The joint July 22 start date for Allison Brashear, M.D., M.B.A., and Stephen Cavanagh, Ph.D., M.P.A., R.N., F.A.C.H.E., F.A.A.N., was a symbolic gesture, meant to reflect heightened collaboration between their top-50 schools in order to promote team-based care – and in doing so, help diffuse a looming health-workforce crisis.
California “doesn’t have enough of the right types of health workers in the right places to meet the needs of its growing, aging and increasingly diverse population,” according to a 185-page report released this spring by the California Future Health Workforce Commission. The panel of prominent health, policy, education and workforce-development leaders – including School of Nursing Dean Emerita Heather M. Young – was assembled by major California health philanthropies and co-chaired by UC President Janet Napolitano.
The report’s multiple recommendations include several that emphasize or lay a foundation for team-based care, such as optimizing the contributions of nurse practitioners, physician assistants and other team members to help fill primary care gaps, and boosting scholarship support for education in those areas.
Noting that “The health care of the future will be team care,” UC Davis Health CEO David Lubarsky has asked Cavanagh and Brashear to work jointly to develop models around integrated care delivery and advanced practice for both of their disciplines. In doing so, they’ll build upon an existing foundation of interprofessional education at UC Davis that sees nursing and medical students learn several skills together in specially designed active-learning case-based curricula, cross-disciplinary graduate groups, and interprofessional simulation exercises.
In a joint interview this summer, Cavanagh and Brashear spoke about educating medical and nursing students to work in teams, and preparing them to adapt to – and hopefully influence – today’s rapid-fire disruptions in health technology, policy and finance. Excerpts:
Q. UC Davis Health’s Vice Chancellor and CEO David Lubarsky has said that “The health care of the future will be team care.” Why is it important, and how do we achieve it through collaboration?
BRASHEAR: I think we would both agree that it really creates better care when everybody is contributing what they can bring to the team. It creates a better environment for the patient and the family, and probably keeps the patient in the home longer.
CAVANAGH: Teams enable every group to bring out their own expertise collaboratively – in ways we may not think about otherwise. In the past, maybe there’s been a little siloed thinking in health care. Team-based care is all about bringing the best of everything together, and that’s really where we can impact patient care and outcomes as much as possible.
Q. What’s the state of the union for team-based care?
CAVANAGH: I would say it’s been around for a while, but the art and the skill of it will now be how best to bring about opportunities for team care to be taught to current students and existing practitioners. So it’s not new, but I think we are changing the way that we’re looking at it – as being a major thrust going forward, and not just an add-on. It’s a major way of thinking about everything we do now.
BRASHEAR: It’s important for students to learn about team-based care and see it role-modeled by their faculty, either in the School of Nursing or School of Medicine. And also to know that it’s the way things are going to be in the future. Team-based care is probably better care at lower costs, because everybody’s at the top of their skill set. And it engages the patient and family together into the community that is caring for the individual. Medicine is not as much of a team sport right now. Physicians will be leaders of teams or members of teams, but their roles will change, just like the nurses’ roles will change and the other providers’ roles will change as things evolve.
CAVANAGH: There’s an ability in teams to create interesting solutions that individual professionals might not think about. What I like about team-based care is the creative solutions that emerge, particularly involving families. And of course all the time we’re improving outcomes and reducing costs. This really is the way forward – and probably the only way forward.
Q. What’s likely to happen if we don’t fully embrace this change?
BRASHEAR: I think there’s some evidence to show that team-based care decreases length of stay and readmissions and improves outcomes. If we don’t start changing the way we teach and provide care, I think costs will continue to go up, and that’s just something that the society can’t handle.
CAVANAGH: Costs, quality and safety – all of those things are very important. It’s really important to pull everybody together as a team working together on the same goals and outcomes.
Q. How can we build models of health care delivery here, and share them?
BRASHEAR: The right provider, for the right place, for the right disease state is important. Figuring out what skill set is needed for that situation will be incredibly important. And also developing communication tools: how many times have we all heard in the past about someone who’s discharged from the hospital and the family doesn’t understand the medicines, they don’t know when the follow-up is, and the patient ends up back in the emergency room? It should be rare that any patient has to be managed in the hospital – we need to develop methods and teams to manage people in the outpatient setting.
CAVANAGH: Absolutely. And that goes right to the heart of what we’ve been discussing about communication, how best we communicate the care plan with other professions, families and caregivers. That’s very important.
Q. How can team-based care help to address health disparities and unmet needs for underserved populations?
BRASHEAR: Oftentimes people from underserved populations don’t have access to care. And they get care later, and sometimes don’t get the same quality of care. Team-based care can help provide wraparound services for those who may face more challenges because of their socioeconomic backgrounds, and in doing so make it less likely for them to be admitted to the hospital or go to the ER for their primary care. Instead they’re getting their medicines and the appropriate care in the home. Those things are so incredibly important, because then they get the higher quality of care.
CAVANAGH: That leads very nicely into team-based education, where UC Davis has done very well in bringing in a wide variety of students from different backgrounds. And the teaching and learning environment becomes an opportunity to share different cultural backgrounds – and many things we might not think immediately important to the delivery of health care in a strict technical sense – in an environment where we can practice and model those things to prepare for when we’re actually caring for patients.
BRASHEAR: Making sure the care team is diverse is absolutely key. When patients see providers that look like them, there’s much more of an uptick in understanding, coming from the same cultural backgrounds. That’s really important. The UC Davis School of Medicine has made substantial strides in the number of underrepresented minorities entering our classes. Health care needs to have more of a diverse face, and I think that will help provide better care.
CAVANAGH: The Betty Irene Moore School of Nursing has also made great strides in achieving greater diversity in students, and this is not something that we’ll become complacent about. It’s always going to be important for us to look for ways to encourage people to come into nursing or other professions who have not thought about them, and to consider the impact of educating teams who ultimately deliver care to their own communities.
Q. So increasing the diversity of our providers is important.
BRASHEAR: Our panels of providers need to look like the communities they serve. We’re moving towards that, but certainly not there yet. Interestingly, the number of medical students going to medical school now is more than 50% women. But there still are challenges in terms of diversity, particularly among groups such as African American males for example. And we as leaders need to make sure that we’re encouraging and facilitating that pipeline. Patients really want to go to a provider that understands their background, and we need to figure out how to provide that.
CAVANAGH: In nursing as well – even though we’ve made great strides in improving diversity, it’s very important to come to an environment where there is a sense that there is a connection between community, their own communities, and other students on campus that’s going to improve learning. It’s going to improve retention, but at the end of the day, it’s going to improve the opportunities for better outcomes.
Q. Our health care system is very complex, and is being disrupted in many ways by technology. How do we prepare future providers for this change, and to adapt to advancements that we haven’t even realized yet?
BRASHEAR: Gone are the days where medical students memorize things. What we really want is students who are lifelong learners and who know how to problem-solve, because whatever we teach them – about a specific drug for example – is likely going to change in two years’ time. We want them to learn how to think, to be problem solvers, to work in teams, and to have the patient at the center of anything they do. They’re also going to need to work in different environments, like telemedicine. There are doctors now who just do telemedicine. Part of the new learning environment is going to have to be understanding and adapting to accelerated change.
CAVANAGH: Absolutely. And another element of this is giving students the ability to understand a little more about the policy and politics of change. Every practitioner we educate is in a position to influence and advocate. I think students should come to understand that this is an important part of what their roles are going to be going forward, as well as delivering fantastic care and great outcomes.
Q. In the future, health care is more likely to be delivered in the home or near home settings. Does this change how we educate the providers?
CAVANAGH: Absolutely. And I think finding the balance for students who obviously need to be with patients in hospital situations to begin with, but also to increase opportunities for community care. Actually understanding how care can be delivered into the community, and how our lives and health are so intricately interwoven with our communities. And so I think part of our responsibility has to be preparing practitioners for all sorts of opportunities.
BRASHEAR: We’re fortunate that UC Davis already has some amazing facilities for teaching students how to provide care in the home through telemedicine. It’s one of the hallmarks of the institution.
Q. How do we balance technology with the human touch?
CAVANAGH: I think almost all practitioners are reminded – and sometimes we have to remind ourselves regularly – that it all begins with the relationship between the patient and their caregiver. Technologies and other things that wrap around that are supportive adjuncts. We work very hard to remind our students that it begins with a patient and their families. All of the other things are useful tools – but if you don’t build that relationship, that communication, that rapport, you’ll have a long way to go if you just rely on technology. And that’s not a way we wish to go.
BRASHEAR: We always remember that the patient is at the center of all we do.