Hello and welcome, I'm Amy Cohen, Associate Director for SMI Advisor and a Clinical Psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, The Work Is Only As Good as a Team, Strategies for Developing a Strong Interpersonal Team Collaboration. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. And now I'd like to introduce you to the faculty for today's webinar, Hella Thorning. Dr. Hella Thorning is a Clinical Professor of Psychiatric Social Work in Psychiatry at Columbia University, Vagalos College of Physicians and Surgeons. She serves on the leadership team of the Center of Practice Innovations in the Division of Behavioral Health Services and Policy Research at the Center for Practice Innovations at New York State Psychiatric Institute, Columbia University. As a researcher, she is a research scientist and director of the Assertive Community Treatment Institute, also known as the ACT Institute. Dr. Thorning's main research area is in the development and application of educational and psychoeducational interventions designed to improve quality of life and outcomes for individuals and families faced with trauma, mental illness, parenting in the context of behavioral health challenges or other significant life challenges, as well as transitional care. Moreover, she studies implementation science to change practice through workforce development, transformative learning processes, organizational change, and quality improvement, and is published in this emergent area of study. Hella, thank you for leading today's webinar. Thank you very much for that nice introduction and for inviting me to present today on the topic of interprofessional collaboration and teamwork. Hello to everyone participating today. I know taking time off and out of your busy schedule to be here is not easy. Welcome, and I look forward to your questions and comments. Before we begin, I just want to say that I have no relationships or conflict of interest related to the subject matter of this presentation. So let's begin. So here is a quick outline of what I'd like to talk about today. First, why is it important to have an interprofessional team when working with people with severe mental illness? How do we build an effective interprofessional team? How do we approach challenges, and how do we optimize opportunities to provide the best treatment for the people we serve? And what are some of the strategies? I'll briefly present concepts from implementation science that can be used to sustain new ways of practicing over time. Finally, I'll talk briefly about assertive community treatment as one evidence-based practice model where we use an interprofessional team approach and the lessons we have learned in setting that up. And finally, we'll have time for dialogue at the end, and Dr. Cohn will facilitate this part. So as we all know, individuals with behavioral health conditions face complex challenges, often a combination of psychiatric disorders and substance use. And as we have become keenly aware of, many also have significant health conditions that are often chronic in nature. We also know that our treatment systems are often complex, fragmented, and therefore difficult to navigate, both for providers and also for our recipients. Our social environments are complex as well, and although these disorders have biological links, they are also substantially influenced by modifiable social, economic, and environmental conditions that affect not only individuals, but whole communities, neighborhoods, and populations. Social determinants influence us all. Health and mental health outcomes depend on our race, identity, where we live, among many other factors. Here's a diagram that illustrates the social determinants. Let us take a brief moment to review. So if we go counterclockwise, we can see that poor mental health and risk factors of mental health are influenced by adverse early life experiences, housing instability, social exclusion or social isolation, poor neighborhoods, poverty, income insecurity, inequality, education inequality, poor access to and quality of health care, food insecurity, underemployment or unemployment. And these factors in this frame, as we see here, like on the top bar, you'll see like the short-term and shifting economic environments in the U.S. that impact all of these factors. And with the lower red bar, you'll see the long-standing historical and sociocultural context in the U.S. that also influence poor mental health and risk for mental illness. So these are all the areas that we need to consider when we are working with people with severe mental illness. So to be able to address these many dimensions, you need many skills. And therefore, there's a great need for many professionals with different knowledge skills and skill sets and scope of practice to work together to work effectively with the people that we seek to serve. So effective teamwork is the cornerstone of interpersonal collaboration. When team comes together, the ability to work towards health and wellness for service participants, families and communities are stronger than any individual efforts. But bringing a team together can also be challenging. It's a significant departure from the current way of cultural care provision. And clinicians are often trained in specialty models that emphasize distinction among professional fields. Service participants are often recipients of care and not equal partners. And families and communities are often in the periphery of the teamwork. So to shift cultural norms and pivot towards collaborative practice, where all participants are equal partners and contributors, that's what we'll try to talk and focus on today. So our learning objectives, what I hope that you'll get out of this presentation, that you will have a better understanding of the opportunities and challenges of collaborative interpersonal teamwork, and that you will identify some strategies to build a collaborative interprofessional team and maybe inspire you to think about this in your own work. And then learn about one model where interprofessional approach, team approach, has been implemented to improve access and care quality for a subpopulation of people with severe mental illness. So let's first start with definition. So how do we define an interprofessional practice? So interprofessional collaborative practice occurs when multiple health workers from different professional backgrounds provide comprehensive health service by working with patients, participants, their families, caregivers, and community to deliver the highest quality of care across these settings. The interprofessional team consists of behavioral health and health professionals, peer staff, specialists or specialists, service users, or we can call them participants, natural supports and family members. So those are the people that make up the team. And where does it take place? It can take place in different configuration. It can be coordinated care, meaning that people are sitting, the team is sitting in various places in the community, agencies. It can be co-located within the same agency, and it can be an integrated practice such like an ACT team, which I will describe later. So let's talk about how to build a collaborative interprofessional team. The first step would be to develop a shared mission and vision. So what does that mean? Who are the people that our team is serving? What do we know about the unique challenges? What do we know about the social determinants for this population? And what's the overall goal of our program? So the first step is to ensure that you and your team have these important conversations so that you're all on the same page. Second would be what is the role or scope of practice that each of you are bringing to the team? For example, a nurse brings unique knowledge and skills and a skill set to the disabled, which is different from the psychiatrist, the vocational specialist, or the mental health professional, social worker, or psychologist who perhaps are working with a family. And they all differ, again, from a substance abuse specialist. So knowing the education and the training that each person has before they arrive into the role that they play on the unit, on the service, on the team. Now knowing who are the people behind the team role is equally important. How you came to the work in the behavioral health field, your background, your race and identity, as well as your strengths and vulnerabilities are importance by individuals on your team who work very closely together with you to know so they can understand and you can understand their reaction, they can understand your reaction, and thoughts and actions where they may be coming from. So knowing the people behind the roles is equally important. Well, collaborative leadership is important. The leader most likely does not have the expertise of all the professions represented on the team, but their openness to listen, problem solving, and synthesizing information and facilitate the development of a joint action step are critical to keep the team on task and to what's working towards the same goal. Furthermore, having a clear structure of the work, how to do the work, when to meet, what will the goals and objectives be for each of the meetings that you have, how long you meet, as well as how to communicate between meetings is important. So establishing the framework and structure for team collaboration is something that is an important step in building a collaborative interprofessional team. Interprofessional communication skills, how do you set the tone for your team of respect and mutuality is key to support each member of the team to be able to provide with the team, provide and put to the team their expertise and scope of practice and for the benefit of the people that the team serves. Also, how you talk, how you interact with respect and mutuality amongst one another can also translate to the work and how you work with participants and their family and their, or their natural supports. The setting, the tone of respect and mutuality is key for effective communication and working together as a team. Finally, I want to emphasize too that having a trauma-informed perspective or a lens to the work of the team is also critical. Remember back to when we looked at all the different social determinants and the situations and the complex situations our participants and their families are in, often written by trauma or trauma experiences, either historical or current, that is very stressful. And it's important for the team to understand how that impacts them in their work on a day-to-day basis. Furthermore, we all react to stress or trauma, what we witness or experience, and that we try to deal with in our day-to-day work, that it's important that we each support each other in our differences in how we, how we experience the work. So that's really establishing a trauma-informed care team, meaning that we understand the stress and trauma's impact on the team as a whole, but also on each individual team member. So how do we do this? Although everyone may endorse the importance of interprofessional team collaboration, it will need to be supported by the way our organization, the way, the agency or the organization in which the team exists or operates, is set up that it'll be supported. And that can be that this team collaboration amongst the interprofessional gets supported, and that can be done in different ways, such as having a standard of care document or use of fidelity measure, and within that, the collaboration of the team can be spelled out. And also that training is explicitly stated in this document as important for sustaining this practice. So this means that there's a clear frame that keep the operation of the interprofessional team in place. So I'll now outline some strategies from implementation science that can assist you in the development of this frame I'm talking about, and how you could sustain interprofessional team collaboration over time. I'll use an example here from the ACT Institute, which is located at the Center for Practice Innovations here in New York. The Center for Practice Innovations at Columbia University and the New York State Psychiatric Institute is a public academic center that provides education, training, technical assistance, and implementation support for New York State Office of Mental Health, Behavioral Health Workforce. We support the New York State mission to promote the widespread availability of evidence-based practices to improve mental health services, ensure accountability, and promote recovery-oriented outcomes for recipients, participants, and their families. CPI serves as a key resource for OMH for spreading those practices identified as most critical to accomplish the OMH, our Office of Mental Health Systems Transformation Initiative. Within that landscape, CPI operates as a purveyor and intermediary organization. So what does that mean? A purveyor organization is an individual group of individuals representing a practice that works in implementing a model program, such as ACT, with fidelity and good effect, and typically involves the implementation of a specific evidence-based practice, as I said. An intermediary organization, an individual group of individuals that acts as an intermediary between two or more entities to promote, again, evidence-based practices, and to try to counteract drift from fidelity. So CPI and ACT, the ACT Institute within CPI, we exist sort of in this middle space between OMH and the teams that are implementing ACT. At CPI, we also have, it was started, just to give a little background, it was started in 2008, and we have since added on a number of different evidence-based practices, and ACT was joined to the CPI in 2009, and has been here since, as we have been scaling up ACT in New York State. We use a particular framework here at CPI, it's called the CPI's Practice Change Model, that incorporates both how you, if you look at the two white boxes in the middle of this picture, it incorporates this idea of inner settings and outer settings. So within the inner settings, we are talking about how the team works, how we think about when we implement changes, if we think about how to keep a frame in place, like I talked about with the interprofessional team approach, how that is operationalized, and we put that into place through an implementation process, from pre-implementation to implementation, and then to maintenance and evolution, or sustainability over time. The same with the outer setting, the outer setting is what was described as the policies, regulations, and fiscal reimbursement structures to programs, must be aligned with what the inner setting is supposed to do, how they are supposed to carry out the intervention, and that all has to be aligned, and the same process for the inner setting, we also promote with the outer setting when we think about introducing new ideas, new practices. Now this is called the Consolidated Framework for Advancing Implementation. So this inner and outer setting is important to consider when you are thinking about putting in a new practice change. Now the Consolidated Framework has 39 constructs that are organized in different domains, and that reflects what can influence the implementation of the practice and have an important outcome for that practice over time. And this framework, the Replicating Effective Programs Framework, which is a framework, again, as I mentioned before, it looks at the pre-implementation, implementation, and maintenance, and evolution, or sustainability over time, and this framework, often with evidence-based practices, they are developed somewhere else, and you try to implement it within your organization or within your county or state, and how do you do that so that you are scaling it up, bringing it into operation within a different setting, and these are some of the, important to have this process of implementation can be critical to make, ensure that you can continue that practice over time. So now I'm going to talk a little bit about the Assertive Community Treatment, sort of as an example of trying to put these concepts together, both in terms of two aspects that I've talked about, how do you, within the interprofessional collaboration, how do you understand the team roles, how do you set up a structure for that, and then also a team structure for communication and collaboration. So just to step back one minute, or second here, to just talk about Assertive Community Treatment. So Assertive Community Treatment is one of our oldest, so to speak, evidence-based practices. It's actually been, it's in its 45th year, and it was a practice that's well-established and has a massive amount of research behind it to demonstrate its effectiveness. So Assertive Community Treatment is an evidence-based practice model now, and it could deliver comprehensive treatment for a subset of our SMI population, and this is a group of people who have multiple hospitalizations and difficulties engaging with traditional mental health services. This population is also at high risk for homelessness, substance use, incarceration, complex mental health, medical problems, they've experienced a lot of trauma and social exclusion and impacted by the social determinants that I described earlier. The team consists of, is an interprofessional team and consists of eight, there's eight roles, very clearly defined, there's a team leader, there's a program assistant that tracks and monitors the activities of the team, there's a psychiatrist, a nurse, and then there are four specialists defined, a family specialist, peer specialist, vocational, and a substance abuse specialist. Now everybody on the team share, all share the caseload, so to speak, the number, they all are involved with all the people on the team. They both provide direct treatment and care coordination, and the model calls for high frequency of contact with participants and low participant to staff ratio. In New York, we have a model where there is a 68 participant to about, to a team in our urban settings, and 48 participants to a team in more rural settings, and it's a one to ten ratio between staff and participants. And the hallmark of a sort of community treatment is that most, 80% of all the work of the team takes place in the community. The ACT Institute was, is now overseeing the training and implementation support for our now 108 teams across the state. We were established in 2003 when ACT, we had 14 teams back then, and then ACT became part of Medicaid reimbursable, or we were able to be Medicaid reimbursable, so it went from a grant program to Medicaid reimbursable format, and it was clear then that this, we needed to have some clear guidelines, not only for training, but also how to implement ACT so that it was consistent throughout the state. We also know that one-off trainings is not enough to ensure implementation of an evidence-based practice, so the ACT Institute was established to set up a training structure and the implementation support so that it could account for, you know, when we have a, you know, staff turnover, or when new, new evidence-based practices are emerging or coming up, being available so that you begin, you can incorporate that into the ACT and ACT delivery, ACT delivery. So we have, at the ACT Institute, we have a combination of both blended, we have a blended learning program, which is both a series of online trainings that people can take whenever they can have the opportunity, and then regional face-to-face training along the way. Furthermore, we do consultations and online phone calls that we, for both, for each of the different roles. The outer, so the inner setting, we support the inner setting of how the team operates, when there's a new practice, when, for example, it's becoming more aware of the health, complex health needs and the importance for ACT teams to pay attention to that, that process of incorporating a new practice, we use the implementation framework of pre-implementation where we investigate, understand the needs of each team, of all the stakeholders in that area, we think about how we implement it, and then we think about how to sustain the practice over time. So that's what we call now the inner setting. The inner setting, you know, is this collaborative team approach, so we have the team approach where it's driven by a person-centered treatment approach, we consider health, substance use, and mental health, and on the outer circle here, you see all of the participants in, on this team that you are, that we are trying to encourage synergy amongst these roles. The training approach is then set up for, as you can see on this graph, where we have the core curriculum that talks about the model of ACT, how to implement it, and person-centered treatment planning are key components of the core curriculum, and then there is the role-based curriculum that helps each of the team members know where their scope of practice is, what their role is on the team. And then the last column speaks more to sort of general clinical intervention and knowledge that all team members should have, and obviously people on all of our ACT teams have different levels of experience, so people can also access the training according to what they think they need for their professional development. This is just a picture of our core curriculum. As you can see, there's a set of first two modules, then a face-to-face, then another module on person-centered treatment planning, and then face-to-face again, and then we have these three clinical modules as well, and so that's our core training. And then each of the roles have their own training, as I showed before, so when you go into the training under each role, you get then a list of trainings that are both required and then some trainings that are recommended for your role. And again, the idea is to clear knowledge about what each person is supposed to do on the team, and how you, for then the team, how do you create the synergy among and between the roles to enhance the team's work with ACT participants and their families or social support. We also think about ACT and using this transitional practice framework that also gives some structure to the way that the team works with each participant. We think of it as that ACT is a move from not engaged in treatment to engaging treatment and then learning some skills and then moving on and integrating it with the community and to less intensive services than ACT is. ACT is a very high-intensive service. So at each dimension, we have the red ribbon here illustrating the dimension of engaging with consumers or participants, where the second dimension is the purple ribbon that shows this is where we begin. We talk about managing wellness and self-efficacy. And then the third, the green ribbon illustrates the integration to the community. This is ACT is not a stage-wise kind of process, but it is, these are the dimensions and they are overlapping dimensions and these dimensions are something you work on with different focus at different times during the life or during the course of ACT. And this is just an example of the team leader and the team leader role. Again, you have the description on top here. This is what a team leader does and here is her training and then other tools that she can access to run the team. So just to look at the outer setting, an important thing. So this is the outer setting that we talked about that has to do with having the policies line up with the guidelines for how the team operates. And one area I just want to point out is around the morning or the meetings around team communication. So we have an item that we have defined that's part of the ACT Fidelity tool that illustrates or clearly documents what the team must be doing, how they need to meet together and follow these components. So how do you meet? The team has to meet four out of five days. They have to be able to review everybody on this, all the clinically relevant issues that have come up for participants on the contact the team has had in the past 24 hours, record the status of participants, et cetera, and a place where there's a discussion of general issues with the person, the individual and his or her family, and also what each of the roles have been working on with that particular participant so that everybody is in the know about what's going on in terms of the treatment. So the morning meetings or the daily meetings, often it happens in the morning, but the daily meeting is critical for the ACT operation and also for how to bring this into a professional team together. So in conclusion, the work is only as good as the team when the team share values, vision and mission, where the roles and scope of practice is clearly defined among team members, participants and natural supports, where communication is efficient, respectful and inclusive of all voices, and collaboration includes service users or participants, and it's, again, key, supported by the outer setting, that the work is lined up with how the expectations are laid out from the outer setting, from policies and regulations. So thank you very much for listening.

interprofessional teamwork

collaboration

severe mental illness

leadership

clear communication

trauma-informed perspective

implementation science