Developing competence in interprofessional collaboration within integrated care teams for older people in the Republic of Ireland: A starter kit

ABSTRACT

Current evidence offers little guidance as to how interprofessional collaboration can be fostered within the context of integrated care and older people. This research describes the co-design of core competencies for interprofessional collaboration within integrated care teams for older people and the development of practical guidance to support teams in building proficiency. Using a co-design approach, we conducted three studies (co-design workshops, qualitative interviews, and an online validation forum), the combined output of which is a Core Competency Framework, that includes three domains describing six competencies for proficiency in interprofessional collaboration within integrated care of older people. Domain one, Knowledge of the Team, includes the competencies; understanding roles, and making referrals. Domain two, Communication, includes the competencies; sharing information and communicating effectively and Domain three, Shared Decision-making, includes the final two competencies; supporting decision making with older people and collective clinical decision-making. In presenting a formal understanding of the competencies for interprofessional collaboration in the integrated care of older people and practical guidance for developing proficiency, this framework provides direction for future health service workforce development.

KEYWORDS:

• Older people
• co-design
• integrated care
• interdisciplinary teams
• interprofessional collaboration
• competency

Introduction

In the shift in health systems in Ireland, and internationally, toward an integrated model of care (Committee on the Future of Healthcare, 2017; World Health Organisation, 2016) interprofessional collaboration is at the forefront of future practice for all health and social care professionals (HSCPs). Current evidence offers little guidance as to how interprofessional collaboration can be fostered and sustained within the context of integrated care of older people. This research describes the co-design of core competencies for interprofessional collaboration within integrated care teams for older people and the development of a framework to support teams in getting started in building and monitoring these competencies.

Background

Internationally, health systems are adopting integrated care approaches involving teams working across disciplines and sectors (Gilbert et al., 2010; Lewis et al., 2021; Miller et al., 2018). There is little consensus on defining or understanding concepts related to integrated care (Baxter et al., 2018). One definition, notes that “integration is concerned with processes of bringing organisations and professionals together, with the aim of improving outcomes for patients and service users through the delivery of integrated care”(Curry & Ham, 2010). Within Ireland, integrated care has been envisaged as requiring both horizontal and vertical coordination in line with recommendations provided by WHO in 2015 (Gilbert et al., 2010). Horizontal coordination spans disciplinary, professional, and departmental boundaries; vertical coordination traverses primary, secondary, and tertiary sectors (Committee on the Future of Healthcare, 2017). This implies effective interprofessional collaboration and integration among all health and social care professionals involved in the care of patients at any age, but particularly those with complex needs, including some older people (Roller-Wirnsberger et al., 2020).

The National Integrated Care Programme for Older People (NICPOP) in Ireland is designed to support older people to live well in their homes by advancing primary and secondary care services. The programme promotes integrated intermediate care through Integrated Care Teams (ICTs) that are interdisciplinary and interagency. This approach to the integration of health services involves changing how health and social care is planned and delivered while ultimately focusing on patient experience, outcomes, and quality of care (Health Service Executive, 2017).

In their reflective review of team-based delivery of care for older people Ellis and Sevdalis (2019) defined highly integrated interprofessional working as follows:

Members come together as a whole to discuss their individual assessments and develop a joint service plan for the patient. Practitioners may blur some disciplinary boundaries but still maintain a discipline-specific base (for instance, aspects of functional assessments may be shared across disciplines). Teams integrate closer to complete a shared goal. (Ellis & Sevdalis, 2019, p. 500)

For this study, we adopted this understanding of interprofessional collaboration as relevant for the integrated care teams being implemented under the NICPOP in Ireland.

In 2017, 13 pioneer integrated care sites for older people were established in the first implementation phase of the NICPOP. This involved the development of 13 integrated care teams (ICTs) that were aligned to the nine Community Healthcare Organizations nationwide. These nine CHOs govern service delivery in local communities across the country. This pilot phase of the implementation of the ICTs has seen the establishment of new community roles for HSCPs to engage in a team-based case management approach to coordinating the care of older people (Barry et al., 2021). Interprofessional integrated care teams are an innovation in Irish health service delivery and require the development of competencies for collaboration across disciplines of care and the care continuum for older people (Ní Shé et al., 2020).

There has been considerable focus in the literature on the development of competencies for interprofessional collaborative practice in general healthcare to support interprofessional education and the development of workforce capacity in health systems globally (Interprofessional Education Collaborative, 2016; Schmitt et al., 2011; Wood et al., 2009). Furthermore, attention has been given to the implementation of core competency frameworks for interprofessional collaboration within specific healthcare settings, recent examples include hospitals, cancer care and critical care units (Chollette et al., 2021; Goldman et al., 2018; McLaney et al., 2022). This literature provides a significant body of evidence affirming the importance of identifying and organizing competencies under a single domain of interprofessional collaboration and within specific specialized settings or contexts. Furthermore, they describe the potential impact of competent interprofessional practice on workforce capacity and retention and the quality of patient care and safety outcomes (O’Donovan & McAuliffe, 2020).

Aside from the development of an interprofessional capability framework for the prevention and management of frailty (Roller-Wirnsberger et al., 2020) there has been limited guidance on how to foster, enhance and sustain meaningful interprofessional team working in the context of integrated care for older people. The European Competency Framework for Health and Social Care Professionals working with older people describes a minimum set of competencies (18 in total) that constitute a common baseline for HSCPs working with older people and their families within their local communities (Dijkman et al., 2016). However, the focus of this framework is not on interprofessional collaboration and integrated care. Furthermore, there has been a lack of involvement of public and patient representatives and HSCPs in the co-design of competencies for interprofessional collaboration in integrated care for older people.

For interprofessional collaboration to be successfully integrated into older peoples’ health and social care, in Ireland there is a need for a co-designed competency framework to support the development of the health service workforce for integrated care of older people (Cameron et al., 2014; Schmitt et al., 2011). The co-designed framework presented in this study supports future health and social care workforce capacity development for effective team working and interprofessional collaboration in the integrated care of older people.

Study aim and objectives

We aimed to co-design a framework of the core competencies for interprofessional collaboration within integrated care teams for older people and outline mechanisms to develop the necessary knowledge, skills, and behaviors to demonstrate proficiency. Core to this framework was the embedding of shared accountability and interdependence for delivering patient care and improving the older person’s healthcare experience and quality of life. To realize this aim, the following objectives were identified:

1. Define and describe core competencies for interprofessional team working in integrated care for older people

2. Determine the appropriate knowledge, practices, and skills for demonstrating proficiency for each core competence

3. Identify mechanisms by which teams can get started in fostering the knowledge, skills, and behaviors required for each core competence

Methods

Project team

The project involved academic health systems researchers, members of a sub-committee of the NICPOP (Inter-Professional Interest Group), and public and patient representatives (PPRs) who were nominated by Age Friendly Ireland. Table 1 provides an overview of the co-design team members including representation from all disciplines involved in delivering integrated care to older people as part of an integrated care team. The 13 HSCP team members were selected based on their representation on the Inter-professional sub-committee of the National Clinical Programme for Integrated Care of Older People.

Table 1. Overview of the co-design team members.

DISCIPLINE	NUMBER
PUBLIC AND PATIENT REPRESENTATIVES	5
SPEECH AND LANGUAGE THERAPY	1
MEDICINE (GERIATRICS SPECIALTY CONSULTANT)	2
DIETETICS	1
SOCIAL WORK	2
PHARMACY	1
PHYSIOTHERAPY	3
OCCUPATIONAL THERAPY	1
NURSING	1
NICPOP PROGRAMME MANAGER	1
ACADEMIC RESEARCHERS	5
TOTAL	23

National Integrated Care Programme (NICPOP)

Definitions of integrated care teams (ICTs)

We developed a working definition of interprofessional ICTs based on that used in the European Competency Framework for Health and Social Care Professionals working with Older People (Dijkman et al., 2016). This framework defines HSCPs as those “who provide systematically direct and indirect professional care and support to individuals or communities of 65 and older and their families”(p. 5). In the Irish context, these integrated care teams may also intersect with multiple existing teams working in acute, rehabilitation, and community settings. These teams encompass many health and social care disciplines including nursing, medicine, psychology, and pharmacy.

Research design

A co-design approach underpinned this research. Co-design, within healthcare, is the process of bringing together service users, clinical and non-clinical staff, and at times, relevant support and advocacy groups to work collaboratively to improve or refine elements of the care system, services, or processes (Slattery et al., 2020). At its core is open reciprocal democratic dialogue where all participants contribute equally (O’Donnell et al., 2019). Employing mixed methodologies, the research was mapped over three consecutive studies (Figure1).

Figure 1. Overview of Research Design Stages

Ethical approval was obtained from the relevant Health Service Executive Research Ethics Committee (Ref: 040919DOD) and UCD Human Research Ethics Committee (LS-E-19-191-ODonnell). Access permissions and support for the study were obtained from the CEO and Head of Service Social Care and the Head of Clinical Service for each of the associated community healthcare organizations.

Study 1: Co-design workshops

The project co-design activities commenced with a capacity-building training workshop for five PPRs. The training was delivered by the designated coordinator for public and patient involvement in the project (ÉNS) and involved orientation to the project objectives and governance and an overview of the policy and service context for integrated care for older people in Ireland. This included an explanation of key terms, an outline of key policy documents, and a description of the health and social care professionals involved in the co-design workshops. Capacity building for PPRs had been identified as a key enabler for meaningful involvement in the co-design of health and social care initiatives (O’Donnell et al., 2019). The capacity-building workshop aimed to empower the PPRs to share their expertise and contribute to the subsequent co-design workshops. Capacity building also was designed to disrupt any potential power hierarchies that may have existed within the team associated with a differential familiarity with the research governance structures and/or the integrated care policy context in Ireland.

Capacity-building of PPRs was followed by three consecutive face-to-face co-design workshops for project team members, including the PPRs. The workshops were facilitated by the project research team (DOD, MOS, ÉNS) and lasted 5 hours. The first workshop focused on building competence statements in response to reflections upon case vignettes. The team was split into groups to work on generating goals for different case scenarios and categorizing these goals according to the four domains of the Comprehensive Geriatric Assessment: physical, functional, psychological, and social (Ellis et al., 2011). The goals were then linked to competencies for interprofessional collaboration and further developed into competence statements that described key performance indicators. Group work was recorded on flip charts displayed on the walls to generate wider team feedback and amendment throughout the session. On completion of the workshop, the research team reviewed flip-notes, whole team feedback, and discussion minutes. Written summaries were prepared that identified six emerging competencies. These summaries were returned to the co-design group at the second workshop.

The second workshop focused on refining the six competencies that emerged from workshop one. The first part of this workshop prioritized the PPRs voice. PPRs were asked to reflect on each emerging competency and describe what it might mean for an older person’s care experience. This was followed by a world-café style session where the team were sub-divided into groups and rotated around six tables (one for each emerging competence) building on each other’s contributions to refine, edit, or validate each competence under the following headings that were agreed with the co-design team: knowing what to do (knowledge), knowing how to do it (skills), and knowing how to behave when doing it (behavior).

Following the second workshop, the research team reviewed the data. Written summaries were prepared for presentation at workshop three. The third workshop adopted a world-café format focused on validating and confirming the six competencies. The team was asked to assist with the development of a qualitative interview guide to further explore the emerging competencies within the two case study integrated care teams (Study 2).

Study 2: Semi-structured interviews

Study 2 employed semi-structured interviews to explore understandings of interprofessional collaboration within two integrated care teams (ICTs) for older people (one urban, one rural). One of the teams was an early adopter ICT established under the pilot implementation phase of the NICPOP. The second team was not formally part of the NICPOP pilot scheme but operated across the boundaries of the acute to community settings. This study aimed to explore the competencies co-designed in Study 1 within different types of integrated care teams for older people. This exploration provided a contextual understanding of the knowledge, skills, and behaviors associated with interprofessional collaboration from the perspective of HSCPs working in integrated care teams for older people. This knowledge contributed to the further development of the co-designed competencies.

Data collection ran for 12 months, in two waves. Due to Covid-19 restrictions in March 2020 data collection was suspended, resuming in September 2020. Twenty-four interviews were conducted face-to-face in the first wave (Feb-Mar 2020) and seventeen via video/telephone call, in the second (Sept 2020-Feb 2021). Table 2 provides an overview of the participants interviewed in each of the waves of data collection. The topics addressed include the interviewee’s professional background and experience of working in an integrated care team. The interview explored their understanding of what interprofessional collaboration means to them including reflection upon perceived benefits of good interprofessional working and barriers or enablers to effective team working and collaboration.

Table 2. An overview of the semi-structured interview participants.

Member	Team 1: Early adopter formal integrated care team (urban)	Team 2: Informal integrated care team (rural)	Total
Physician	1	1	2
Nurse	1	5	6
Dietitian s	1	1	2
Occupational therapist	5	2	7
Pharmacist	2	1	3
Physiotherapist	3	6	10
Social Worker	3	0	3
Speech and Language Therapist	3	4	7
Total	19	20	39

Interviews were digitally recorded and transcribed professionally. Transcript coding was undertaken via NVivo-12 Pro (licensed version). A deductive framework analytical approach was adopted (Smith & Firth, 2011). The six competencies identified in Study One provided the conceptual framework that guided transcript coding. The competencies also supplied the initial macro-thematic structure, which was modified and adapted according to the reported experiences of interprofessional collaboration. The focus was to identify the ‘competencies in action’ from testimonies and thereby refine and provide context to the framework model that emerged from Study One. This led to a refined model of six competencies brought back to the co-design team members for validation in Study 3.

Study 3: Development and validation of final competency framework

Study 3 involved an online meeting with the co-design team. The refined model was presented for discussion and validation. A summary document prepared by the research team included a written and visual description of the refined model and contextualization of the competencies using the qualitative data that had been shared with the co-design team before the workshop (held in March 2021). The workshop lasted 2.5 hours and involved a presentation with active elicitation of feedback for each competence. Following the workshop, written summaries of the feedback were reviewed for adaptation of the model. It was identified that further validation was required from a representative of General Practice and the NICPOP programme administrative lead. Therefore, the refined document was shared with a primary care physician with expertise in the care of older people and the National Programme Manager. Feedback was incorporated into the emerging model. Final validation involved a second online workshop to which only the PPR co-design team members were invited. This was to ensure that their voices were given primacy in the validation of the final competence model.

Results

Six competencies, within three domains, were agreed upon (Figure 2). Each of the three domains contains two competencies that support proficiency in that area of interprofessional collaboration. Domain one, Knowledge of the Team, includes the competencies understanding roles and making referrals. Domain two, Communication, includes the competencies sharing information and communicating effectively. Domain three, Shared Decision-making, includes the final two competencies supporting decision-making with older people and collective clinical decision-making. The domains are collectively exhaustive in their description of the competencies required for effective interprofessional collaboration in the care of older people. The six competencies are developed through a linear cyclical process whereby proficiency in Domain one supports proficiency in Domain two, which supports Domain three. For example, when team members demonstrate an understanding of team roles, they are supported in making effective referrals, which supports sharing of information and so forth. We suggest that teams approach the framework by building their competency in Domain one before moving to Domain two and then Domain three. Competency in Domain three supports further development of competency in Domain one. In this way, the framework supports a cyclical process for teams to build six competencies for interprofessional collaboration across three consecutive domains. This approach is supported by a practical step-by-step guide and resource toolkit for integrated care teams (ICTs) getting started in building their competencies for interprofessional collaboration (O’Donnell et al., 2021).

Figure 2. Three Domains Describing Six Competencies for Proficiency in Inter-Professional Collaboration within Integrated Care of Older People

The six competencies are described below and contextualized through the qualitative data. Table 3 provides a summary of the key steps for getting started in building proficiency for each competence and suggested mechanisms that teams may use to monitor or self-evaluate their level of competence (O’Donnell et al., 2021). The table provides practical guidance to teams to initiate the development of each of the six competencies and recommendations for monitoring or measuring performance. The following identifiers are used to present the findings: MD (medical doctor), Ns (nurse), SW (social worker), SLT (speech and language therapist), OT (occupational therapist), PT (physiotherapist), Pharm (Pharmacist)

Table 3. Key steps for building competence as well as recommended mechanisms for self-evaluation of team competence.

Key Steps for Building Competency with ICTs working with Older People	Recommended Mechanisms for Monitoring or Measuring Competency
Understanding Roles
Step One: Establish team values, vision and mission Step Two: Establish role clarity for all team members Step Three: Build and measure trust in the team Step Four: Schedule regular team meetings	Professional role descriptors are available for each team member. Knowledge of each team member's disciplinary expertise and competences Knowledge of team vision and values Attendance at team meetings Regular measurement of trust with a team approach to resolution should a breach of trust be identified.
Making Referrals
Step One: Gather information from the older person on their preferences and values Step Two: Compile a list of services available for referral Step Three: Develop a standard operating procedure for making referrals Step Four: Agree a standardized mechanism for communicating the referral to the older person (or family carer/nominated decision-supporter, where appropriate)	A Standard Operating Procedure for making referrals has been agreed upon and developed by the team and is being adhered to. The older person (or family carer/nominated decision-supporter, where appropriate) has a document that details which services they have been referred to, why they have been referred and what they can expect from that referral A service directory (listing services available in the area) is accessible to all team members and is regularly updated Appropriate referrals (right person, right info). When receiving a referral, each team member receives accurate information relevant to their function Duplicate, declined and/or missed referrals as identified from case review Episodes of missed, poor quality or unsafe care
Sharing Information
Step One: Identify what the relevant consent policy is and apply it Step Two: Co-design with the team a standardized dossier for recording information that can be shared Step Three: Provide a summary information document to the older person (or family carer/nominated decision-supporter, where appropriate) Step Four: Identify what is the best available information and communication technology system that can be utilized by the team for secure information storage and sharing across settings	The relevant consent policy for information sharing has been identified and is accessible to all team members The older person’s preferences and consent regarding sharing information (who to share with and in what manner) is documented and reviewed regularly Every older person (or family carer/nominated decision-supporter, where appropriate) has a copy of their assessment and care plan, their discharge letter as well as any written documentation between HSCPs A standardized dossier has been co-designed by the team for recording information that can be shared (with consent) and is accessible as a shared document Consistent utilization of the best available information and communication technology infrastructure
Communicating Effectively
Step One: Co-design a strategy for communication within the team Step Two: Identify the preferred method for communication with the older person (or family carer/nominated decision-supporter, where appropriate) Step Three: Support the communication competence of older people who have complex communication needs Step Four: Identify a key worker in any given case	A strategy for team communication has been developed and is accessible to all team members in a shared file. Consistent utilization of the older person’s preferred methods of communication (for example, verbal, written or communication aid) Provision of consistent information to older persons (or family carer/nominated decision-supporter, where appropriate) from all team members A key worker is identified for any given case. The older person (or family carer/nominated decision-supporter, where appropriate) is aware of who their key worker is Regular measurement of conflict with a team approach to resolution should conflict be identified
Supporting the Decision-Making of Older People
Step One: Undertake continuing professional development and training in supporting the decision-making capacity of all older people Step Two: Foster a team culture of including the older person as a partner in their care Step Three: Co-design with the team a values statement that recognizes an older person’s will, preferences and values as the drivers for all care planning and decision-making Step Four: Encourage and where necessary assist an older person to express their will, preferences and values in relation to their care	The older person’s will, preferences and values for care planning and decision-making have been ascertained and are documented in an accessible and shared file The older person’s will, preferences and values are identified and discussed in all care planning conversations Where clinical and care planning decisions are made, they are explicitly aligned with the older person’s will, preferences and values All team members are undertaking CPD training or education in relation to supported or assisted decision-making.
Collective Clinical Decision-Making
Step One: Set the team goals to include a commitment to collective decision-making in care planning with older people Step Two: Gather collective input of all team members for collaborative team decisions Step Three: Build and measure psychological safety in the team Step Four:Schedule regular team meetings and monitor attendance	Knowledge of the team co-designed goals and every team member has access to a shared file that documents these goals Team discussions for care planning actively elicit the input of all team members Issue-specific decision-making is led by the team member with the most professional competence for that issue. Frequency of team meetings and regular attendance Psychological safety within and across the team Regular measurement of conflict with a team approach to resolution should conflict be identified

Domain one: Knowledge of the team

The first competency domain describes the knowledge, skills, and behaviors required for integrated care teams to demonstrate a knowledge and understanding of their team. This domain includes an understanding of the roles of individual team members and the goals of the overall team. The domain includes proficiency in making referrals within the team and with service providers and health and social care professionals outside of the team.

Competence one: Understanding roles

Central to this competency is an understanding and articulation of one’s role and the role of other team members in service delivery. The importance of coming together as a team to discuss roles and build team cohesion was highlighted. “So, I think to get everybody around the table and discuss each other’s roles in depth so that we all understand what everybody does.” (SLT 1)

The co-design team aligned role understanding with a shared vision and mission for the overall team that facilitates cohesion and assists team members to articulate their roles in relation to the overall aim of the team. “Each profession has maybe a specialty or has specific skills, but it’s knowing when they need to be used and contacting their colleagues too for them to utilize them.” (OT 1)

While always adhering to the professional scope of practice the co-design team noted that roles should be flexible and fluid to guarantee seamless service delivery. “ … allowing each other to take on pieces of work that might traditionally be let’s say a social work or nursing thing or a physiotherapy thing, an OT thing, you know.” (SW 1)

The behaviors that were aligned to this competence by the co-design team included respectful communication and demonstrating team commitment by attending and engaging in team meetings. They noted the importance of open-mindedness and willingness to negotiate and reflect upon roles while recognizing the value and contribution of every team member.

Competence two: Making referrals

Central to this competency is making the right referral to the right person at the right time. In addition, it is necessary to ensure that the referral is received and acted upon by the person to whom the referral is being made. Trust was presented as a key enabler for this competence. “And there is a kind of trust built up there in terms of the appropriateness of patients that we were referring. It’s very rare that we do get rejected – referrals into them.” (PT 1)

Building trust through open and informal dialogue and relationship building was also identified by an interviewee who noted the importance of these conversations for good referral practice:

Any time I wasn’t sure. I came back and said, “I’m not sure about this person” and we discussed it, and they’d say, “no you’re right to refer”. So, it was just trusting that I would use their information correctly, but not overstep the mark and then refer on. (PT2)

Competency in this domain was enabled through having up-to-date knowledge of available services across different sectors and directing older people to these available services (community, departmental, out-patient, etc). This knowledge was considered essential to making referrals and was understood to be cultivated over time through both formal and informal processes of information gathering and referral processing:

I’m still kind of getting to know the services that are there. And like, even knowing what’s there. And then the next step after that would be having ways to contact people directly … So, when I think of good inter-professional collaboration, I think of some kind of face to face or phone interaction. (SLT 2)

The behaviors that were associated with competence in making referrals included respect for the will and preferences of the older person and clear communication with them as to why they are being referred and what the referral will entail. Furthermore, respect for the workloads of other team members was considered important and understanding the different prioritization protocols of different professionals.

Doman two: Communication

The second competency domain describes the knowledge, skills, and behaviors associated with communication. This domain includes competency in sharing information and effective communication skills and behaviors.

Competence three: Sharing information

Central to competency in shared decision-making is the ability to apply professional judgment as to the information that should be shared within the team and obtain relevant informed consent to share. The PPR members of the co-design team emphasized that information sharing within the team is essential for reducing the assessment load on an older person. This was also highlighted by an interviewee

That person needs to see six different disciplines to be assessed whereas I can go in as one person and do all the basic screens. I’m not an expert in any of them, but for them to allow me to do that is major because now six people don’t have to see the patient. (PT2)

When considering information sharing, the importance of including the older person, or family carer where appropriate ‘in the loop’ was emphasized. Information sharing within the team was associated with improved consistency of information provision for the older person:

they might have one person, let’s say, who’s keeping them in the loop or each team member that does speak to the older person will actually be saying the same thing as opposed to mixed messages from different team members. (SW1)

Competent information sharing within the team was viewed as core to interprofessional working and integrated care as it facilitated a holistic approach to care planning. This was associated by one interviewee with the sharing of perspectives and being open to different disciplinary input on care planning. “The patient gets the benefit of having input from all the different people on the team and also, your own knowledge would be improved, you know.” (Pharm 1)

Attending and engaging in team meetings was noted as essential behavior for enabling competence in information sharing. This involved open reflection about the information that team members required to perform their roles while being mindful of older people’s right to privacy, autonomy, and self-determination.

Competence four: Communicating effectively

Fundamental to this competency is an understanding of what needs to be understood, by whom, and in what format. It involves using appropriate language, mediums, and aids, if necessary when communicating with team members, older people, family carers and other professionals external to the team. “I suppose the skills would be just communication skills because you know, all the verbal and written and all of that. And I think just being a good listener and asking the right questions to patients.” (MD 1)

Formal mechanisms for enabling effective communication include having access to shared accessible electronic storage where team strategy and policy documents could be viewed by all. This would improve communication within the team and also assist with overall care planning by reducing duplication and time wasted on tracking down information. The challenges of operating as a team without a formal means of communication and information sharing were highlighted. “But there’s no formal information sharing at all … So other than communicating directly with that person, there isn’t any sharing of information. There’s no single file or anything like that.” (Ns1)

One interviewee noted the importance of shared working spaces and regular team meetings for effective communication:

I think a shared working space … I think that breaks a lot of barriers. It really helps communication for patients … And obviously good communication between teams, weekly meetings are really important. I believe in joint goal planning … and also joint outcome measures. (OT1)

Competency in effective communication involves seeking clarification of information when required, supporting the communication competence of others where necessary, and ensuring that the relevant people are included in any conversation and that their voices are heard and acted upon.

Domain three: Shared decision-making

The third domain refers to the knowledge, behaviors, and skills required by integrated care teams working with older people to harness collective intelligence to share decision-making within interprofessional teams and with older people. This core competency, for interprofessional collaboration, includes proficiency in supporting older people to be involved in decisions that affect their lives. Furthermore, knowledge and skills related to collective and shared approaches to decision-making within the team are recognized.

Competence five: Supporting decision-making with older people

It was stressed that the will and preferences of the older person must take center stage for teams supporting decision-making with older people. It was noted that this requires knowledge and skills in supporting the decision-making capacity of all older people, including those with a cognitive or communication impairment. “Helping people to, I suppose, consider what their wishes would be in the future, making sure that the voice of the service user is heard.” (SW 1)

Mechanisms for assisting the decision-making of older people include the strategic use of decision-supporters such as family carers and knowledge of advanced care plans, enduring powers of attorney, or statements of values and preferences. This competency necessitates a shared commitment within the team to proportionality in balancing the care of an older person with their right to autonomy, freedom of choice, and control over what is important to them. The interviewees described creating joint goals for your patient as essential to collaborative team working that places the will and preferences of the patient at the center. “People are still able to make their own choices and decide whether they want to do that or not. So, when we work pretty well together … people’s choices are at the higher self.” (SW 2)

Actively seeking and encouraging the older person to have input into their care planning conversation and decisions was identified by the PPR members as critical to their vision of team working that placed the older person at the center. They noted that this involved interprofessional team members having an open, reflective discussion of their values and beliefs concerning the balance between a duty of care and an older person’s autonomy.

Competence six: Collective clinical decision-making

Central to this competency is inclusivity and value for disciplinary knowledge and expertise. This competency requires the harnessing of collective input for care planning by actively eliciting each team member’s insight and expertise into the discussion\

I think you kind of need to feel that you’re there for a purpose. You know, we’re all quite highly trained and highly educated. You don’t want to be there thinking that you’re not wanted or you’re wasting your time … There has to be openness and willingness to utilize colleagues, colleagues’ skills and expertise … we’re all there kind of for the same end, you know, like we’re all there for the patient. (Ns 1)

Collective decision-making does not necessarily indicate that there is no tension or dispute within a team concerning care planning. Proficiency in this competence encourages open discussion and the sharing of opposing viewpoints through positive debate and negotiation of perspectives. The necessity for different opinions in teams and the importance of listening and focusing on the patient in interprofessional care planning were highlighted:

… there are different personalities and priorities, people will have different opinions as to what their priorities are. And that is, I suppose, one of the beauties and one of the hardest things about working interdisciplinary … even though you put your priorities across, it’s important to listen to other people because at the end of the day, it’s not about my priorities, it’s about the patients’ needs. (PT 1)

Core to this competence was an understanding that the individual with the relevant expertise/disciplinary competence related to the decision being made should be enabled to take the lead with the older person. However, this is done with collaboration, and the team takes collective responsibility for the care planning. The importance of a collective leadership approach to care planning for team cohesion was identified by an interviewee:

there’s really good trust in opinions. And I think something that’s kind of helped with that is when you see other people acting on what you’ve said at the meeting … that seems to have really strengthened our meetings and it means that everybody goes to the meeting. So, like, you’re actually at a loss if you don’t turn up at it. (SLT 2)

The behaviors associated with competence in collective clinical decision-making included an open debate with respective active listening. This includes a willingness to change opinions based on emerging evidence or a team member’s expertise. All team members should be encouraged to express their ideas even if other team members disagree.

Discussion

Evidence indicates an association between team cohesion and interconnectedness and improved patient outcomes, increased staff retention, and lower levels of burnout (Baxter et al., 2018; Körner, 2010; O’Donovan & McAuliffe, 2020). Interdisciplinary or multidisciplinary teams are increasingly common features of older people’s health and social care, particularly within an integrated care context (Ellis & Sevdalis, 2019). There is a clear international policy commitment to placing interprofessional collaboration at the center of health and social care integration across the life span (World Health Organisation, 2016). Interprofessional working is critical for effective comprehensive geriatric assessment and care planning (Ellis et al., 2011). However, a formal assessment and understanding of how interprofessional working can be enhanced, trained, and supported in older people’s care are underdeveloped compared with other specialist health areas (Ellis & Sevdalis, 2019).

Our co-designed framework addresses the gap in international knowledge of the skills, processes, and values required for a formal understanding of the competencies for effective interprofessional collaboration in the care of older people. The framework describes the knowledge, skills, and behaviors required by HSCPs to demonstrate proficiency. It provides practical guidance as to how to build this proficiency within integrated care teams for older people. The involvement of PPRs and HSCPs in the co-design offers a novel and innovative methodological co-design approach to generating authenticity and relevance for the competency framework emerging from this study.

The six competencies described in our framework are aligned with the existing body of evidence describing the core competencies for interprofessional collaborative practice in healthcare (Interprofessional Education Collaborative, 2016; Schmitt et al., 2011). Furthermore, it expands upon the European Collaborative and Interprofessional Capability Framework for Prevention and Management of Frailty (Roller-Wirnsberger et al., 2020) by providing detailed guidance for the building and monitoring of knowledge, skills, and behaviors associated with proficiency in interprofessional working in integrated care teams. We build upon these frameworks by providing practical guidance on how teams collaborating in the care of older people can get started in developing their competence for effective interprofessional team working.

Non-technical skills have been recognized as being fundamental to effective team working (Ellis & Sevdalis, 2019), and they are core to our co-designed framework. These skills support effective communication, shared and collective decision-making and successful alignment of disciplinary roles and responsibilities toward a team vision. Evidence-based processes associated with principles of good governance of data and information sharing and operational processes for referral pathways and care planning are recognized and detailed in our framework (Health Service Executive, 2017). A collective leadership approach to healthcare provides the foundation for this study. Our framework aligns with values-based principles of non hierarchical leadership and collective approaches to decision-making (O’Donovan & McAuliffe, 2020). The competencies represented in the framework prioritize mutual respect and the active elicitation of input from all disciplines thereby empowering disciplinary-specific expertise. Finally, the knowledge, skills, and behaviors described in our framework are underpinned by person-centered values that place the will and preferences of the older person at the center of effective integrated interprofessional working (World Health Organisation, 2016).

Implications for future workforce capacity development

Building the capacity of health and social care professionals for effective team working and interprofessional collaboration has been identified as critical for future health service workforce development internationally (Interprofessional Education Collaborative, 2016; Roller-Wirnsberger et al., 2020; Schmitt et al., 2011). Our co-designed framework guides health and social care professionals to foster interprofessional team working in the integrated care of older people. A realist evaluation of the implementation of the competency framework described in this publication within Integrated Care Teams (ICTs) established under the national scale-up of the NICPOP is planned for commencement in 2022.

The realist evaluation will generate evidence regarding the outcomes associated with interprofessional team working and how teams foster, enhance, and sustain their proficiency in interprofessional collaboration. The realist implementation evaluation will generate evidence to support the applicability and transferability of this framework to ICTs across the National Clinical Programme domains including chronic illness, disability and palliative care. Of further significance will be the evaluation of framework implementation in ICTs outside Ireland. This is an important future step for the project and will involve realist process evaluations identifying factors that support the transferability and applicability of the framework to ICTs across international health systems.

The programme theory that arises from the realist evaluation of the implementation of the framework in ICTs established under the NICPOP will support the development of a curriculum that has the potential for scalability and transferability to international health professional educational programmes. This curriculum will provide interdisciplinary education and training through the identification of learning activities, mechanisms, and outcomes for fostering and monitoring competence in interprofessional collaboration in the integration of care for older people.

Conclusions

To the best of our knowledge, this is the only framework that provides practical guidance for building competencies for interprofessional collaboration in the context of older people’s integrated care. A key strength of our framework is the co-design approach underpinning its iterative development and validation. We engaged key HSCP stakeholders representing all the disciplines working in the integration of older people’s care in the co-design of this framework. Furthermore, Public and patient representatives were supported to play a central role in the co-design process. A further strength of this framework is the contextualization of the competencies through qualitative exploration of interprofessional working in two different types of integrated care teams (ICTs). This co-designed framework provides direction for health service workforce development by describing and providing practical guidance for developing the core competencies for interprofessional collaboration within ICTs for older people. This framework has potential to support the development of interprofessional working in international ICTs operating across programme clinical domains for example, palliative care, disability and chronic disease. Future work will involve a realist evaluation of the transferability and applicability of this framework to ICTs operating in international health systems.

Acknowledgments

We thank our public and patient representatives, collaborators, members of the co-design team, and members of the participating ICTs. We would also acknowledge the support of the National Integrated Care Programme for Older People and the National Clinical Programme for Older People (NCPOP) for their joint support for this programme of research. We give special mention to John Brennan, chair of the Interprofessional Sub-Group of the NCPOP who championed and supported this study as a key knowledge user.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data Availability Statement

The anonymised data that support the findings of this study are available from the corresponding author, upon reasonable request.

Additional information

Funding

This research and publication was supported by the Health Research Board, Ireland [APA-2019-018]