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Module 4: Interprofessional Collaboration (INTER)

Thumbnail of downloadable Module 4 PPT Presentation.

The ability of health care and other professionals, as well as direct care workers, community health workers, persons living 
with multiple chronic conditions, families and caregivers, to work effectively within and between professions and with PLWMCC, families, and communities1 to provide appropriate and effective healthcare.

Making the Case for Interprofessional Collaboration for Persons Living With Multiple Chronic Conditions (PLWMCC)

Health is multidimensional and the healthcare needs of PLWMCC are complex and require considerable time to manage2. No single health care professional can effectively address all of the care that PLWMCC require, much less manage a growing number of PLWMCC3. Many organizations – including the Institute of Medicine, the World Health Organization, and the Family Medicine for America’s Health project -- have called for the development and education of interprofessional teams to improve the provision of care for PLWMCC4, 5, 6, 7, 8. Collaborating as an interprofessional team can improve the workload of an individual practitioner, create synergy among team members that leads to higher quality care, and make resources available to PLWMCC that were not otherwise provided9. The members of an interprofessional team vary with the need but might be comprised of physicians, nurse practitioners, physician assistants, nurses, pharmacists, nutritionists, social workers, behavioral health specialists, care coordinators, and community-based personnel10 as well as PLWMCC and their families and caregivers11, 12. The care provided to PLWMCC by their families or other caregivers can be substantial in scope, intensity and duration13, especially in rural settings, smaller clinics, and in other situations that are outside of a larger healthcare system, and therefore without the benefit of consistent access to a more diverse team.

Effective teamwork, team-based care delivery, and the development of competencies needed to provide such care14 are important in achieving the Institute for Healthcare Improvement’s Triple Aim15, 16 of better care, better health, and lower costs. Many healthcare providers and systems are developing team-based models of care that encourage collaborative relationships between clinical and community-based providers, PLWMCC, and their families and caregivers. There is growing evidence that interprofessional collaboration can result in improved care quality, safety, cost-effectiveness, and satisfaction among both PLWMCC and providers17, 18, 19, 20. Additional evidence supports care that is coordinated across professionals, facilities, and support systems, provided continuously over time and between visits, tailored to PLWMCC needs and preferences, based on shared responsibility among healthcare and community providers and PLWMCC 21, 22.

New and evolving Patient Centered Medical Home (PCMH) models support interprofessional team care that optimizes the role of each team member. The PCMH interprofessional team is actively encouraged to be interdependent and to work through established means of communication to ensure that various aspects of PLWMCC health care needs are integrated and addressed23. The PCMH model highlights important principles of interprofessional collaboration, such as coordinated care, team leadership, and effective communication between team members and PLWMCC.

Successful interprofessional endeavors specify and clarify roles and responsibilities, teamwork processes, conflict resolution, and strategies for accessing community-based resources. Interprofessional teams increase their effectiveness by designating specific team members to identify appropriate resources, connect PLWMCC to resources, and ensure that communication between the clinical and community settings is clear and consistent24.

Members of a successful interprofessional team organize around a common goal, work collaboratively to optimize outcomes, and have a clear understanding of their roles on the team and the tasks required of them to optimize the healthcare of PLWMCC25. Leadership is distributed throughout the team so that, as tasks change and goals of the care plan are met or modified, team leadership may also be adjusted appropriately26. Such teamwork optimizes the management of a care plan that addresses goals, strategies, and processes for improving the care and health of PLWMCC. When fully executed, an interprofessional team has the ability to improve population health, care quality and satisfaction27.

Learning Objectives by Competency

Competencies and associated learning objectives are presented below for use by educators. The competencies apply to a wide variety of health professions students, faculty, and practitioners including physicians, nurses, psychologists, psychiatrists, dentists, pharmacists, social workers, allied health professionals, care coordinators, as well as interprofessional teams. These competencies apply across the educational continuum, and can be discipline specific or interprofessional. Examples of learning objectives are provided below. Educators may tailor objectives for a specific healthcare discipline and for a specific phase of education.

INTER 1. Recognize that PLWMCC are central members of their own healthcare teams.

Learning Objectives

  1. Place the interests of PLWMCC at the center of care delivery.
  2. Integrate collaboratively set goals into a comprehensive care plan.
  3. Ensure that the care team works with PLWMCC to develop the care plan and also makes sure PLWMCC review, understand, and agree with the care plan.
  4. Create communication channels for PLWMCC to engage with the care team at any time.


INTER 2. Negotiate roles and responsibilities with all team members that align with their scopes of practice.

Learning Objectives

  1. Document that all members of the team, including PLWMCC, understand their function on the team.
  2. Document that all team members are able to articulate roles and responsibilities of other team members.
  3. Seek out team-based training opportunities to enhance team performance.


INTER 3. Collaborate with all team members in executing a care plan that meets the complex needs of PLWMCC.

Learning Objectives

  1. Develop care plans with PLWMCC and ensure their concerns are addressed.
  2. Ask PLWMCC to identify their short and long term healthcare goals.
  3. Revisit the care plan monthly to meet the changing needs of PLWMCC.


INTER 4. Support culturally competent care for PLWMCC by the interprofessional team.

Learning Objectives

  1. Ask PLWMCC whether their interactions with healthcare staff are respectful of their unique cultures, values, role/responsibilities, and knowledge base.
  2. Ask PLWMCC if team communication with them is linguistically and culturally appropriate.
  3. Include persons on the interprofessional team who are knowledgeable about culturally specific needs of PLWMCC.


INTER 5. Engage community partners as key members of the interprofessional team.

Learning Objectives

  1. Use the goals of the care plan to pair PLWMCC with resources.
  2. Document resources that are needed for goals to be met.
  3. Develop effective communication channels with organizations outside the traditional care setting to update PLWMCC’s care.
  4. Establish working relationships with healthcare professionals who complement roles and responsibilities of existing team members.


INTER 6. Coordinate team-based synergistic interventions that address all person-centered goals.

Learning Objectives

  1. Demonstrate the capacity to coordinate multiple recommended interventions by members of the interprofessional team.
  2. Communicate with the team when goals are met or need to be modified.
  3. Ask PLWMCC if the recommended interventions meet their care plan goals.


Selected Curricular Resources

The following is a list of curricular resources that address, at least in part, Interprofessional Collaboration. Additional resources can be found in the MCC Education and Training Repository with live links.



1. Schmitt, M., Blue, A., Aschenbrener, C. A., & Viggiano, T. R. (2011). Core competencies for interprofessional collaborative practice: reforming health care by transforming health professionals' education. Acad Med, 86(11), 1351.

2. Vanderwielen, L. M., Vanderbilt, A. A., Dumke, E. K., Do, E. K., Isringhausen, K. T., Wright, M. S., Enurah, A. S., Mayer, S. D., & Bradner, M. (2014). Improving public health through student-led interprofessional extracurricular education and collaboration: a conceptual framework. J Multidiscip Healthc, 7, 105-110.

3. Goodman, R. A., Boyd, C., Tinetti, M. E., Von Kohorn, I., Parekh, A. K., & McGinnis, J. M. (2014). IOM and DHHS meeting on making clinical practice guidelines appropriate for patients with multiple chronic conditions. Ann Fam Med, 12(3), 256-259.

4. Tubbesing, G., & Chen, F. M. (2015). Insights from exemplar practices on achieving organizational structures in primary care. J Am Board Fam Med, 28(2), 190-194.

5. Framework for action on interprofessional education & collaborative practice. (2010). Geneva, Switzerland: World Health Organization.

6. Institute of Medicine (US). Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academy Press.

7. Family Medicine for America’s Health: future of family medicine 2.0. Retrieved from http://www.aafp.org/about/initiatives/future-family-medicine.html.

8. Gittell, J. H., Beswick, J., Goldmann, D., & Wallack, S. S. (2015). Teamwork methods for accountable care: Relational coordination and TeamSTEPPS(R). Health Care Manage Rev, 40(2), 116-125.

9. Lewis, V. A., Larson, B. K., McClurg, A. B., Boswell, R. G., & Fisher, E. S. (2012). The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles. Health Aff (Millwood), 31(8), 1777-1785.

10. Ladden, M. D., Bodenheimer, T., Fishman, N. W., Flinter, M., Hsu, C., Parchman, M., & Wagner, E. H. (2013). The emerging primary care workforce: preliminary observations from the primary care team: learning from effective ambulatory practices project. Acad Med, 88(12), 1830-1834.

11. Green, B. B. (2013). Caring for patients with multiple chronic conditions: balancing evidenced-based and patient-centered care. J Am Board Fam Med, 26(5), 484-485.

12. Patient Centered Medical Home Resource Center. Retrieved from http://pcmh.ahrq.gov/.

13. Reinhard, S. C., Given, B., Petlick, N. H., & Bemis, A. (2008). Supporting family caregivers in providing care. Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD.

14. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. (2011). Washington, D.C.: Interprofessional Education Collaborative.

15. Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: care, health, and cost. Health Aff (Millwood), 27(3), 759-769.

16. Institute for Healthcare Improvement Triple Aim Initiative. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx.

17. Boult, C., Reider, L., Leff, B., Frick, K. D., Boyd, C. M., Wolff, J. L., Frey, K., Karm, L., Wegener, S. T., Mroz, T., & Scharfstein, D. O. (2011). The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med, 171(5), 460-466.

18. Boult, C., Reider, L., Frey, K., Leff, B., Boyd, C. M., Wolff, J. L., Wegener, S., Marsteller, J., Karm, L., & Scharfstein, D. (2008). Early effects of "Guided Care" on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci, 63(3), 321-327.

19. Marsteller, J. A., Hsu, Y. J., Reider, L., Frey, K., Wolff, J., Boyd, C., Leff, B., Karm, L., Scharfstein, D., & Boult, C. (2010). Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med, 8(4), 308-315.

20. Center for Health Sciences Interprofessional Education, Research and Practice. IPE handout. Retrieved from http://collaborate.uw.edu/sites/default/files/files/WSNA_Zierler.pdf.

21. Singer, S. J., Burgers, J., Friedberg, M., Rosenthal, M. B., Leape, L., & Schneider, E. (2011). Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Med Care Res Rev, 68(1), 112-127.

22. The San Francisco Center and Education for Patient Aligned Care Teams. Retrieved from http://www.va.gov/oaa/coepce/sanfrancisco.asp.

23. Boyd, C. M., & Lucas, G. M. (2014). Patient-centered care for people living with multimorbidity. Curr Opin HIV AIDS, 9(4), 419-427.

24. Agency for Healthcare Research and Quality Clinical-Community Linkages. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/.

25. Grumbach, K., & Bodenheimer, T. (2004). Can health care teams improve primary care practice? JAMA, 291(10), 1246-1251.

26. Harris, M. F., Dennis, S., & Pillay, M. (2013). Multimorbidity: negotiating priorities and making progress. Aust Fam Physician, 42(12), 850-854.

27. " Front Matter ." Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes. Washington, DC:: The National Academies Press. (2015).

28. Aston, S. J., Rheault, W., Arenson, C., Tappert, S. K., Stoecker, J., Orzoff, J., Galitski, H., & Mackintosh, S. (2012). Interprofessional education: a review and analysis of programs from three academic health centers. Acad Med, 87(7), 949-955.

29. Schoenbaum, S. C., & Okun, S. (2015). High performance team-based care for persons with chronic conditions. Isr J Health Policy Res, 4, 8.

30. Abraczinskas, J., Brenner, J. . (2012). Camden Coalition's Model for High Needs Patients. Physicians News Digest

31. Woolf, S. H., Dekker, M. M., Byrne, F. R., & Miller, W. D. (2011). Citizen-centered health promotion: building collaborations to facilitate healthy living. Am J Prev Med, 40(1 Suppl 1), S38-47.

Content created by Assistant Secretary for Health (ASH)
Content last reviewed on July 1, 2015