Interprofessional Collaboration: If Not Now, When?

Introduction

Interprofessional collaboration is a term that is gaining recognition and momentum. Although definitions vary, interprofessional collaboration is seen as an approach to health care that creates a positive and helping environment to provide care and advise patients. It has been called a “partnership between a team of health providers and a client in a participatory collaborative and coordinated approach to shared decision making around health and social issues.”¹ Elements of collaborative practice include responsibility, accountability, coordination, communication, cooperation, assertiveness, autonomy, mutual trust and respect.²

Success with interprofessional collaboration is contingent upon interprofessional education (IPE). In essence, interprofessional collaboration cannot be realized IPE. IPE has been defined as “members or students of two or more professions associated with health or social care, engaged in learning with, from and about each other.”^3,4 IPE facilitates the sharing of skills and knowledge between professions, thereby promoting a better understanding, shared values and respect for the roles of other health care professionals.^4,5 IPE affords students the opportunity to place value on working within interprofessional teams before they begin to practice.⁶

Team-based practice has been a mantra in health care delivery for decades, however, little has been done to normalize, embolden or translate it into patient care delivery and outcomes. Persistent problems plaguing health care delivery systems remain. The state of health care requires broad brush strokes to move from crisis, to reform, to effectiveness. As early as 1978, the Institute of Medicine (IOM) raised the question of teamwork and asked “how should we educate students and health professionals in order that they might work in teams?”⁷ The IOM Report on Dental Education highlighted the relevance and necessity of teamwork, but specifically focused on oral health professions education.⁸ The report encouraged dental education to break down barriers to avoid professional silos and to adopt a more liberal stance regarding the scope of practice for allied health professionals. Although the report initially met with some positive response, for the most part, it did not result in dedicated change.

A recent hallmark document, the Lancet report, reiterated the problems elucidated in the 1970s. The report described professional education as “fragmented, outdated, and static” with “curricula that produce ill-equipped graduates … a mismatch of competencies to patient and population needs; poor teamwork; narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; quantitative and qualitative imbalances in the professional labor market; and weak leadership to improve health-system performance.”⁹

Interprofessional education and collaboration are viewed as possible antidotes to the persistent problems in U.S. health care delivery.^8-11 The “so-called tribalism of the professions—i.e., the tendency of the various professions to act in isolation from or even in competition with each other” – is identified as a key reason that change has floundered.⁹ A consortium of leaders in the U.S. representing a diverse group of health professions' organizations met to address some of the current health care problems with interprofessional collaboration and IPE as the focus. Their concerted efforts culminated in a consensus statement with recommendations for how health professions' curricula could be redirected to attain interprofessionalism in education and practice.¹⁰ The American Dental Education Association represented oral health professionals in this interprofessional collaboration. The document developed entitled “Core Competencies for Interprofessional Collaborative Practice” (IPEC) provides a roadmap for developing and implementing IPE into academic programs.¹⁰ The four key domains of IPE address teamwork, communication, professional responsibilities and ethics and values. Within each domain, specific competencies for incorporation into community, clinical and didactic learning experiences were developed. The ultimate goal of the initiative is to bring more collaborative practice to health care delivery.

The advanced dental hygiene practitioner, as a partner in a collaborative model, offers a viable option for bringing oral health to the forefront.^12-14 Several dental hygiene advanced therapy models are operational while others are in a developmental stage.¹⁵ Ideally, the dental hygienist serving in a collaborative capacity should possess the requisite knowledge, skill set and critical thinking capabilities for practice in stand-alone delivery settings such as rural clinics, community health centers, long term care facilities, in assisted living arrangements and hospitals. The advanced dental therapist educational model enables dental hygienists to meet these requirements. The Advanced Dental Therapists in Minnesota are an example of advanced practitioners who deliver care to diverse underserved groups who might otherwise not receive dental services.¹³ Many of these groups require the oversight of a collaborative team. Interdisciplinary dialogue, patient care, consults and referrals naturally evolve from collaborative practices. The advanced practice dental hygienist is positioned to collaborate with health professionals from multiple disciplines such as nutritionists, nurses, physicians and social workers. Innovative dental hygiene practice models are inherently collaborative.

An environment that welcomes the advanced dental therapist or practitioner collaborative model considers financial, socioeconomic, political and demographic variables.¹⁶ Usage of an advanced dental hygiene practitioner could reduce third party costs and provider salaries. Since prevention is a key piece of the collaborative model, long term costs for health care could decline if extensive curative measures could be curtailed.^8-11 A decline in the number of dentists also predicates the need for a larger scope of practice for dental hygienists.^15-17 In instances where cost-effectiveness is crucial, a facility may want to hire a dental hygienist rather than a dentist. The advanced dental therapist could use teledentistry for immediate dental consultation, should the need arise during patient treatment. Further, access problems could be addressed by providing care to underserved population groups. With health care reform's expected increase in patients eligible for oral health services, the presence of an advanced therapist could be essential.^18,19 Public health issues, populations requiring immediate attention, and existing, yet inefficient, health care delivery systems serve as platforms for collaboration.^8-12,14 With the growing recognition that oral health is pivotal to systemic health,²⁰ dental hygienists can assess patients' oral well-being and triage with nursing professionals (e.g., nurse practitioners), physicians and social workers to treat the elderly in hospitals, long term care facilities and in assisted living arrangements. Dental hygienists can address the impact that oral concerns have on patients' nutritional well-being, self-esteem and systemic disease (e.g., pneumonia). The geriatric epidemics of obesity, high blood pressure and diabetes are conditions that dental hygienists can screen for and address.

From a public health population perspective, dental hygienists working in collaborative models can reach a diversity of patients including the underserved pediatric population and hospital in-patients. As oral health preventive specialists, dental hygienists can reduce chronic childhood oral disease. Young children and toddlers suffering from early childhood caries require the attention of a team of providers. Compromised nutrition retards normal growth and untreated dental caries subjects children to needless pain. Dental hygienists can work side-by-side with pediatric dentists, pediatricians and social workers. In hospital environments, dental hygienists can triage with oncologists, nephrologists, nurses and doctors of obstetrics and gynecology as they deliver prophylaxes and offer cancer patients palliative options for oral comfort, ensure that patients receive prophylactic oral care prior to dialysis and educate new mothers about proper oral health for themselves, their fetuses and infants.

Rural states that encompass large geographic areas with limited numbers of dental providers offer an environment amenable to advanced practice, and broadened scopes of practice for dental hygienists do exist.¹⁴ In states where there is a more limited scope of dental hygiene practice, alternative models affording collaboration still must be considered. Building on the advanced dental therapist model, interdisciplinary specialty tracks can be developed. Dental hygienists could be educated as geriatric dental nurses who specialize in the treatment of the elderly and hold a certificate in gerontology. Advanced certifications and degrees enrich practitioners' medical knowledge. In constituencies where practice acts constrain the services dental hygienists provide, perhaps co-therapy practice with physicians and nurse practitioners is warranted. If supervision is the legal term used, dentists need not be the sole supervisors, particularly in collaborative practices.

An advanced education is a major ingredient for professional accountability, respect and successful collaboration. Educationally-based collaborative models must adhere to high standards. Advanced dental therapists should hold at least a baccalaureate degree with graduate education most desirable.^12,14 To move forward, the dental hygiene profession needs to seek partners outside of dentistry to provide support and collaboration. As health care providers continue to recognize the importance of oral health, dental hygiene will move beyond professional tribalism and be a true collaborative partner. Astute providers also recognize that prevention is the key to optimal oral and systemic health and is a means to lower health expenditures. Dental hygienists' preventive orientation and knowledge regarding the oral systemic link enhances their contributions in the collaborative setting. The IPEC report states that when “professional teams work collaboratively, they value one another's perspectives and contributions, they understand and appreciate true teamwork, they communicate effectively, and share an ethical code that is premised on just and high quality care.”¹⁰ Dental hygienists, as members of a collaborative team, have the dedication, knowledge base and desire to fulfill these expectations.