Geriatric patients are more likely to have multiple medical comorbidities, physical limitations, and mental impairments that warrant careful consideration while providing patient care. Dentistry, along with other health care professional programs, incorporate interprofessional education (IPE) experiences to provide students with skills they need to deliver collaborative care in their future practice. Health professional programs should consider geriatric training in simulated learning environments, adult day programs, nursing homes, long-term care facilities, and home care experiences to provide students valuable IPE experiences. Lastly, this article presents a call to action for professional organizations to consider offering continuing education courses in IPE.
Key points
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With the increasing number of older patients with natural dentition and complex medical needs, communicating and collaborating with other health care providers will be paramount in providing comprehensive dental care in the twenty-first century.
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There is a growing need for health professional programs to provide students with interprofessional education (IPE) experiences to prepare their graduates for the workforce.
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Geriatrics provides an excellent channel for IPE experiences, resulting in improved patient outcomes of some of the most vulnerable members of society.
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Existing models of interprofessional practice in geriatrics such as adult day programs, nursing homes, long-term care facilities, home care, and simulated learning experiences are avenues to implement IPE experiences.
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Continuing education (CE) programs across the health professions should consider offering training and CE credit for learning skills in IPE and collaborative practice for all members of the dental community.
Introduction
Have you noticed a shift in the age of your patients? Or, are you making fewer dentures than you thought you would in your practice? Whether you acknowledge it or not, your patient population is likely aging, primarily if you practice outside of a densely populated urban area. As the US population ages, so do their dentition; however, the clinical presentation of elderly dentition looks different than it did even half a century ago. Rates of edentulism are declining, and an increasing number of patients are maintaining their natural dentition well into their golden years. A general dentist will likely encounter a geriatric patient weekly, if not daily, in their practice. Elderly patients are more likely to have complex medical needs that may require a different approach to care. As dentistry becomes more accustomed to treating medically compromised geriatric patients, providing comprehensive, collaborative care will become standard practice.
Collaboration among health care professionals has demonstrated benefits of improved patient outcomes. Despite knowledge of patient benefits, often, in practice, health care specialties operate in silos with minimal communication and coordination of patient care. Although the benefits of collaborative care are known for patients throughout their lifetime, geriatric patients may benefit from the partnership between health care providers due to their significant medical needs. To address this gap, professional organizations such as the American Medical Association have called for increased collaboration between members of the health care team. As a response, health professional education programs across the disciplines have started to implement interprofessional education (IPE) requirements to model collaborative patient care experiences for students. These experiences aim to graduate a new generation of health care professionals equipped with valuable collaborative knowledge and skills to enter the workforce and become meaningful contributors to the patient care team.
As this chapter explores the role of IPE in geriatric dental medicine, the hope is that you will acknowledge the limitations of a ‘uni-professional identity,’ one which isolates the dental profession and by nature and generates misunderstandings amongst healthcare providers and establish a ‘multi-professional identity’. Failure to develop a dentist’s view as a partner in collaborative person-centered practice can propagate negative stereotypes between health care professionals and ultimately negatively affect patient care. By viewing the role of a dentist more broadly, as a valued contributor to a patient’s health care team, the hope is to improve patient outcomes and prepare the dental profession for the health care delivery system of the future.
Interprofessional education
IPE is a purposeful, planned interaction between health professional students of different disciplines. The World Health Organization and the Center for the Advancement of Interprofessional Education define IPE as the learning experience that “occurs when two or more professions (students, residents and health workers) learn with, about, and from each other to enable effective collaboration and improve health outcomes.” A Health Resources and Services Administration report indicated that interdisciplinary education best exists in collaborative teams where (1) teams work to address a sizable complex problem where no one individual can create a solution alone, (2) teams represent a variety of fields that will make solving the problem easier, (3) all contributors’ skills and knowledge are considered equally as important, and (4) team members share a collective goal.
Early attempts to provide interprofessional experiences for health professional students included educating students from different health professions together through combined courses and voluntary educational experiences. Elective or happenstance types of IPE experiences are not as effective as carefully crafted experiences designed to provide collaborative training. Cahn (2014) argues how interprofessional skills must be strategic and well planned to maximize their effect. These findings suggest that IPE experiences require a carefully selected, specific, and permanent place in the health profession curriculum. Accrediting bodies of dental, medical, and nursing programs, among many others, include accreditation standards requiring institutions to provide IPE experiences. Table 1 outlines the IPE accreditation requirements of the Commission on Dental Accreditation (CODA), Liaison Committee on Medical Education (LCME), and the Commission on Colligate Nursing Education (CCNE). Similar standards have emerged in pharmacy, physical therapy, physician assistant, dietician, and social work programs to ensure administration craft collaborative opportunities within their curriculum.
| Accreditation Standards | |
|---|---|
| Dentistry | “2–20 Graduates must be competent in communicating and collaborating with other members of the health care team to facilitate the provision of health care. Intent: In attaining competence, students should understand the roles of members of the health care team and have educational experiences, particularly clinical experiences that involve working with other healthcare professional students and practitioners. Students should have educational experiences in which they coordinate patient care within the health care system relevant to dentistry.” |
| Medicine | “7.9 Interprofessional Collaborative Skills The faculty of a medical school ensure that the core curriculum of the medical education program prepares medical students to function collaboratively on health care teams that include health professionals from other disciplines as they provide coordinated services to patients. These curricular experiences include practitioners and/or students from other health professions.” |
| Nursing | “III-H The curriculum includes planned clinical practice experiences that: a) enable students to integrate new knowledge and demonstrate attainment of program outcomes, b) foster interprofessional collaborative practice and c) are evaluated by faculty.” |
Because IPE earns a permanent spot in the health profession curricula, professional schools will produce new graduates more experienced and prepared for collaborative practice. Although team-based collaborative care is not a new concept for nursing and medical programs, dental programs have started to include IPE experiences within the last decade in response to changes in CODA accreditation standards. Often, IPE experiences are part of special care or pediatric courses and clinics. Demonstrated benefits of increasing student knowledge, confidence, and clinical practice have been shown in pediatric IPE experiences. In addition, significant changes in students’ attitudes toward IPE and collaborative care are known results of geriatric training programs. Regardless of which courses dental schools use to incorporate IPE into their curriculum, collaborative practice should start early and occur often in dental students’ training. Dental schools may consider IPE programs to partner with other health professional programs to reduce disparities in the frail and community-dwelling elderly.
Interprofessional Education and the Geriatric Patient
Older adults may benefit significantly from an interdisciplinary team-based approach to care, as geriatric patients are more likely to have multiple medical comorbidities and physical and cognitive impairments. Managing various health concerns adds additional layers of complexity for providers of geriatric patients, as risks and benefits of treatment options need careful evaluation in the treatment planning process. Models of collaborative care in geriatrics are known to aid health care teams in prioritizing patient-specific care plans. Initial multidisciplinary team assessments have shown improved patient outcome measures for geriatric patients over time. Therefore, the geriatrics curriculum is ideal for professional schools to integrate IPE and significantly affect patient quality of life and health outcomes.
Models of IPE experiences readily exist in geriatric education and training across the disciplines. Authentic IPE experiences expand beyond providing care within a multidisciplinary network and allow students to collaborate on interdisciplinary teams to address complex patient problems. Medical geriatric training programs have a strong history of promoting interdisciplinary and collaborative care, whereas evidence is more variable in other health professional programs. Dentists should communicate with geriatricians and learn from their approach to collaborative practice. Dental schools should consider including IPE experiences in geriatrics throughout the dental curricula to best prepare students for future practice.
Successful Interdisciplinary Care Requires Teamwork
As a practicing dentist, you are no stranger to the importance and value of teamwork. Similar to how your dental team’s success relies on all members having clearly defined roles, understanding others’ roles, and working together to achieve a shared mission, interdisciplinary care and IPE experiences also rely on teamwork. A key component of successful collaborative care is that groups understand the roles and responsibilities of all collaborators as they establish and work toward a common goal. Therefore, interdisciplinary groups should set agreed-on rules and create standards of communication, with plans that will allow members to identify and resolve conflict when it arises. It is considered best practice to spend some time acquainting one another with specific roles and establishing protocols and guidelines once interdisciplinary teams form.
In addition, similar to how a general dentist relies on all team members’ flexibility, members of interprofessional care teams need to demonstrate flexibility with changing circumstances. It is considered good practice for interdisciplinary teams to establish a means to receive feedback and provide performance reviews to improve the team’s function. Feedback can be a successful way to identify successes and isolate growth opportunities, making the team-based approach to care more efficacious.
Lastly, the collaborative approach should consider patients’ desires through shared decision-making. Finding common ground can be challenging when team members have different beliefs of what shared decision-making is or what shared decision looks like in their specialty. Although the concept of shared decision-making is evolving in geriatrics, collaborative teams should work to identify patient’s values and goals, as they collectively construct a plan of care. In geriatric dental medicine, there are endless examples of shared decision-making related to providing treatment or not providing treatment to our most vulnerable and frail elders. In practice, this may translate to a conversation with a patient’s family and interprofessional team to decide to collectively monitor and apply periodic fluoride to a calcified root tip in a 92-year-old patient, instead of extraction. It may also mean relining an old set of worn dentures with porcelain teeth instead of making them new dentures based on the patient’s esthetic preference and likeliness to comply with treatment. Regardless of the level of shared decision-making, all members of the patient’s care team must be on board with the decision to provide or monitor specific treatment options, especially when the decision has the potential to affect the care of multiple members of the team.
Teamwork is essential for effective interdisciplinary care. It is crucial if you are interested in forming or joining a collaborative care team to set aside time to create common goals, be open and receptive to feedback, communicate effectively, and participate in shared decision-making with patients, patient families, and caretakers.
Establishing Excellent Collaborative Care Models Is Challenging
Regardless of the inherent benefits of collaborative care in geriatrics, institutions and programs face many challenges when designing interdisciplinary experiences. Known problems associated with the design and implementation of IPE in health professional programs are seen in Fig. 1 . , , The challenges listed in Fig. 1 apply to providing students with IPE experience in health professional programs but also applying collaborative care in clinical practice.
Two specific challenges are associated with implementing IPE experiences to highlight (1) the lack of experienced dental faculty and (2) status differences among different health care disciplines. These challenges make it more difficult for dental schools to establish active IPE experiences for their students and create potential roadblocks to collaborative care in their future practice.
Although IPE in dentistry is considered an emerging practice, dentists who have significant exposure to meaningful collaboration with professionals across disciplines are uniquely poised to become leaders in IPE in academia. These practitioners may seek partnerships with dental schools or dental organizations to provide IPE experiences to students or offer examples of effective collaborative care to practicing dentists.
Status differences in health care disciplines can present a challenge for designing IPE experiences in health professional programs and establishing effective collaborative care teams in practice. The American Dental Association Action for Dental Health Initiative offers strategies that dentists can use to collaborate with other health professionals and bridge disciplines. Suggestions from the Health Resources and Service Administration include (1) developing relationships with local physicians and pediatricians for referrals, (2) taking body mass index of the patient and referring patients to primary care if they are at risk of being overweight, and (3) collaboration with pediatricians to apply fluoride varnish and/or refer children with high caries risk. Although these strategies may not eliminate the potential for status-related challenges in interprofessional teams, it opens up communication lines. In addition, it demonstrates to other health care providers the potential for meaningful collaboration with dental professionals.
Gaining additional insight from practicing dentists who participate in interdisciplinary patient care is essential for the widespread, long-term effects of IPE. Even though professional programs in dentistry, medicine, nursing, social work, pharmacy, and psychology have IPE experiences within their curriculum, many consider existing IPE experiences inadequate to graduate a workforce ready to make interdisciplinary team care a priority. Therefore, health professional programs must form meaningful partnerships with community stakeholders to offer optimal IPE experiences. Existing interdisciplinary practice models in geriatrics may provide an avenue for dental schools and practicing dentists to develop relevant collaborative care skills.
Existing models of interdisciplinary practice for geriatric patients
Existing models of interprofessional education and collaborative practice in geriatrics are readily available within health professional education programs and health care delivery systems across North America. This section explores examples of collaborative practice in adult day programs, nursing homes, long-term care facilities, home care programs, and simulation-enhanced IPE.
Day Programs
There were close to 4,600 adult day centers across the country that serve close to 300,000 older adults each day in 2010. In the last decade, the number of adult day centers has dramatically increased; reports now suggest that there are more than 7,500 centers. Approximately 70% of adult day centers are not-for-profit and most are affiliated with home care, medical centers, or skilled nursing facilities and offer various social and health services. Projections suggest that 74% of attendees of adult day programs live at home, which makes day programs accessible options for families who serve as primary caretakers, as these programs are known to help ease the burden of caregivers on older adults.
One existing collaborative care model for geriatric patients is the Program of All-inclusive Care for the Elderly (PACE), which uses a day center model to provide comprehensive and collaborative care. The PACE program’s goal is to reduce unnecessary hospital stays and nursing home care by focusing on maintenance of function and prevention of acute disease. As of September 2019, there are 263 PACE centers nationwide, with programs spanning 36 states. Training programs in medicine are known to use PACE programs as rotation sites for medical and family practice residents on the collaborative care model. Partnership with an existing PACE site or similar elder adult day program could afford IPE experiences for trainees across all disciplines. Each PACE site is required to have a primary care physician, social work services, physical therapy, occupational therapy, personal care and supportive therapies, nutritional counseling, recreational theory, and meals. Although geriatric dentists are not essential members of the collaborative team, PACE programs readily offer dental services and include dentists in patient care conferences. Often this includes partnering with a community dentist. Occasionally, this includes providing dental services on-site, affording more significant interaction between dental professionals and other members of the patient care team. Physically including dentistry within PACE programs sites could allow community dentists to shadow, network, and refer complex medically compromised geriatric patients. Dental schools may also seek partnerships with local PACE programs to expose students to a model of collaborative team-based care in geriatrics.
Nursing Homes
Nursing homes and facilities for community-dwelling elders present another avenue for collaborative geriatric patient care. Interdisciplinary care is essential in nursing facilities, as the increased collaborative practices in these environments have shown increased health outcomes. The percentage of older adults living in nursing homes decreased over the last two decades, as the priority focuses on keeping elders residing within the community. Today approximately 4.5% of adults older than 65 years live in nursing homes, which suggests that older adults living in nursing home facilities have complex needs and would benefit from a team-based approach to care.
Examples of IPE in nursing home facilities exist within the United States; however, they are not distributed evenly in all areas or across all populations. There is a lack of geriatric IPE experiences in settings of community-dwelling older adults in underserved areas. This gap in services presents an opportunity for health professional institutions to partner with nursing homes to establish educational training centers that could foster collaboration between dental, medical, nursing, pharmacy and social work students. These programs would allow students to work together to treat some of our nation’s most vulnerable older adults. Dental and dental hygiene students may play an essential role in nursing facilities.
Studies suggest that the burden of oral health disease in the population of community-dwelling older adults is high, and a significant need for oral health promotion programs exists. Practicing dentists may seek opportunities to volunteer or provide meaningful services in nursing homes in their community by providing dental services and/or oral health education to older adults, their families, and nursing home staff.
Long-Term Care Facilities
Older individuals in long-term care facilities typically suffer from chronic conditions, trauma, or illnesses that interfere with their ability to complete activities of daily living (ALDs). ALDs include household chores, preparing meals, managing finances, and personal hygiene, such as proper tooth brushing or caring for dentures. Health care goals in long-term care facilities no longer focus on curing an individual’s illnesses. Instead, they focus on maintaining a maximum level of function. While developing patient care plans in long term care facilities, it is essential that care teams consider an individual’s oral health condition, especially as it relates to their ability and willingness to chew and eat food. This plays a significant role in a geriatric patient’s care plan, as individuals with chronic illness are more likely to be undernourished and lack vital nutrients in their diet. Offering dental students training in this collaborative setting is critical, as they weigh the risks and benefits of an ideal dental treatment plan. This environment may also emphasize shared decision-making and collaborative care with the patients’ health care team and family. Developing modified treatment plans is an essential skill that health profession students could practice through collaborative experiences in long-term care facilities. Because these patients have significantly complex medical teams, long-term care facilities often have extensive provider networks, making them an excellent resource for training new professional students and providing practicing professionals exposure to collaborative care models.
Home Care
Home care is an additional avenue to provide trainees with experience in collaborative, interdisciplinary care. By 2050 more than 27 million people in the United States will be living at home and need some help with ADLs. For that reason, a substantial increase in home health care jobs will be available to meet this growing need, and the US Health professional training programs should develop training experiences in treating patients outside of a typical clinical setting. Home care interdisciplinary team visits have demonstrated benefits for medical, physician assistant, occupational theory, social work, physical therapy, pharmacy, and dental students. Continuing education training experiences in home-based care for dental professionals may be a way to expand at home services for older patients and expose practitioners to best practices and professional standards when treating patients outside of the typical dental setting.
Simulation-Enhanced Interprofessional Education
One model that allows students and clinicians to gain experience and practice in interdisciplinary collaborative outside of the patient care experience is through simulation-enhanced learning activities. The goal of simulation-enhanced IPE experiences is to provide opportunities for training and learning in collaborative care while offering trainees opportunities for evaluation and reflection. Simulation-enhanced IPE makes use of a simulator such as a standardized patient, mannequin, avatar, or virtual, procedural, or computer-based model, minimizing many of the physical barriers that exist when designing collaborative patient-based experiences. Simulation-enhanced IPE may be a way for health professional programs to provide valuable IPE experiences to students in a remote learning environment. Benefits of simulation-enhanced IPE include (1) similarities to clinical practice, (2) objective scoring opportunities through a comprehensive evaluation of team and individual performance, (3) opportunity to provide meaningful feedback, and (4) reflection and ability to design a variety of simulations to meet specific program’s needs.
Health professional education programs are unique in their ability to incorporate simulation-enhanced IPE experiences into their curriculum and continuing education programs through their simulation learning centers. These simulated learning environments may provide schools with space and resources when designing interprofessional experiences with other health professional programs. Simulated learning environments of dental schools or other health professional programs may serve as ideal locations for interprofessional training for practicing clinicians who seek learning opportunities for the best practices of collaborative care. Conducting virtual IPE training experiences may also expose clinicians to best practices when training centers are not available within their community.
Table 2 summarizes pertinent characteristics, services available, and opportunities for collaborating care for day programs, nursing homes, long-term care facilities, home visits, and simulation-enhanced IPE experiences.
