices, 2009; and Accreditation of Inter-professional Health Education: National Forum, 2009)

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inform professional licensing and credentialing bodies in defining potential testing content for inter-professional collaborative practice

(Interprofessional Education Collaborative Expert Panel (IPEC),2011. p7)

Currently, the transformation of health professions education is attracting widespread interest. The transformation envisioned would enable opportunities for health professions students to engage in interactive learning with those outside their profession as a routine part of their education. The goal of this inter-professional learning is to prepare all health professions students for deliberatively working together with the common goal of building a safer and better patient-centred and community/population oriented health care system. Achieving that vision for the future requires the continuous development of inter-professional competencies by health professions students as part of the learning process, so that they enter the workforce ready to practice effective teamwork and team-based care (IPEC, 2011).

4.3.4 Enablers and Challenges of Inter-professional Education and Practice.Key enablers and challengers identified in the literature that influence the use of research evidence, knowledge transfer and inter-professional education and practice are summarised in Tables 1 and 2.

Table 1: Key Enablers Identified in Literature Partnerships within and between academic institutions, health care facilities

and stakeholders Identification of additional sources of support and resources Support and incentives for inter-professional collaboration, facilitated by

horizontal integration of medical, nursing and allied health training activities Vertical integration across undergraduate, postgraduate and vocational health

training The need for staff to model inter-professional collaboration and ensure that

curricula make explicit the rationale for inter-professional learning Structuring learning activity toward developing inter-professional competence

for contemporary health service delivery Ensuring that the espoused values of inter-professional practice and learning

are reflected in assessment events. Ensuring inter-professional learning is not extracurricular or non-credit Valuing faculty time dedicated to this work Realising the potential to initiate systems change at the clinical level Ensuring the pursuit of educational goals does not compromise patient care Engagement with clinicians in the clinical practice setting who are

instrumental in assisting students make sense of their knowledge through practice

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Table 2: Key Challengers Identified in Literature The negotiation of competing curricula, clinical supervision, timetabling,

resistance to change Logistical incompatibilities within and between academic institutions and

healthcare facilities including scheduling difficulties and faculty workloads Discontinuity in student availability -students can neither make up for staffing

shortages nor be expected to maintain programs Negotiating conflicts i.e. response to community needs vs careful curricular

development. Sustaining inter-professional collaboration is challenging- historical inter-

professional and intra-professional rivalries Differing expectations of each profession. This is seen at an academic level,

as well as with site-based educators and placement supervisors and often a result of differences in requirements and regulations between the professions

The fear that inter-professional practice will lead to a loss of status, a loss of professional identity, and a dilution of the role of individual professions in patient care

Heavily committed curriculum and clinical placement schedule for each profession.

Lack of availability of suitably trained academic staff and clinical placement supervisors to facilitate inter-professional programs

Lack of facilities and resources to deliver campus based inter-professional programs e.g. tutorial rooms

Lack of geographical co-location of individual schools/ faculties

4.4 Student Inter-professional Practice Initiatives Relevant to Healthy Ageing Clinics

4.4.1 Description of Student Inter-professional Practice InitiativesA literature search about student inter-professional practice initiatives relevant to healthy ageing clinics yielded 183 published studies and papers at first instance from which 46 were subsequently selected for their relevance to the proposed Model for analysis (Appendix 2). These papers revealed that there has been substantial growth in the number of student managed health initiatives over recent years. For instance in 2007, there were 49 Medical Schools in USA operating 110 medical student-run health clinics offering chronic disease management. Other exemplars were identified from the literature which embraced:

mental health(depression screening) maternity nursing practice falls prevention Medication management geriatrics autism communicable disease adolescents – young adults disabled people rural outreach.

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Significantly, there was only one student run health initiative which addressed the outcome of healthy ageing and this was conducted in the early 80’s and was not inter-professional.

The literature also reported evaluations of the student-run, inter-professional initiatives and provided evidence of significant impacts in the following areas:

Consumer health interventions Improved access to disadvantaged/underserved consumers Improved management of chronic disease Consumer satisfaction Inter-professional student learning outcomes Improved supervision/innovative clinical placements Work readiness Curriculum development Systems change Cost effectiveness.

4.4.2 Alignment of Student Inter-professional Practice Initiatives with Health, Education and the Proposed Model.A qualitative thematic analysis of the 46 studies was conducted looking for themes that were relevant to the proposed Model (see Table 3). Thirty six recurrent themes were identified falling into four broad domains:

Evidence of Need Health System/ Service directions Health Profession Education System directions Outcomes.

The recurrent themes (characteristics) emerging from the studies represent innovative collaborations of health professional educators, health professionals and, students which,

address the evidence of health needs and priorities propose a health promotion and population health approach adopt a client centred, interdisciplinary, team based model of healthcare develop inter-professional/practice based learning and work readiness conduct consumer, service and student evaluations.

Additionally, all other literature reviewed from health, policy and education was examined for these recurrent themes. It was revealed that the other literature also contained these themes.

In summary, the thematic analysis provides evidence of substantial alignment of and between:

Reforms and strategic directions for Ageing, the Health Service Systems and Health Professional Education Systems

Health Service models of care and models of inter-professional education

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The student led service initiatives reviewed from research literature and the model of a student led inter-professional healthy ageing clinic which is proposed.

For the purpose of this project the evidence to support the proposed Model may be conceptualised from three inter-reliant perspectives,

Health Outcomes for consumers and communities, Health system reform and service delivery outcomes, Student education, learning and practice outcomes,

but progress will require reconceptualising and reconciling the entire paradigm.

Importantly, one of the four domains, the Outcomes, which contains the three themes, wellness focus, inter-professional/inter-sectoral collaborative learning and practice, and building workforce capacity, defines the paradigm shift which is required to address the current and emerging health needs of the population. These three themes are also the pillars of the reform agendas; the studies from the literature search; and the model which is the subject of this project.

Further from the student interprofessional practice initiatives reviewed several themes from the Evidence of Need section in Table 3:

Underserved Groups/Service Gaps, Chronic Disease/outcomes, Health Promotion/prevention, Population health approach, Health equity, and Cost benefit/effectiveness,

underline the core areas of education, learning and practice undertaken by students and clinical supervisors. These themes proposed core areas of “learning in common” which are being facilitated collaboratively and they likewise underpin the international health reform agenda.

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Table 3: Domains and themes identified from the literatureEvidence of NeedDemography Epidemiology Policy AlignmentUnderserved Groups/Service Gaps

Chronic Disease/outcomes Health Promotion/prevention

Population health approach

Health equity Cost benefit/effectiveness

Health System/Service DirectionsService Model Primary Healthcare Client centredConsumer health capacity Health literacy Inter-agency collaboration

Multidisciplinary/team skills/consultation

Health and Academic Partnership

Inter-professional learning

Student led Service location Pilot initiatives/evaluation

OutcomesHealth Paradigm shift (pathogenic>salutogenic/)Wellness focus

Health, and Education Paradigm shift(inter-professional/inter-sectoral collaborative learning and practice)

Health Service/Workforce (building capacity to meet emerging needs)

Education System DirectionsCompetency development/assurance

Curriculum development Simulation/resource development

Health Practice modification

Shift in Service demand Evaluation

Replication Research Barriers, enablers, ethics

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4.5 Health and Education Policy Nexus

This section presents the results of a further analysis of the international and national health and education policy literature. The policies were evaluated for convergence. Boxes 1, 2, 3, and 4 detail the extent of the alignment found.

Box 1: Policy Alignment- WHO and Health Reforms

WHO Health Frameworks, International and National Health Reform(s) converge to propose healthcare systems/services with the following features: People-centred primary health care model Accessible, clinically and culturally appropriate, timely and affordable Strong focus on addressing inequities in access to health services focus on disease prevention and preventive care, including support of healthy

lifestyles Greater use of population health approaches Well-integrated, coordinated, and providing continuity of care, particularly for

those with multiple, ongoing, and complex conditions Interdisciplinary teamwork and inter-sectoral collaboration Supportive of health literacy, self-management and individual preference Safe, high quality care which is continually improving through relevant research

and innovation Responsive to the needs of local communities. Inter-professional education and training arrangements for both new and existing

workforce Fiscally sustainable, efficient and cost-effective.

Box 2: Policy Alignment- WHO and IPE

WHO, International and National Frameworks for Inter-professional Education and Knowledge Translation reveal and propose: Globally, the policy drivers for inter-professional education (IPE) reflect the

increasing pressures on the healthcare system There is greater awareness that one profession alone can no longer meet the

needs and expectations of the patient, nor can professions continue to work in silos

Changing the way health professionals are educated is a critical step to achieving broader system change and ensuring that health practitioners have the necessary knowledge and training to work effectively within a complex and evolving health care system

Inter-professional education and collaborative patient-centred practice are key to building effective health care teams and improving the experience and outcomes of patients

IPE focuses on maximising capacity of health and education systems to meet the projected workforce demands, and ensuring that education and training is appropriate, responsive and relevant to the changing health system needs

IPE facilitates consideration of education and training issues on an integrated rather than profession-by-profession basis and provides greater scope to identify

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common education and training requirements across particular professions all health professionals should be educated to deliver patient-centred care as part

of an interdisciplinary team IPE incorporates an agreed competency-based framework as part of a broad

teaching and learning curriculum for all health professionals core skills undertaken on a shared basis with other professions, should be

included from the earliest stages in professional preparation in both theory and practice settings

IPE core skills can facilitate the development of, amongst others, skills in the areas of communication, problem solving, multidisciplinary teamwork, consultation, chronic disease management, population health, planning and evaluation, health promotion and prevention.

IPE supports the transition of learners from the classroom to the workplace and enhances the sustainability of inter-professional education and collaborative practice initiatives generally.

Inter-professional education underpins the development of a practice-ready health workforce

Health care workers who are educated and trained to work together can reduce risks to patients, themselves and their colleagues

Box 3: Policy Alignment- Health Workforce

Implementation of COAG Health Workforce package includes consideration of the following issues: Students experience clinical education in primary health care, early and often, in

a supportive working environment; Supporting inter-disciplinary learning across primary health care professions

through streamlining organisational infrastructure at the regional level; Testing models of vertically integrated training whereby different stages of clinical

training are aligned; Infrastructure requirements for community-based clinical training (where

appropriate) and boosting teaching capacity; and Financing arrangements that can better support training of primary health care

professionals within the sector.

Box 4: Policy Alignment- WHO and Ageing

WHO and National Frameworks for AgeingA number of propositions can be drawn from the foregoing review of International and National Health Service Reforms and Health Education Reforms which strongly support the feasibility and pertinence of the establishment of “a community based inter-professional student managed Healthy Ageing Clinic” as is proposed by this study, but even beyond that particular application, there is a critical need to address the promotion of inter-professional education and practice initiatives per se within a strengthened primary healthcare model. These propositions are outlined below:

International and National Health Service Reforms and Health Education Reforms are calling for both a strengthened model of primary healthcare to deal with present and emerging health concerns, and agree that,

Changing the way health professionals are educated is a critical step to achieving

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broader system change and ensuring that health practitioners have the necessary knowledge and training to work effectively within a complex and evolving health care system.

The predominant influence will remain ageing, which will cause most change in the use of primary health care services.

Active ageing policies and programmes are needed to enable people to continue to work according to their capacities and preferences as they grow older, and to prevent or delay disabilities and chronic diseases that are costly to individuals, families and the health care system.(WHO, 2002)

The above reform directions focus on:o A people-centred primary health care model, with a strong focus on

addressing inequities, prevention of chronic disease, a population health focus, greater use of multi-disciplinary teams, increased accountability for performance, and improved access to services.

o The health sector need to refocus on wellness, prevention and primary health care if it is to be sustainable in the future.

o Sustainability will require re-balancing many aspects of the current system: making decisions based on consumer and community need and focusing on the most cost-effective and efficient workforce arrangements to provide care. (HWA)

o This will mean re-configuring the workforce and the education and training programs that prepare and support them.

o Inter-professional education and collaborative patient-centred practice are key to building effective health care teams and improving the experience and outcomes of patients

o A major shift towards inter-professional education and practice, where health professionals from different backgrounds learn with, from and about one another to improve collaborative team-based practice and the quality of care delivered.

o core skills undertaken on a shared basis with other professions, should be included from the earliest stages in professional preparation in both theory and practice settings

o Strong partnerships across the health and education sectors is critical to effectively plan the pipeline from education to work, especially clinical training placements that involve collaborative planning with service providers.

In summary, international and national health service and health education reforms are calling for both a strengthened model of primary healthcare to deal with present and emerging health concerns, and agree that, changing the way health professionals are educated is a critical step to achieving broader system change and ensuring that health practitioners have the necessary knowledge and training to work effectively within a complex and evolving health care system. The predominant influence will remain ageing, which will cause most change in the use of primary health care services.

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5 Examples of Inter-professional Education in Practice in Australasia

Majority of advanced models of integrated inter-professional education are aggregated in the northern hemisphere and primarily in the United Kingdom, Canada and the United States of America. The Canadian system is the most unified, advanced and mature supported through national policy and recurrent funding. There is a strong inter-professional education movement in the United States led by a number of Medical Schools. External to Curtin University and the Auckland University of Technology, inter-professional practice is at an embryonic stage across Australasia.

5.1 Curtin University, Western Australia

Curtin University’s transformation to inter-professional learning and education commenced with pilot programs as recently as 2009 and has progressed to an Inter-professional based curriculum and clinical placement program. The program covers the disciplines of nursing, occupational therapy, pharmacy, and physiotherapy. Medical students from the University of Western Australia and Notre Dame University participate in the program. Partners in this initiative include a consortia of education providers, Western Australian Health Department and Health Consumer Council.

Current inter-professional initiatives: A student managed general medical ward at Royal Perth Hospital. Campus based inter-professional clinics Aged care facility in partnership with Uniting Church Early childhood service Rural based mental health service

Curtin University has received a number of national and international awards, and maintains ongoing collaboration with national and international leaders in inter-professional education including the Karolinska Institute in Sweden.

5.2 Auckland University of Technology

Auckland University of Technology (AUT) hosts the National Centre for Inter-professional Education and Collaborative Practice and has been successful in implementing a number of inter-professional initiatives through their Faculty of Health and Environmental Sciences. AUT has a developing and integrated program of initiatives in collaboration with educational institutions, hospitals and district health boards.

Current inter-professional initiatives: Akoranga Integrated Health Clinic Healthcare Team Challenge

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Inter-professional rural and primary health care placement - Wellsford Inter-professional education workshops and lectures Currently developing an inter-professional summer school project with the

Waitemata District Health Board

Three inter-professional first year courses (Papers) have been developed in: Lifespan Development and Communication Knowledge, Enquiry and Communication Health and Environment

6 Stakeholder Consultation

Significant consultation and engagement of clinical and academic experts, project partners and community stakeholders occurred throughout the course of the project

A clinical expert panel was established from the onset. This expert panel consisted of clinical leaders, educators and researchers in specialist fields relevant to healthy ageing and inter-professional education.

Broad stakeholder consultation was undertaken across the following relevant community organisations who were agencies developing and implementing innovative services for older people and/or inter-professional initiatives and advocacy bodies representing the interests of older people (see Box ).

Box 5: Stakeholders ConsultedHunter Medicare LocalNew England Medicare LocalAwabakal Newcastle Aboriginal Cooperative LtdNewcastle City CouncilLake Macquarie City CouncilMercy ServicesTAFE NSW Hunter InstituteNovaCareCentral Coast Medicare LocalCentral Coast Aged Care TaskforcePort Stephens CouncilMen’s Sheds AustraliaUniting CareAnglicareThe Whiddon GroupCalvary Silver CircleMaitland City CouncilVeterans AffairsGosford Aged Care Task Force includes Central Coast Medicare LocalCurtin University of TechnologyAuckland University of Technology

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Briefings to all Local, State and Federal Members also occurred, which culminated in two proposals by members for presentations to State and Federal Governments.

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7 Project Outcomes

7.1. Specific Project Outcomes

From the outset the project’s aim was to answer 4 questions to determine feasibility of a community based, inter-professional, student managed Health Ageing Clinic, which were identified in the Project Process section. In answering each question specific project outcomes are provided.

1. What is the evidence base to support the capability of the proposed model to achieve the following outcomes?

• Wellness in Ageing• Inter-professional and inter-sectoral collaboration between Health, Education,

relevant agencies and consumers • Develop Service/workforce capacity to address emerging health concerns,

From the broad community consultation and international literature search, there is no doubt that the concept of a healthy ageing clinic supported through an inter-professional team-based curricular is not only feasible but strategically fits with changes in global demographics, policy reform and is therefore a perfect vehicle for introducing authentic inter-professional team-based training

2. How does the policy environment align with and enable the implementation of the proposed model?

The World Health Organisation and the international and national health policy environment is in substantial agreement that the health sector needs to refocus on wellness, prevention and primary health care and identifies inter-professional education and collaborative patient-centred practice as key foundational steps to building effective health care teams and improving the experience and health outcomes for the community

3. What are the systemic enablers/challengers of the proposed model?

It has been identified that there is a professional tendency to be educated and to work in silos. Inter-professional learning presents many challenges for educational organisations, health care providers and professional associations. The following was identified from the literature search:Enabling factors

Partnerships within and between academic institutions, health care facilities and stakeholders

Identification of additional sources of support and resources

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Support and incentives for inter-professional collaboration, facilitated by horizontal integration of medical, nursing and allied health training activities

Vertical integration across undergraduate, postgraduate and vocational health training

The need for staff to model inter-professional collaboration and ensure that curricula make explicit the rationale for inter-professional learning

Structuring learning activity toward developing inter-professional competence for contemporary health service delivery

Challenges Differing expectations due to requirements and regulations between the professions The fear that inter-professional practice will lead to a loss of status, a loss of

professional identity, and a dilution of the role of individual professions in patient care Historical inter-professional and intra-professional rivalries An already full course curriculum and clinical placement schedule for each

profession. Conflicting academic calendars and timetables offering very few opportunities for

inter-professional activities (e.g. clinical placements) Differing ability and interests across students. Lack of availability of suitably trained academic staff and clinical placement

supervisors to facilitate inter-professional programs Time and resource commitments involved in establishing inter-professional programs Lack of dedicated inter-professional learning spaces Lack of geographical co-location of individual schools/ faculties

4. What is the cost/benefit of implementation? What would be required for sustainability?

Whilst there is a financial cost to setting up community based clinics, stakeholders including city councils, community based-aged care providers and others indicated a willingness to support ‘in-kind’ with resources such as accommodation, transport and programs contingent on the model being authentically based in primary healthcare.

Older community members will be able to discuss their health status, lifestyle issues, and concerns and receive quality and evidenced-based advice either free or for minimal cost without overburdening their local GP service.

Promote ageing in good health, minimise the burden of disease, improve health literacy and maintain optimal health

Introduce students at an early stage in their professional development to team-based practice, enhance inter-professional respect, improve inter-professional communication and create team work readiness on graduating. Learning gained in the clinic will be further enhanced through the use of established simulation facilities.

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Teamwork readiness will create a more rounded graduate who is able to ‘hit the ground running’ offering greater productivity to the employer during their transition to work year and thereafter

Create new and exciting clinical placements. Number of placements will depend on the size and number of the clinics and length of placements. Similar inter-professional programs at Curtin University and the Auckland University of Technology proved to be very popular.

Sustainability will be achieved through blending team-based learning and discipline specific learning embedded across the suite of undergraduate programs commencing at year 1.

The model could accommodate students studying health and aged related subjects from across the Australian Qualifications Framework from certificate through to bachelor degrees.

7.2 Strategic Outcomes

The project has also achieved, influenced and aligned to a number of major strategic initiatives that have the potential to provide a high return on investment (ROI) for future inter-professional education, team-based training and clinical placement:

1. University of Newcastle-Faculty of Health and MedicineThe Faculty of Health and Medicine is strategically committing to developing a framework for blending inter-professional team-based with discipline specific learning.

It is anticipated that the blended model will consist of three sequential levels of theory and exposure supported through a series of titrated inter-professional competencies designed to develop the students’ ability to function effectively as members of an inter-professional health care team.

Level 1 Exposure (First Year)Level 1 Exposure is an introductory level to team-based function focusing on inter-professional learning for all undergraduate health disciplines. Learning at this stage of the curricular blends discipline specific with fundamental inter-personal skills and competencies directed at respect, communication, understanding other discipline roles and shared knowledge.

Level 2 Immersion (Second Year) Level 2 Immersion draws on the skills gained through Level 1 exposure and moves the students’ attention to team functioning and inter-professional education blended with their discipline specific curricular learning objectives. Level 2 introduces the student to inter-professional team-based clinical placement and is supported through

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competencies focusing on pertinent team-skills of collaborative leadership; team functioning, role clarification and inter-professional conflict resolution. It is at this level that the concept of a healthy ageing clinic will be introduced.

Level 3 IntegrationLevel 3 Integration through inter-professional clinical placement and extracurricular activities, extends the students’ capacity to strengthen their collaborative leadership

2. Central Coast Aged care Task Force and Medicare LocalThe Central Coast Aged Care Task Force is a combined public and private provider group led by the Central Coast Medicare Local. The task force have given their solid commitment to supporting our clinic model for healthy ageing and team-based curricular for clinical placement of healthcare students. This group are primed and offer a wonderful opportunity to pilot such a model incorporating all significant health disciplines and providing significant quality student placement opportunity. Discussions have also commenced with the New England Medicare Local and the Mid North Coast Local Health District based in Port Macquarie.

3. Political SupportFederal and State members of Parliament have been consulted and vouched their commitment to advocating for funding and support promoting the healthy ageing clinic model as a service to the public and clinical training initiative. The project lead team have been invited to maintain a dialogue on progress and opportunity with local members.

4. Andrew Fisher Applied Policy Institution for AgeingThe Federal Government has sought application from the University of Newcastle for the establishment of the Andrew Fisher Applied Policy Institute for Ageing. The Institute will provide an opportunity for Australia to be at the forefront of world leadership in terms of political and strategic responses to population ageing. The model of a healthy ageing clinic and team based curricular would form a foundation training program of the Institute.

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9 Appendix

Appendix 1: Qualitative analysis on 42 studies selected from literature searchReport ThemesBeck, E. (2005). "The UCSD student-run free clinic project: Transdisciplinary health professional education." Journal of Health Care for the Poor and Underserved 16(2): 207-219

student-run free clinic, managed by health professional

students, supervised by licensed health professionals, offering free health services to those without health access

the purpose of this article is to describe the UCSD Student-Run Free Clinic Project, its history, mission, partners, clinical services, curriculum, funding, replicability, outcomes, elements of success, transdisciplinary nature, and hopes for the future.

Bennard, B., Wilson, J. L., Ferguson, K. P. & Sliger, C. (2004). "A student-run outreach clinic for rural communities in Appalachia." Academic Medicine 79(7): 666-671.

student-run outreach clinic series that addresses health care needs of communities

the clinics link academic family physicians and students with community health care providers

Identified weaknesses are attributed to the fact that the outreach clinics were established in response to community needs and did not follow a careful curricular development.

Berman, R., Powe, C., Carnevale J., Chao A., Knudsen J., Nguyen A., & Edgman- Levitan, S.(2012). "The crimson care collaborative: A student-faculty initiative to increase medical students' early exposure to primary care." Academic Medicine 87(5): 651-655

joint student-faculty initiative in post-health-care-reform

goal of attracting medical students to primary care

student-run clinics, providing evening access to primary care services for patients

plus aim of decreasing emergency department use

integrated into the mainstream health care structure of an existing primary care clinic

can bill for its services student-run research team

evaluates the quality of care and the patients' experiences

how medical schools can expose students early in their training to primary care and clinic operations

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Buchanan, D. & Witlen, R. (2006). "Balancing service and education: Ethical management of student-run clinics." Journal of Health Care for the Poor and Underserved 17(3): 477-485.

balancing service and education ethical management of student-run

clinics medical schools across the United

States provide health benefits to patients students operate free clinics unique educational opportunities for

students collaborate with faculty to ensure that their clinics attain

high standards ensure educational goals don’t

compromise clinics' patient care actively supporting clinic organizers'

applications for external fundingCadzow, R. B., Servoss, T. J., & Fox, C. H. (2007). "The health status of patients of a student-run free medical clinic in inner-city Buffalo, NY." Journal of the American Board of Family Medicine 20(6): 572-580

explores the health status and the social and economic correlates of adults 20 years of age and older who presented at an urban free medical clinic in Buffalo

health risk assessment questionnaire (469) that addressed their chronic disease and illness history, mental health, social support, substance use, income, education, and housing

identified prevalent health conditions in this patient population and compared these rates to regional and national data

the data reflect the health disparity experienced by low-income minority populations in the United States

findings also serve as an introduction to the patient population for volunteer medical students who have limited exposure to urban, low-income populations.

Cashman, S. B., Hale, J.F., Candib, L.M., Nimiroski, T.A., & Brookings, D. (2004). "Applying service-learning through a community-academic partnership: depression screening at a federally funded community health center." Education for Health 17(3): 313-322

safety-net services challenged to meet patients' needs additional resources for needed

initiatives. develop and initiate a depression

screening and treatment project. meet the needs of patients community health centre

partnership with an academic medical/nursing institution

enhancing students' education

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initiate systems change at the clinical level

service-learning framework curricula students help implement or pilot discontinuity in student availability logistical incompatibilities schedules and length of

commitmentChen, S. & Bhimji-Hewitt, S. (2012). "Enhancing the clinical experience with interprofessional education (IPE)dA radiation therapy student's perspective." Journal of Medical Imaging and Radiation Sciences 43 (2): 144.

continuous shift in the healthcare system towards collaboration and patient-centred care

Patient-centred care demands that healthcare professionals work together in an effective manner

often these professionals do not collaborate well

Inter-professional education (IPE) offers a possible way to improve this

cultivate knowledge of and establish collaboration with other professionals early on in the career of healthcare providers in order to enhance future practices

current IPE curriculum in the MRS program and student-led inter-professional activities.

Clark, D.L., Melillo, A., Wallace, D., Pierrel, S., Buck, D. S. (2003). "A multidisciplinary, learner-centered, student-run clinic for the homeless." Family Medicine 35(6): 394-397.

Conclusions: Student participants, especially basic science medical students, value the program due to its contributions to their professional and personal education, as well as their increased understanding of biopsychosocial issues. Learners develop empathy, compassion, and heightened social awareness.

Conway, J. (2009). "Implementing interprofessional learning in clinical education: findings from a utility-led evaluation." Contemporary Nurse: A Journal for the Australian Nursing Profession 32(1-2): 187-200.

clinical practice provides the stimulus for students and practitioners alike to recognise best practice and enhance and modify existing practice

need for collaborative inter-professional work practices

inculcating among those students a desire to work collaboratively and collegially in practice

inter-professional learning in a single ward of a public hospital in New South Wales

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need for staff to model inter-professional collaboration

ensure that curricula make explicit the rationale for inter-professional learning

structure learning activity toward developing inter-professional competence for contemporary health service delivery

ensure that the espoused values of inter-professional practice and learning are reflected in assessment events

Cooksey, N. R. (2010). Bridging the Gap Between Textbook and Maternity Patient: A Nurse-Developed Teaching Model for First-Year Medical Students." Birth 37(4): 325-333.

opportunities for first-year medical students to interact with patients in clinical settings

medical student education reform bridge the gap between textbook

and patient patient-centred care develop the skills needed to work

cooperatively as members of a multidisciplinary health care team

a component of a non-credit extracurricular, student-run perinatal program

Davenport, B. A. (2000). "Witnessing and the medical gaze: How medical students learn to see at a free clinic for the homeless." Medical Anthropology Quarterly 14(3): 310-327

analyses doctor-patient communication as it is taught to medical students in a student-run free clinic for the homeless

Dvoracek, J. J., Cook, K. M., & Klepser, D. G. (2010). "Student-run low-income family medicine clinic: controlling costs while providing comprehensive medication management." Journal of the American Pharmacists Association 50(3): 384-387.

medication management with a closed formulary in a diverse uninsured population reduced expenditures, with the largest savings coming from using prescriptions more efficiently while also providing a similar level of medical care.

Dort, S., Coyle, J., Wilson, L., Ibrahim, H.M.(2013). "Implementing the World Report on Disability in Malaysia: A student-led service to promote knowledge and innovation." International Journal of Speech-Language Pathology 15(1): 90-95.

this research evaluated a student-led service in community-based rehabilitation that supplemented existing and more typical institution-based services

emphasis on increasing the equitability and accessibility of services for people with disabilities

expanding awareness-building, education, and training activities about communication

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to provide students with experience of working in such settings, and facilitate their development as advocates for broadening the scope of practice of speech-language pathology services

findings pertaining to the collaborative process and the learning experiences of the adult participants

(2006). "Erratum: Students in the Community: An interprofessional student-run free clinic (Journal of Interprofessional Care (2006) vol. 20 (3) (254-259))." Journal of Interprofessional Care 20(6): 692.Frutiger, A. D. & Eakes, G. B. (1985). "The developmental evaluation center as a clinical setting for mental health nursing students." Perspectives in Psychiatric Care 23(1): 27-32.

developmental evaluation centre a viable option to the more

traditional clinical settings used for psychiatric/mental health nursing students

placement affords students the opportunities for direct involvement with individuals, families, and communities in the application of theoretical concepts within the framework of the nursing process

interdisciplinary nature of the DEC assists students in more clearly identifying their role and function as nurses within the larger health care team

developing and utilizing collegial relationships to more effectively meet the needs of clients

Gray, B. & MacRae, N. (2012). "Building a sustainable academic-community partnership: Focus on fall prevention." Work-a Journal of Prevention Assessment & Rehabilitation 41(3): 261-267.

inter-professional/interdisciplinary education

develop a 6 week fall reduction program

elder volunteers who were independently living in the community

opportunities for inter-professional student learning,

faculty practice and development improve the health of the

participants sustaining inter-professional

collaboration is challenging scheduling difficulties and faculty

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workloads developing the team skills of

students knowledge of the contributions each

discipline holistic view of elders

Guirguis, L. & Sidhu, K. (2011). "An exploration of pharmacist preceptors' and pharmacy students' experiences at an interprofessional student-run clinic." Canadian Pharmacists Journal 144(4): 179-184.

this study examines pharmacist preceptors' and pharmacy students' experiences at an inter-professional student-run clinic

students and preceptors from medicine, dentistry, pharmacy, nursing, social work and nutrition work together to care for adolescents and young adults from Edmonton inner city areas

pharmacist preceptors and pharmacy students were invited to participate in open-ended interviews to explore their experiences at the SHINE clinic

three themes arose: dynamic team roles, inter-professional role understanding and personal benefits

benefits of the SHINE clinic experience included enhancing preceptor skills, inter-professional relationships and confidence working in teams

the SHINE clinic provided a beneficial experience, where preceptors and students could learn with, from and about each other while caring for a vulnerable population

Hamso, M., Ramsdell, A., Balmer, D., & Boquin, C. (2012). "Medical students as teachers at CoSMO, Columbia University's student-run clinic: A pilot study and literature review." Medical Teacher 34(3): e189-e197.

although medical students are expected to teach as soon as they begin residency, medical schools have just recently begun adding teacher training to their curricula. Student-run clinics (SRCs) may provide opportunities in clinical teaching before residency

the practical experiences in clinical teaching that students have at SRCs can supplement classroom-based trainings. Medical schools might revisit their SRCs as places for exposure to clinical teaching

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Hastings, J., Zulman, D. & Wallis, S. (2007). "UCLA Mobile clinic project." Journal of Health Care for the Poor and Underserved 18(4): 744-748

we report on a man seeking care at the UCLA mobile clinic, illustrating and then discussing the challenges of caring for people who are homeless (especially mental illness and potential distrust of providers). Student-run free clinics can be beneficial but further research must examine how well such clinics meet homeless patients' needs

Henderson, A.J., O'Keefe, M.F., & Alexander, H.G. (2010). "Interprofessional education in clinical practice: Not a single vaccine." Australian Health Review 34(2): 224-22

in increasingly complex health service environments, the quality of teamwork and co-operation between doctors, nurses and allied health professionals, is 'under the microscope'. Inter-professional education (IPE), a process whereby health professionals learn 'from, with and about each other', is advocated as a response to widespread calls for improved communication and collaboration between healthcare professionals. Although there is much that is commendable in IPE, the authors caution that the benefits may be overstated if too much is attributed to, or expected of, IPE activities. The authors propose that clarity is required around what can realistically be achieved. Furthermore, engagement with clinicians in the clinical practice setting who are instrumental in assisting students make sense of their knowledge through practice, is imperative for sustainable outcomes. AHHA 2010.

Heravi, M. & Bertram, J.E. (2007). "A novel resource model for underprivileged health support: Community Medical Outreach." Rural and remote health 7(1): 668.

Community Medical Outreach is a student-run organization that provides healthcare access to medically underprivileged farm workers

all of the partners benefit from the interchange.

students gain from a unique first-hand medical experience that demonstrates their leadership, management skills, commitment to a healthcare team, and focus on

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care at the community level shaping students in the process of

becoming physicians, shaping those involved with the process of admitting students, shaping training experiences, and shaping new models of health care

Howell, D. M. & Wittman, P. (2012). "Interprofessional clinical education for occupational therapy and psychology students: A social skills training program for children with autism spectrum disorders." Journal of Interprofessional Care 26(1): 49-55.

inter-professional clinical learning experience

occupational therapy (OT) and psychology graduate students

inter-professional teams to plan and implement a social skills training program for children with autism spectrum disorders (ASD)

student-led clinical experience facilitate inter-professional

collaborative learning faculty performed qualitative

research to explore how the students worked together to provide intervention

four themes emerged: learning who I am as a professional, learning to appreciate our professional differences, learning to communicate with each other and figuring it out

ensure that students are adequately prepared to represent their profession as part of a diverse inter-professional health care team.

Hunter, D. C., Brustrom, J., & Garrett, K. (2010). "Motivating an underserved African American population to seek breast and prostate cancer screening utilizing a coalition of 11 community-based organizations." Journal of Clinical Oncology 1).

African Americans (AAs) suffer a higher mortality rate due to breast and prostate cancer compared to Caucasians for multiple reasons

evidence that partnering with trusted community-based organizations can successfully motivate underserved AA populations to seek preventive services

Community Cancer Coalition was formed to increase the number of underserved AA individuals in the Sacramento, California area receiving age-appropriate breast and prostate cancer screening

one-day health fair at a student-run free clinic in which breast and

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prostate cancer screening examinations were offered free of charge

the health fair was successful at encouraging AAs to attend the event

Jakobsen, F., Larsen, K., & Hansen, T.B. (2010). "This is the closest I have come to being compared to a doctor: views of medical students on clinical clerkship in an Interprofessional Training Unit." Medical Teacher 32(9): e399-406.

the need for inter-professional education has been apparent for decades

in 2004, we established the first Inter-professional Training Unit (ITU) in Denmark.

nursing, occupational therapy and physiotherapy students were in the ITU for its first 2 years and in 2006, medical students joined in

students in collaboration run a ward with eight beds under the supervision of trained personnel

our results showed that the medical students in the ITU developed their professional knowledge and capability simultaneous with the learning of inter-professional collaboration. The students valued the teaching methods because the students were in the forefront and treated as professionals. The students demanded more homogeneous instruction and a better introduction to the ITU

a stay in an ITU with a safe learning environment can increase both uni-professional and inter-professional learning for medical students. The students stressed the importance of supervision before and after carrying out a hospital task

Jiminez, M., Tan-Billet, J., & Babineau J. (2008). "The promise clinic: A service learning approach to increasing access to health care." Journal of Health Care for the Poor and Underserved 19(3): 935-943.

The goal of the Promise Clinic (a project of an academic medical centre and a local social services group) is to increase access to primary care for an underserved population while addressing deficiencies in medical education. Students manage common primary care problems, creating access for this mostly uninsured population.

Kelley, A. & Aston, L. (2011) An evaluation of using champions to

the promotion of inter-professional working is a key government target

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enhance inter-professional learning in the practice setting Nurse Education in Practice 11 (2011) 36-40

for healthcare professionals by utilising current unprofessional

support systems for developing the learning environment, inter-professional learning opportunities were created for students

inter-professional 'champions' in a targeted number of placements self-selected themselves to participate in a new innovation

these healthcare professionals were given preparation, support and facilitator training

inter-professional learning opportunities were developed using a variety of formats.

evaluations of the innovation demonstrated the usefulness of this approach for qualified staff as well as for students

sustainability was achieved and expansion of the initiative has been guaranteed through further funding

Liang En, W., Koh, G. C-H., Lim, V. K. G. (2011). "Caring for underserved patients through neighborhood health screening: outcomes of a longitudinal, interprofessional, student-run home visit program in Singapore." Academic Medicine 86(7): 829-839.

service learning, an effective vehicle for teaching undergraduate public health while providing underserved communities with medical care

medical and nursing undergraduate students provided in-home medical services to patients in a low-income neighbourhood

assessed student-reported pedagogical effectiveness in nine domains

most students felt NHS was beneficial across all domains

after a single year, amongst patients with known hypertension, treatment increased from 63% to 93% (P < .001), and blood pressure control amongst those who were on treatment improved from 42% to 79% (P < .001).

Mathys, M., & Bakshi, R. (2011). "Utilizing 4th year pharmacy students as the primary pharmacy members within mental health interdisciplinary teams." Journal of Pharmacy Practice 24 (2): 247.

the Dallas VA Medical Center inpatient mental health unit is a 42-bed facility with an average daily census of 36 patients. Veterans admitted to the facility are assigned to 1 of 5 interdisciplinary treatment

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teams without the use of fourth year

students, clinical pharmacy services would not be available to the 5 treatment teams and their patients

each student is assigned to serve one of the interdisciplinary teams

the students have helped meet one of the National Patient Safety Goals by providing medication reviews and reconciliations for more than 90% of patients admitted to inpatient mental health in 2009 and 2010

utilizing fourth year pharmacy students to serve as the pharmacy member within interdisciplinary mental health teams has expanded clinical pharmacy services beyond what was possible

provided the pharmacy students with a positive rotation experience

the current practice has improved patient care within mental health.

Meah, Y. S., Smith, E. L. & Thomas D. C. (2009). "Student-run health clinic: novel arena to educate medical students on systems-based practice." Mount Sinai Journal of Medicine 76(4): 344-356.

substantial growth in the number of student-run clinics for the indigent

over 49 medical schools across the country operate over 110 student-run outreach clinics that provide primary care services to the poor and uninsured

it highlights the student-run clinic as a unique enhancement of medical education that may supplant current curricular arenas in teaching students about systems-based practice principles such as cost containment and financing, resource allocation, interdisciplinary collaboration, patient advocacy, and monitoring and delivery of quality care.

this article underscores the student-run clinic as a potentially ideal experiential learning method for preparing young physicians to confront a US healthcare system currently facing crises in cost, quality of care, and high rates of

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uninsuranceMoskowitz, D., Glasco, J., Johnson, B. & Wang, G.(2006). "Students in the community: an interprofessional student-run free clinic.[Erratum appears in J Interprof Care. 2006 Dec;20(6):692]." Journal of Interprofessional Care 20(3): 254-259.

students in the Community (SITC) is an inter-professional collaboration of health science students at the University of Washington

SITC runs a weekly free clinic at the Aloha Inn, a transitional housing facility for 70 homeless men and women

focus of this clinic is on health education, chronic disease management, and re-integration of patients into the healthcare infrastructure

valuable service learning opportunity for students

in addition to direct clinical services, students gain experience in planning health education strategies, community collaboration, and evaluating intervention outcomes

SITC also oversees a lecture and discussion-based elective course at the University of Washington focused on health issues of the homeless community and provides formal teaching which complements the service-learning component of the endeavour

Pham, H.H., Simonson, L., Elnicki, D. M., Fried, L. P., Goroll, A. H., Bass, E. B.(2004). "Training U.S. Medical Students to Care for the Chronically Ill." Academic Medicine 79(1): 32-41.

growing prevalence of chronic illness has important implications for the training of all physicians.

assessed the degree to which undergraduate medical curricula explicitly address chronic care competencies

interviewed directors of required medical school courses

all 70 eligible course directors responded

course directors agreed about the importance of many competencies in chronic care but reported considerable variation in how they addressed competencies in their courses

medical schools can improve training in chronic care by paying greater attention to specific

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methods for addressing important chronic care competencies.

Reeves, S., Freeth, D., McCrorie, P. & Perry, D.(2002). "It teaches you what to expect in future...': interprofessional learning on a training ward for medical, nursing, occupational therapy and physiotherapy students." Medical Education 36(4): 337-344.

inter-professional training ward placement for medical, nursing, occupational therapy and physiotherapy students

students, under the supervision of practitioners, to plan and deliver inter-professional care for a group of orthopaedic and rheumatology patients

enabled students to develop profession-specific skills and competencies

also allowed them to enhance their teamworking skills in an inter-professional environment

student teams were supported by facilitators who ensured medical care was optimal, led reflective sessions and facilitated students' problem solving

students valued highly the experiential learning

the ward prepared them more effectively for future practice

many encountered difficulties adopting an autonomous learning style during their placement

facilitators were concerned that the demands of their role could result in 'burn-out'

patients scored higher on a range of satisfaction indicators than a comparative group of patients

Robinson, W. D. & Barnacle, R. E. S., (2004). "An interdisciplinary student-run diabetes clinic: Reflections on the collaborative training process." Families, Systems and Health 22(4): 490-496.

because of the complexity of diabetes, researchers have found collaborative care for diabetic patients to be effective.

interdisciplinary student-run clinic to provide treatment to low-income, noninsured, diabetic patients.

including medicine, nursing, pharmacy, dietetics, and medical technology.

medical family therapy was added to the team after a need for more holistic treatment arose

biopsychosocial perspective from which to view treatment

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foundation for future collaboration an opportunity for cross training,

and immediacy of on-site consultation.

Sheu, L. C., Toy, B. C., Kwahk, E., Yu, A., Adler, J., & Lai, C. J. (2010). "A model for interprofessional health disparities education: student-led curriculum on chronic hepatitis B infection." Journal of General Internal Medicine 25 Suppl 2: S140-145.

health professional students designed a preclinical service-learning curriculum on hepatitis B viral (HBV) infection

integrating lectures, skills training, and direct patient care at student-run clinics

organized a preclinical didactic and experiential elective, and established two monthly clinics offering HBV screening, vaccination, and education to the community

between 2004 and 2009, 477 students enrolled in the student-led HBV curriculum

student-led didactic and experiential elective can serve as an inter-professional curricular model for learning about specific health disparities while providing important services to the local community

Sheu L.C., Zheng, P., Coelho, A.D., Lin, L. D., O'Sullivan, P. S., O'Brien, B.C., Yu AY, Lai, C.J.(2011). "Learning through service: Student perceptions on volunteering at interprofessional hepatitis B student-run clinics." Journal of Cancer Education 26(2): 228-233

student-run clinics (SRCs) are widespread, but studies on their educational impact are limited

student responses revealed positive perceptions of the volunteer experience

benefits included interacting with patients, developing clinical skills, providing service to disadvantaged populations, and collaborating with health professional peers

students who participated in clinic reported enhanced skills compared to those who did not attend.

Sheu, L., Lai, C. J., Coelho, A. D., Lin, L. D., Zheng, P., Hom, P., Diaz, V>, & O’Sullivan, P. S.(2012). "Impact of student-run clinics on preclinical sociocultural and interprofessional attitudes: A prospective cohort analysis." Journal of Health Care for the Poor and Underserved 23(3): 1058-1072.

descriptive studies suggest student-run clinics (SRCs) positively affect preclinical students' sociocultural and inter-professional attitudes, but few studies use validated measures

Randall, D., Lammers, C., Hegge, K., multidisciplinary student-led

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http://i11.cgpublisher.com/proposals/214/index_html#author-0

Shiyanbola, O., Richards, A.,Clem, J., Pollard, M., & Brunick, A. (2011). "Development, implementation, and evaluation of an innovative health promotion model for an underserved population with diabetes: A pilot project." Journal of the American Pharmacists Association 51 (2): 231-232.

diabetes clinic underserved patient population demonstrate an improvement in

clinical outcomes health literacy serve indigent medically

underserved patients five health career disciplines

(medicine, pharmacy, nursing, nutrition, and dental hygiene)

six educational sessions designed to demonstrate critical components of diabetes management

patients completed surveys and tests assessing their knowledge of diabetes, diabetes care, health behaviours, health literacy, and perceptions of the health care system

assessments were repeated to determine if there were improvements in these outcomes

potential value of an inter-professional team approach to diabetes education

could be applied to other practice settings and used for the management of other chronic diseases

Shiyanbola, O. O., Lammers, C., Randall, B., & Richards, A. (2012). "Evaluation of a student-led interprofessional innovative health promotion model for an underserved population with diabetes: A pilot project." Journal of Interprofessional Care. 2012 26(5):376-82.

inter-professional education interact and learn together during

their training process collaborative healthcare practices improved care for patients implementation of an

interprofessional health promotion program

sixty-three students from five health professions led six educational sessions

there were significant improvements in students' knowledge of diabetes care, understanding of the roles of healthcare professionals and ability to work with other healthcare professionals

could be applied to other practice settings and used for the management of other chronic diseases

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Simpson, S. A. & J. A. Long (2007). "Medical student-run health clinics: Important contributors to patient care and medical education." Journal of General Internal Medicine 22(3): 352-356.

the prevalence and operation of medical student-run health clinics nationwide.(USA)

ninety-four schools responded (76%); 49 schools had at least 1 student-run clinic (52%).

nationally, clinics reported more than 36,000 annual patient-physician visits,

most student-run health clinics had resources both to treat acute illness and also to manage chronic conditions

clinics were most often funded by private grants

medical student-run health clinics offer myriad services to disadvantaged patients and are also a notable phenomenon in medical education

wider considerations of community health and medical education should not neglect the local role of a student-run health clinic.

Simmons, B. B., DeJoseph, D., Diamond, J., & Weinstein, L. (2009). "Students who participate in a student-run free health clinic need education about access to care issues." Journal of Health Care for the Poor and Underserved 20(4): 964-968.

we surveyed first-year medical students about preparedness for work at student-run clinics, and for addressing patients' access to care, and social issues. Most students did not know how to get uninsured patients ongoing care or medications outside of the student-run clinic. A large majority of students desired an orientation addressing these issues.

Stark, R., G. Yeo, et al. (1984). "An interdisciplinary teaching program in geriatrics for physician's assistants." Journal of Allied Health 13(4): 280-287.

through a series of Saturday classes held in community facilities serving seniors, physician's assistant students had the opportunity to learn clinical geriatrics from a faculty team including a physician's assistant, physician, nurse, physical therapist, social worker, gerontologist, and health educator. Local seniors served as consumer consultants and models of health and vigour. This interdisciplinary approach was modelled by the faculty to demonstrate the need for a team

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approach to deliver quality care to seniors.

Strowd, R., & Strowd, L. (2011)."Comprehensive care at a student-runhealth clinic: a unique partnership."Medical Teacher 33(5): 422

partnering a SRC with an established community clinic promotes student education and facilitates quality of care

Taylor, L., & Holubar, M. (2011). "Stroke risk assessment and education in the underserved community." Journal of the American Pharmacists Association 51 (2): 220.

goal of the Stroke Prevention Patient Care Project is to improve stroke risk awareness and access to screening tools in underserved, uninsured communities

the project will also introduce a follow-up component whereby student pharmacists will evaluate patient adherence to risk-lowering recommendations

this project connects to underserved communities by hosting free screenings in local community centres and churches, and by addressing a highly prevalent health risk that is complicated by poor nutrition, lack of education, and minimal access to quality medical care

follow-up is completed 2 weeks after screening

Thomsen, L. & Lisby, H. (2011). "Professionalism is a prerequisite for multiprofessionalism [Danish]." Sygeplejersken / Danish Journal of Nursing 111(15): 66-68.

integrating an interdisciplinary approach in clinical aspects of nurse training

create an authentic learning environment for students from disciplines that include occupational therapy, physiotherapy and nursing, as well as social and healthcare assistant students

promotes individual student competencies and provides optimal opportunities for development of interdisciplinary competencies in order to provide beneficial patient outcomes

an interdisciplinary approach gives nursing students a greater awareness of their own professionalism, and optimises their use of this in cooperation with the other professions

results in a greater understanding and respect between the individual

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professional groups improve nursing students' ability to

deal with the highly complex tasks within the health care system.

Welsh, K. J., Patel, C. B., Fernando, R. C., Torres, J. D., Medrek, S. K., Schnapp, W. B., Brown, C. A., & Buck, David, S.(2012). "Prevalence of Bipolar Disorder and Schizophrenia in Houston Outreach Medicine, Education, and Social Services (HOMES) Clinic Patients: Implications for Student-Managed Clinics for Underserved Populations." Academic Medicine 87(5): 656-661.

determine the prevalence of certain mental illnesses and comorbid conditions among the patients of a student-managed free clinic for the homeless

Westra, R., Skube, S., & Zant, M.. (2011). "HOPE clinic: a place to care." Minnesota medicine 94(11): 49-51.

clinic is a student-run, faculty-organized effort that offers students an opportunity to develop their clinical skills and learn how to work in inter-professional teams while providing needed care to people who are underserved or uninsured.

Zucker, J., Gillen, J., Ackrivo, J., Schroeder, R., & Keller, S.(2011). "Hypertension management in a student-run free clinic: Meeting national standards?" Academic Medicine 86(2): 239-245.

evaluate, using national care guidelines and quality standards, the quality of care provided at the Student Family Health Care Center

SFHCC patients with hypertension received pharmacotherapy as recommended by JNC 7 guidelines and were at the blood pressure goal set by Healthy People 2010.

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