Multidisciplinary team-based primary healthcare: questions for general practice training

Michael Bentley iD icon1, Rohan Kerr 2

Abstract

Multidisciplinary teams delivering person-centred care are a central feature of primary healthcare reforms in Australia and North America. General practice is a primary healthcare service that prioritises clinical person-centred care. The recent Strengthening Medicare Taskforce Report recognised that a person-centred team care approach needs strengthened education and training programs to support multidisciplinary teams in general practice. While the premise of multidisciplinary care is well established, the strengthening of education and training programs in general practice offers opportunities at the vocational training level and for intra-practice education.

This Education in Practice paper discusses the relevance to contemporary general practice of findings from Tasmanian research projects conducted over the past decade, addressing two questions for general practice training:

1. How can approaches to team-based education be tailored to different general practice settings?

2. What strategies are best for delivering interprofessional training in general practice?

The challenges presented by these questions are addressed by drawing from a consensus project on best practice in interprofessional training for collaborative primary healthcare, and from projects using in-person and online education and training. We propose a model that uses the clinical training space as a way of promoting multidisciplinary general practice. The model incorporates online and face-to-face spaces, where primary healthcare professionals, patients, practices/teaching organisations, educators and technology are aligned through facilitation and feedback channels in ways that promote collaborative practice.

Tasmania, as an island state with close connections between its university, state public health service and general practitioner training, is well placed as a case study for strategic conversations about coordinating general practice education and training to meet the need for an integrated, multidisciplinary primary healthcare workforce.

Keywords: Interprofessional education, primary care, collaborative practice

1 The Royal Australian College of General Practitioners, Hobart, Tasmania

2 Ochre Medical Centre, Claremont, Tasmania

Corresponding author: Dr Michael Bentley, Senior Research Assistant, GP Training Research, The Royal Australian College of General Practitioners, 62 Patrick Street, Hobart, Tasmania, 7000, Australia. [email protected]

INTRODUCTION

Multidisciplinary teamwork is a distinctive feature of primary healthcare reforms in Australia and elsewhere (Brewer et al. 2024; Harris et al. 2016; Saint-Pierre, Herskovic & Sepúlveda 2018), and its importance has been reinforced by the recent Strengthening Medicare Taskforce Report, which recommended strengthening education and training programs “to support an integrated, person-centred team care approach” (Strengthening Medicare Taskforce 2022).

The Royal Australian College of General Practitioners (RACGP 2023) supports:

increasing investment to support multidisciplinary teams in general practice that are responsive to local needs, as long as patients are accessing centrally coordinated care via their general practice.

In its submission to the 2024/25 Federal Government budget, the RACGP reiterated this support with a call to “[i]ncrease support for collaborative, multidisciplinary care teams to deliver coordinated and continuous care to improve patient outcomes” (RACGP 2024).

In this Education in Practice paper, we discuss the relevance of findings from Tasmanian research projects conducted over the past decade to interprofessional education for multidisciplinary teams in general practice. The terms ‘multidisciplinary’ and ‘interprofessional’ are often used interchangeably to describe health care teams (Chamberlain-Salaun, Mills & Usher 2013). In this paper, we use ‘multidisciplinary’ to describe teams and care, and ‘interprofessional’ for education and training.

The terms ‘primary health care’ and ‘primary care’ are also used interchangeably (Muldoon, Hogg & Levitt 2006). We use ‘primary healthcare’ when referring to general practice and other first point of contact health services.

MULTIDISCIPLINARY PRIMARY HEALTHCARE

While the premise of multidisciplinary care is well established, we suggest that the strengthening of interprofessional education and training programs in general practice offers opportunities at the vocational training level and for continuing professional development. The diverse literature on interprofessional education and collaboration covers primary healthcare broadly. In general practice, the focus on collaboration is often that between doctors and nurses, with other combinations including a physician-nurse-pharmacist triad as well as broader multidisciplinary and specialised teams (Saint-Pierre, Herskovic & Sepúlveda 2018).

Integrated, person-centred team care in general practice requires a commitment to collaborative practice, which, in turn, requires an understanding of interprofessional roles (Al-Bedaery et al. 2023). In undergraduate interprofessional education, a safe learning environment enables students from different professions and disciplines to build trust in working together as a team to solve problems, bringing their knowledge and skills to the task of providing optimal person-centred care (Maddock, Dārziņš & Kent 2023). In the transition from undergraduate learning to collaborative practice in primary healthcare, the experiences from interprofessional education – communicating, working together, and recognising the skills and contribution of other professionals – facilitate collaborative practice. However, lack of time, poor communication and concerns over professional identity have been identified as barriers to continuing collaborative practice (Rawlinson et al. 2021).

QUESTIONS FOR GENERAL PRACTICE TRAINING

A panel of 56 primary healthcare (medical, nursing, allied health, and workforce) experts participated in a Tasmanian study on best practice for interprofessional training for collaborative primary healthcare, which used a Delphi technique to determine the level of consensus on a series of statements across four domains of interprofessional education for collaborative practice: big picture, organisation, capabilities, and teaching and learning (Bentley, Kerr & Powell 2016).

The study raised the following questions for general practice training and education within practices:

These questions took on further significance during the COVID-19 pandemic, as training shifted to online formats (Winters & Patel 2021). Earlier Tasmanian projects offer some insights into these questions.

How can team-based approaches be tailored to different general practice settings?

There are many local contextual factors that influence collaboration in general practice – for example, practice size and location, and the collocation of teams and services (Harris et al. 2016). In seeking consensus on best practice in interprofessional training for collaborative primary healthcare, the expert panel agreed on a set of capabilities for interprofessional learning outcomes (what is needed) and on a range of teaching and learning strategies (how to do it) but needed to know more about why we were doing it and where it could be most effective.

Capabilities included applying principles of teamwork, communication, and learning/reflection to interprofessional learning outcomes. Strategies relevant to general practice included practice-based, small group learning programs; simulation-based interprofessional learning; and interprofessional learning based on issues/problems/cases. Identifying interprofessional training opportunities through continuing professional development was seen as an area for further consideration (Bentley, Kerr & Powell 2016).

What strategies are best for delivering interprofessional training in general practice?

Primary healthcare teams can be collocated or dispersed. Collocation facilitates teamwork at a local level but is not necessarily a sufficient condition for collaboration (Harris et al. 2016). Two projects conducted in Tasmania highlight responses to the challenges of delivering interprofessional training in general practice.

· An in-practice emergency simulation was piloted for interprofessional learning within multidisciplinary teams collocated in general practices (Kerr et al. 2015). Practice nurses, general practitioners (GPs), GP registrars, and practice administration staff from three general practices participated in the project. The pilot study found positive engagement across multiple levels of learners in the general practice. A common goal, in this case a simulated emergency, is an important facilitator of collaborative primary healthcare (Supper et al. 2015). Simulation-based learning is an example of “being immersed in an authentic scenario, [where] learners feel what it is like to work in their professions” (Maddock, Dārziņš & Kent 2023).

· Online interprofessional education can apply to dispersed primary healthcare teams. A dementia care training and education program developed for GPs and practice nurses is an example of this approach (Bentley et al. 2019). In this study, although participants completed the education on their own, team approaches to identification, diagnosis and management of patients with dementia were integrated into the online content, as a way to promote shared decision-making behaviours (Thompson‐Leduc et al. 2015). In the evaluation of the program, participants reported increased awareness, knowledge and confidence in assessing and managing people with dementia, and as a result, there were some early changes in clinical management of dementia in the practice (Bentley et al. 2019).

IMPLICATIONS FOR FURTHER RESEARCH

One question that is not addressed by the projects described is how patients can be involved in the process of training and education of collaborative healthcare teams. While other studies show that patients with chronic conditions report positive experiences of multidisciplinary collaborative primary healthcare, the nature of the engagement and involvement of patients in the primary healthcare team is still unclear (Bombard et al. 2018; Davidson et al. 2022). The Tasmanian consensus project agreed on the central role of the patient in collaborative care but acknowledged research is needed on how patients can be integrated into the collaborative healthcare team (Bentley, Kerr & Powell 2016).

One approach to the challenge of integration, proposed in response to the COVID-19 pandemic, is a clinical-training space model that incorporates online and face-to-face spaces, where primary healthcare professionals, patients, practices/teaching organisations, educators and technology are aligned through facilitation and feedback channels in ways that promote collaborative practice (Winters & Patel 2021).

Technology-driven interprofessional learning is the major facilitator in this model. An important feature of the model is that the unit of analysis is the interprofessional learning that takes place across the clinical training space itself rather than individual components (e.g., uptake of technology by a single profession). However, implementing a clinical training space presents challenges, not least adapting to new technologies (Jeffries et al. 2022). Teaching general practices are well placed for vertical integration of medical education across stages of training (Dick et al. 2019; Stocks et al. 2011). Less is known about learning opportunities for multidisciplinary team-based care in general practice (Thistlethwaite et al. 2007). Findings from a South Australian study show that the uptake of telehealth during and post COVID-19 improved access to GPs for patients living with chronic conditions in metropolitan Adelaide but not necessarily their access to multidisciplinary care (Javanparast, Roeger & Reed 2021).

The response to COVID-19 by interprofessional education has largely been focused on undergraduate students (McKinlay et al. 2021; Raynault et al. 2021). Hybrid modalities using online and face-to-face methods are being used in general practice training and education and appear to work best when there are strong social connections between registrars and with medical educators to support the learning engagement of GP registrars (Smith et al. 2022; White et al. 2022). However, further research is needed on postgraduate interprofessional training and education interventions, with longer follow-up intervals required to demonstrate multidisciplinary primary healthcare outcomes (Brienza, Zapatka & Meyer 2014; Pelone et al. 2017).

Tasmania, as an island state with close connections between its university, state public health service and GP training, is well placed as a case study for strategic conversations about coordinating general practice education and training to meet the need for an integrated, multidisciplinary primary healthcare workforce.

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