Interprofessional Collaborative Practice:

In the desert or on the mountain…

Stefanus Snyman

International Classification of Functioning, Disability & Health

--- Interprofessional Care Framework for the biopsychosocialspiritual

approach to patients, communities and systems ---

DAY 1: The ICF? What is it?

What on earth are you doing here?

• Name

• What do you do?

• Expectations of the ICF course?

Outcomes of ICF series of workshops

• Apply the WHO’s ICF as a framework for

interprofessional collaborative practice to

improve patient outcomes and strengthen

health systems.

• Argue why the ICF framework may be a

catalyst to improve patient-centred and

community-centred care, as well as the

morale and motivation of staff.

CPD

• If everything is attended and all assignments

done on time:

• 14 General

• 3 Ethics

Overview of ICF series (1)

• Day 1: (2h)

• Introduction to Health Professions Education for

21st century:

• Overview of the ICF framework in the context of

ethics and human

• Interprofessional teams case study

• After Day 1

• Structured reflection (½h) (within 1 week)

• Each interprofessional team prepare 1 case study

to present at next workshop (3h)

Overview of ICF series (2)

• Day 2 (2h)

• Presentation by interprofessional teams on their

real case study (Summative and formative

assessment by peers (including ethics / human

rights)

• Sit in with student case discussions / assessments

• After Day 2

• Structured reflection on interprofessional case study

that your team presented (1hour)

• Prepare a draft document to submit to the

Department of Health motivating the ICF framework

as an approach to encourage patient-centred and

community-centred care (4 hours)

Overview of ICF series (3)

• Day 3:

• Interprofessional teams conduct a ward round in

hospital (1 patient for a group) based on the ICF

framework, including team discussion, management

plan and feedback to patient

OR

ICF coding for quality improvement purposes

• Feedback by interprofessional teams regarding their

proposed approach to present to the Department of

Health a motivation to promote the use of the ICF

framework to improve patient- and community-

centred care

• Summative and formative assessment of

presentation

• After Day 3:

• Evaluation of course

Learning Resources

• Taking notes during this contact session

• ICF Practical Guide

• ICF and ICF-CY Books

• ICF online: http://www.who.int/classifications/icf/en/

• ICF eLearning tooI:

Your common sense !!!

The future of HPE in 1910

• Introduction of basic sciences in medical curricula

• Doubling of human lifespan1910

November 2010

Lancet December 2010

Health professionals have made huge contributions to

health and socio-ecomonic development over the past

century, but we cannot carry out 21st century health

reforms with outdated or inadequate competencies….

That is why we call for a new round of more agile and

rapid adaption of core competencies based on

transnational, multi-professional, and long-term

perspectives to serve the needs of individuals and

populations

What we need, more than just disciplinary knowledge and

skills, is a well-rounded health professional acting as

change agent to address the health needs of the 21st

century

Transformative

Learning

Interdependence

in

Education

Health Equity

Patient-centred Population-

based

Locally responsive

Globally connected

Open educational resources

Competency-based

Responsive to rapidly

changing needs

Creative use of IT

VISION

Adapted from: J

Frenk, L Chen, ZA

Bhutta et al: Health

Professionals for a

new century:

transforming

education to

strengthen health

systems in an

inderdependent

world.

www.thelancet.com,

2010;376:1923-1958

The Lancet et al. challenge

Adapted with the permission of CanMEDS © 2005

In search of an Interprofessional Care/Collaboration

Framework: a common language and approach

A statistical, research,

clinical, social policy

and educational tool to:

• Provide scientific basis

• Interprofessional

teamwork

• Common language

• Permit comparison

• Systematic coding

scheme

The pilot study: ICF – catalyst for IPECP

Interdependence

• Appreciate community workers

role

• Commit to teamwork

Transformative learning

• Ownership for holistic

patient care

• Question biomedical model

used in tertiary hospitals

• Integrate ethics and

human rights in patient

care

• Initiate IPE community

projects in response to

gaps indentified using ICF

Health system strengthening

• Preceptors apply ICF in

teaching and practice

• Adopt ICF as approach to

patient care in PHC and district

hospital settings

• Service providers request

capacity building in ICF

• Influence patient outcomes

Assessment drives

practice

Results from study

International importance

• Play role to write WHO’s ICF Practical Guide

• WHO book on CBE just published

• 1 of 4 projects worldwide selected by Institute of

Medicine’s Global Forum of Innovation in Health

professions Education

The qualifiers

Individual / Community

Functioning & Disability

Body function & structure

Change in body function

Change in body structure

Activities & Participation

Capacity Performance

Contextual factors

Environmental factors

Barriers / Facilitators

Personal Factors

Defining concepts (1): Body function and

structure

• Body functions

Physiological functions of body systems

• Body structures

Anatomical parts of the body

Body function and structure: Impairment

• Any loss of, or abnormality to body

structures/functions

• Anatomical, physical or psychological

• Manifestations of underlying pathology

• Temporary / permanent

• Progressive / regressive / static

• Intermittent / continuous / fluctuant

• Vary in severity

Body function and structure: Impairment

• Mental status

• Sensory functions (vision, hearing, vestibular,

pain)

• Voice and speech

• Vascular and circulatory system

• Respiratory system

• Endocrine, digestive and metabolic

• Genito-urinary and reproductive systems

• Skin and related structures

Defining concepts:

Activity and participation

• ActivityTasks or actions

• Activity limitationInability / difficulty to perform an activity in the manner

or range considered normal for all individuals of a

similar group

• ParticipationLife roles

• Participation restriction

Problems related to social roles

Activity / Participation domains (1)

• Learning and applying knowledge

• General tasks and demands

• Organising and planning tasks

• Multiple tasks

• Using money and finance

• Communication

• Verbal (understanding and producing)

• Nonverbal (understanding and producing)

Activity / Participation domains(2)

• Mobility

• Indoors (home)

• Outdoors

• Transportation

Activity / Participation domains(3)

• Self care

• Personal care

• Health care

• Domestic life

• Domestic management

and tasks

Activity / Participation domains(4)

• Interpersonal interactions

• Family

• Intimate

• Informal

• Major life

• Education

• Employment

Activity / Participation domains (5)

• Community, social

and civic life

• Community

• Recreation and

leisure

• Religion and

spirituality

Defining concepts (4): Contextual factors

• Environmental

• Personal

Represent the specific context and background

of an individuals life

Environmental factors

Barriers or facilitators

2 levels – individual /

social

• Products and

technology

• Natural environment

and man made

changes

• Support &

relationships

• Attitudes

• Services, systems &

policies

Environmental factors

Personal factors

Positive / negative

• Age

• Gender

• Race

• Education

• Experiences

• Personality

• Aptitude

• Coping styles

• Lifestyle

• Fitness, etc.

The ICF

• Function & Disability is…• Result of a complex relationship between

health condition, participation and contextual factors

• Contextual factors

• May hinder / cause barriers

• May facilitate

• No linear relationship between impairment /

activity / contextual factors – demonstrating

the complexity of health

Examples: Disabilities that may be associated

with the 3 levels of functioning linked to a health

condition.

Different levels of disability are linked to three

different levels of intervention.

Example of patient presentation

Rumours

• Time

• Complex

• Impossible

Barriers

• Professional tribalism

• Biomedical model

• Tradition

• Individual stars

• Against transformative learning – a threat

BATHO PELE

Access

Openness and Transparency

Consultation

Redress

Courtesy

Service standards

Information

Value for Money

PATIENT CHARTER

Healthy and Safe environment

Participation in Decision-Making

Access to Health Care

Knowledge of one’s health insurance/medical aid scheme

Choices in health services

Treated by a named health care provider

Confidentiality and privacy

Informed consent

Refusal of treatment

A second opinion

Continuity of care

Complaints about health services

Better patient outcomes and Improvement of health

system

ICF within ethical, human rights and legal

framework

• Ethics:

• Autonomy

• Benevolence

• Non- malevolence

• Justice

• Human rights

• Legal framework

Questions

Let’s apply it…

Health condition / disorder /

disease

Body

function &

structure

(Impairment)

Activities

(Limitations)Participation

(Restriction)

Personal

factorsEnvironmenta

l factorsContextual

factors

In context of ethics, human rights and legal

framework

Peter’s story (See handout and video)

PETER

Peter is a 76-year-old male who was diagnosed with Parkinson’s disease approximately 5 years ago. He has been referred by his

neurologist for a PT and OT consult. He lives in a two story row home in South Philadelphia with his wife, Mary. Peter reports that he

had a good understanding of his disease initially, but now feels confused. He has tried to stay active in order to maintain his level of

function. He is very involved in the community and has many long time friends. He has been taking medication, Sinemet, for about 3

years and it has “helped tremendously.”

Peter states that his condition has been steadily worsening, especially over the last 6 months. When he was diagnosed 5 years ago,

his right arm and leg seemed stiff and he had trouble moving them. Now he has more difficulty initiating his movements, especially in

the morning and after he gets to the bottom or top of the stairs. He says, “I get stuck, and I just can’t move.” He also states that it has

been taking him longer and longer to get to where he is going and he is often late for his community activities, such as attending church,

meeting friends for breakfast, and playing cards. He reported falling twice within a week about 2 months ago, both times tripping over

uneven sidewalks. Since then Mary suggested he carry a cane that she used after her hip replacement surgery ten years ago. He

reports that he is “embarrassed” to use it.

He is experiencing increased shaking, and more recently has had some difficulty eating, holding cards, and keeping his buttons on the

bingo cards. Two weeks ago when he was calling numbers for bingo, he pushed the wrong numbers several times and was very upset

and embarrassed. His wife reports that he has always carried the bags for their grocery shopping, but recently he has had difficulty

because he is “too tired.” Mary also reports that he has been getting extremely frustrated with his condition, and wonders if he is

depressed, as he has been leaving the house less frequently.

PMH: BPH, GERD, dyslipidemia, hypertension, Parkinson’s disease (PD)

Peter’s story (See handout and video) 2

Current medications:

terazosin 4mg PO daily

omeprazole 20mg PO daily

atorvastatin 10mg PO daily

hydrochlorothiazide 25mg PO daily

Sinemet (carbidopa/levodopa) 50/200 ER PO at 8am, noon, 3pm, and 7 pm

Sinemet 25/100 IR at 8am, 10am and 5pm

Azilect (rasagaline) 0.5mg PO daily

Comtan (entacapone) 200mg PO four times daily

At Peter’s appointment:

VS: BP 100/68; HR 82; RR 25, T 37°C, Ht 5’11”, Wt 180 lbs

On physical examination, Peter demonstrated decreased passive and active range of motion in bilateral knee extension as well as bilateral shoulder

flexion and abduction, the right being worse than the left. He shows a slight thoracic kyphosis in both sitting and standing posture which can be

minimally corrected with cues, and almost completely corrected with manual assist. He shows decreased active and passive range of motion in trunk

extension, rotation and side bending.

There is limited shoulder ROM in BUE with greater limitations in R vs L (flexion, abduction, rotation), limitations in elbow extension bilaterally,

decreased flexion in fingers leading to decreased dexterity and coordination and in hand manipulation skills, problems with fine motor tasks such as

grasping utensils, manipulating fasteners, and handling small items such as money/coins, and cards.

While walking throughout his home, he had some “freezing” episodes. He also displays some intermittent resting tremors. Mild cogwheel rigidity is

evident in all four extremities. Sensation appears intact throughout.

Peter’s story (See handout and video) 3

Equilibrium reactions appear delayed as evidenced when challenged in standing on a flat surface. He is afraid to stand on a balance beam. He can

stand on right leg for 20 seconds with eyes open, on left for 5 seconds. He starts to fall when he closes his eyes. When walking, there is diminished

arm swing and no trunk rotation. He also has a decreased step length and a slightly narrowed base of support. Walking is worse when he is tired.

Peter manages his medications now with his wife’s help. He has a regimen of taking all his medications at 8AM every morning with his breakfast that

typically consists of eggs and bacon. He used to be very good at remembering to take the other Sinemet doses at the scheduled times, but lately is

forgetting.

His activities include: playing cards and bingo 3 days a week at the local senior center a few blocks from his home, meeting at a breakfast club 3 days

a week at the local diner, attending Sunday and Wednesday Mass, and walking his dog, Paul, at least twice a day.

Peter likes the current lifestyle that he and Mary have established, especially assisting her in household duties of shopping, carrying laundry, and

chopping/prepping for meals. He is looking for ways to decrease his symptoms.

(Acknowledgement: George Washington University

Rest of the day

1• Map your case study's information on the ICF

framework.

2• What additional information do you believe your

team need to adequately address the issues in the

case study? Ask facilitators for information.

• Indicated gaps in the information with "?" on the ICF

framework (or in another colour).

• Does this case raise any specific ethical or human

rights conflicts? Map it on your ICF framework with

"E" (or in another colour).

3• Looking at your completed ICF framework,

determine the management priorities.

• What are the interventions in the case study that the

various professions are qualified to address?

• Compile an interprofessional management plan

(tasks) using the completed ICF chart.

• Motivate who will be doing what.

• What other professions would need to be involved

in this case? Why?

• Ask facilitators for information.

What now?

• Structured reflection • Max 500 words (1-1½ pages). Email to ??

• Prepare your real case study to present on ?? 201?• Each interprofessional team prepare 1 case study to

present at next workshop on ???

• Compile your teams now! Give names to??

• Pitch on ?? 201?: The ICF - it works!

• Diarise the last workshop: ?? The ICF -

what are we waiting for?

Instructions for structured reflection

• Introduce yourself (name, family, occupation,

position)

[2 paragraphs]

• What was your understanding of the ICF before

today? (Refer to the notes you made during the

introductions)

[1 paragraph]

• What on earth were you doing here today? What

was your expectations of this series of

workshops? (Refer to the notes you made during

the introductions) [1 paragraph]

• Identify and critically analyse your positive and

negative feeling about the ICF after the first

session in the context of (1) health professions

education and (2) patient-centred care. [½ -1

page]

Thank you