Virtual interprofessional (VIP) education, a family medicine-occupational therapy-physiotherapy collaborative experience: the perspectives of patients, learners and providers on the opportunities and challenges

ABSTRACT

This study examined the experiences of patients, Occupational Therapy (OT), Physiotherapy (PT) and Medicine learners, Providers, and Faculty, in implementing a Virtual Interprofessional (VIP) education initiative in two academic Family Medicine (FM) collaborative clinics. A qualitative descriptive study drew on a strength-based approach as part of the evaluation of the interfaculty VIP initiative. Participants involved in VIP care were conveniently sampled. Interviews were conducted with four patients, and focus groups were held with a total of 16 providers, preceptors and learners in OT, PT and FM. Data were analyzed using content analysis and managed using NVivo12. Four main categories emerged: 1) Challenges in implementing VIP care in FM; 2) Operational challenges, 3) Facilitators of VIP care in FM; and 4) Experiential learning outcomes and benefits of VIP care. This innovation supported knowledge and insights on interprofessional competencies acquired during practice, provided inclusive and comprehensive access to care for patients, and identified opportunities to enhance medical, OT and PT education in VIP care in FM. A collaborative approach with faculty from different disciplines (FM, School of Health Professions: OT and PT) can provide ongoing opportunities for VIP care for patients, and foster IP learning and acquisition of competencies for FM, OT and PT learners and providers.

KEYWORDS:

• Collaborative team
• family medicine
• IPE
• learner-centered
• OT
• PT
• virtual care

Introduction

Academic collaborative family medicine (FM) clinics with teams composed of academic family physicians, family practice nurses, interprofessional team members, and administrative support, offer unique opportunities for clinical training, education, and research. They also include opportunities for innovation in education in the advancement of Interprofessional (IP) primary health care situated in the community (The College of Family Physicians of Canada [CFPC], 2011). The College of Family Physicians of Canada (CFPC) Medical Home Model of Care supports comprehensive and collaborative IP primary care with a range of providers who work together, utilizing their skills to provide holistic and comprehensive patient care (CFPC, 2011). The additions of IP team members such as occupational therapists (OTs) and physiotherapists (PTs) support this model of care through enhanced access and services within the patient’s medical home (CFPC, 2011).

Recent innovations in collaboration have emerged in FM in Newfoundland and Nova Scotia (Moores, 2020). The expansion of IP engagement in clinical and fieldwork placements of Occupational Therapy (OT), Physiotherapy (PT), and Social Work (SW) evolved pre-COVID. The first in the Atlantic region was initiated in Newfoundland at the Ross Clinic (Moores, 2020). Early feedback regarding this initiative suggested that the primary care team approach provided a supportive and collaborative learning environment, faculty and learners gained knowledge, skills, and understanding of scope of practices of OT and PT health professionals, and that the environment provided a foundation for IP learning and innovation in care delivery within FM (Tzenov et al., 2021).

In March 2020, at the onset of COVID in Nova Scotia, a Virtual Interprofessional (VIP) pilot project was implemented through collaboration between the Department of Family Medicine and the Schools of OT and PT in the Faculty of Health at Dalhousie University. Evaluation of this pilot project focused on developing an understanding from stakeholders of the opportunities, challenges, and role for VIP clinical education and collaboration in primary care community-based clinics.

Background

Opportunities for interprofessional education (IPE) have been recognized as being important for developing skills needed to effectively practice team based collaborative family medicine (Paré et al., 2012). Building on the experiences and findings of an IP collaboration between OT, PT and FM developed in Newfoundland, an innovation in virtual delivery of OT and PT services in two collaborative community-based academic FM clinics was developed in Nova Scotia (Tzenov et al., 2021). This Dalhousie University initiative involved FM residents, OT and PT students, and clinical faculty from the Department of FM and Schools of OT and PT, in developing a unique approach to care in the patient’s medical home.

During COVID, both locally and globally, access to primary care services were halted to reduce spread of infection through direct contact. This VIP innovation was initiated during COVID during the period of time traditional in-person rehabilitation services were paused. At that time, the issue was particularly challenging for patients with chronic conditions and those who depended on publicly funded hospital-based outpatient services.

Virtual care in Canada was quickly adopted during COVID to reduce the risk of spreading infection, maintain patient continuity, and provide access where in person care was not an option. Virtual care has been endorsed for low acuity patient care where physical examination is not required (Fujioka et al., 2023). Tenforde et al. (2020) established that virtual OT and PT patient care was well accepted by patients receiving these services. In this study, the effectiveness of virtual care in the delivery of OT and PT services or clinical training was not considered (Tenforde et al., 2020).

Clinical training for OT and PT students was also impacted by the loss of hospital-based clinical rotations so it was an opportune time to explore community-based clinical training rotations. This approach to clinical training was novel in that the OT and PT students became members of collaborative FM teams, and most clinical work, training and supervision was completed virtually.

This intervention involved mandatory virtual orientation of OT and PT students, and preceptors. All students completed 5 IP online modules on telerehabilitation prior to commencing the placement. Medical residents were trained through the rapid uptake of Zoom technologies for health within the family medicine context. The OT and PT preceptors were trained in the processes of virtual rehabilitation supervision by an experienced preceptor with procedures for offsite and virtual student supervision. Students met daily with preceptors to review and reflect on cases, to plan for assessments, and review documentation and communications. A referral system through the EMR was established by the FM clinics where physicians and residents were able to refer patients and communicate information with students. Virtual team huddles involved all students, residents, preceptors, and physicians to discuss patient cases, referrals, and progress. Students communicated with patients, by telephone, Zoom and e-mail to coordinate assessments and rehabilitation.

In developing this approach, the interfaculty team (faculty members from the Faculty of Health and the Faculty of Medicine) identified that IPE and collaboration in FM clinics could positively impact patient care outcomes during COVID and beyond, and that an interfaculty approach could support the evaluation of IPE in Medicine, OT and PT (Price et al., 2009). Thus, the co-creators planned a study to evaluate the VIP initiative from the perspective of feasibility, acceptability, and scalability of advancing an IPE approach in community-based FM, and opportunities to advance clinical education curriculum in medicine, OT, and PT.

Several key aspects were considered in this part of the evaluation. Miller et al. (2019) suggested that IPE evaluation needs to include input and impact from faculty members, learners, patients, preceptors, and community partners. Thus, the evaluation included insights from all the participants. Second, Miller et al. (2019) identified that IPE plays a significant role in the development of IP competencies. However, there is little literature on the knowledge of the Canadian Interprofessional Health Collaborative (CIHC) competencies that are experienced and demonstrated in experiential learning settings such as in the FM community-based primary care setting (Canadian Interprofessional Health Collaborative [CIHC], 2010). Thus, the interfaculty team further identified the need to explore which IP competencies were experienced in VIP care in FM by learners and providers.

Method

A qualitative inquiry guided the initial evaluation of the VIP approach in FM. The evaluation drew on the theoretical frame of Appreciative Inquiry (AI) approach given the interfaculty approach (two different faculty’s co leading the project) and organizational context of the pilot project (Cooperrider, 1996). AI from a theoretical stance supported the discovery of how and why things work within this organizational context (FM community-based primary care) and how the organization and systems (interfaculty education medicine, OT and PT, primary health care and collaborative clinics) can transform (Trajkovski et al., 2013). The positive outcomes from the learnings and benefits of all participants from both the Newfoundland Ross Clinic and the Department of Family Medicine clinics in Nova Scotia (Moores, 2020; Tzenov et al., 2021) demonstrated alignment with the presumption of the positive with AI. Furthermore, AI necessitates that the key stakeholders are the knowers, who have direct experience in the system, context, and setting (Cooperrider, 1996). This informed the approach used in this study to involve knowers from two academic faculties in health and medicine and two collaborative primary care settings.

The research objectives of this inquiry were: 1) to use a strength-based oriented inquiry to understand what is working to support and advance IPE across systems to further the benefits of medical, OT and PT learner centered approach in primary care; and 2) to identify the IP competencies that were demonstrated by the participants in the VIP innovation.

Data collection

Convenience sampling included patients, learners, (OT, PT, FM residents), providers (Family physicians and Nurses), and preceptors who experienced virtual care through the VIP project. All patients who had received VIP care and were discharged prior to May 20, 2021, were invited to participate in an interview via a letter mailed to their address on file. Four patients completed 30-minute telephone interviews. Student providers and preceptors participated in online 50- minute interactive focus groups or interviews (Table 1). An interview guide was collaboratively developed by the project co-creators, research faculty representatives, and a patient representative. (See interview guides in Appendices 1 and 2).

Table 1. List of participants included in study.

Participant setting	Participant type	Number of participants
Focus group 1	Student Physiotherapist	2
Focus group 2	Occupational Therapy Preceptor	1
	Family Physicians (Providers)	4
	Residents	1
	Family Practice Nurse	1
Focus group 3	Student Occupational Therapist	4
Focus group 4	Student Occupational Therapist	2
Preceptor interview	Occupational Therapy Preceptor	1
Patient representative interview	Patient representative	4
Total	Number of participants (n=)	20

Data analysis

Interviews and focus groups were audio-recorded and then transcribed verbatim. The research team of two co-creators and research assistant (RA) conducted a content analysis of the data in accordance with qualitative description (Sandelowski, 2000). This team achieved a description that captured the experiences of the different participants. Step one of analysis involved the team independently coding the transcripts for content to gain an understanding of participants’ experiences. Step two involved use of reflexive dialogue where researchers met multiple times to develop categories and descriptions and to go back to the data. During these dialogic sessions the description was modified to add context or refine categories of the challenges, facilitators, benefits, and outcomes experienced by patients, students, providers, and preceptors in receiving and/or in delivering VIP care within a learner-centered model. This dialogic process was used to achieve consensus on the identification and the naming of the categories and subcategories for each group of participants that reflected the descriptions of their experiences. The third step of analysis involved reviewing data across participant experiences to identify the challenges and facilitators, challenges, benefits, and outcomes that were common to at least two or more of the participant groups of patients, providers, learners, and/or preceptors. A final set of categories was achieved through consensus and reported on in the results section (Table 2).

Table 2. Overview of categories and subcategories.

Category	Sub-Category
Challenges of enacting VIP care in FM	1. Lack of suitability of virtual practices for some patients and services 2. Learning to communicate using virtual technologies
Operational challenges	1. Inadequate development of virtual documentation processes for learners and lack of face-to-face on boarding and orientation 2. Inadequate technologies 3. Long term sustainability of VIP learner opportunity and continuity of VIP care for patients
Facilitators of enacting VIP care in FM	1. Using innovative virtual team huddles to promote dialogue and collaboration 2. Using technologies to optimize and expedite interprofessional communications and opportunities for patients 3. Learner and physicians’ direct collaboration 4. Learner to learner collaboration
Experiential Learning Outcomes and Benefits of VIP care in FM	1. Patient Care 2. Interprofessional Competencies Acquisition

Data management

NVivo12 data management software was used to manage the data and analysis. Team based shared documents, that were password protected, were used to organize files, and communicate with the interfaculty team in the development of the knowledge dissemination presentations and manuscripts.

Findings

At the time of the pilot study, there were a total of 51 participants involved including 20 FM providers, six FM residents, four family practice nurses, two OT preceptors, one PT preceptor, 12 OT learners, and six PT learners. In total, 20 participants were included in the study between focus groups and interviews. The findings were grouped into four main categories: 1) the Challenges of implementing VIP; 2) Operational challenges; 3) Facilitators; and 4) Experiential Outcomes and Benefits. Table 2 provides an overview of the categories and sub-categories. The findings represent the experiences of the patients, providers, learners, and preceptors in delivering VIP care beginning in May 2020 during COVID up until July 2022.

Challenges of enacting VIP care in FM

The challenges of enacting VIP care in FM shared by learners, patients, and providers involved the lack of suitability or alignment of virtual care with the needs of patients and with learner professional practices, and the challenges of learning to communicate virtually.

Virtual telehealth did not always align with the capacities of some patients. For instance, learners noted the unsuitability for older patients who were hearing impaired or not comfortable with technology. One learner shared “older patients …aren’t super comfortable with computers or … cell phones.” One patient expressed that when dealing with complex issues virtually it was not easy to manage, “it was hard for me to figure out, I had to make sure which department (or professional service) it was, because I was getting confused because there were so many virtual appointments.” For PT learners they encountered a lack of alignment of virtual care technology with the need to do hands-on assessments. A PT learner expressed “virtual is hard (be)cause you don’t get to actually see the client.”

Adapting professional communication for virtual technologies was initially a challenge for learners and some providers. For learners it was a struggle to learn how to align their communication style to provide care virtually, one explained, “you cannot see the social cues (when using the phone).” Another shared, “I find it a lot more impersonal at times (using the phone), which can kind of make it hard to… gain rapport with your clients … …., it’s so different.” One of the preceptors noted that it takes a bit of time for learners to “warm up (to virtual technologies) especially if it is the first time interacting with clients”. A provider elaborated that virtual communication “takes more brain power … I’m needing to think about all of things I cannot see … it is more tiring than in person.”

Students learned that in using virtual technologies that they needed to become more adaptable and flexible in communicating and sharing information with patients. A learner explained,

I’ve definitely learned that it’s very important with the words you choose and how you’re speaking. You can’t use your body language or facial expressions or any of that at all. You have to be very, very mindful about how you’re delivering. (information)

Learners said that they had to rethink and plan,

if we mention the transfer belt to the client they will ask what that is, and (we need to think) how can we explain that without showing her the pictures. Instead, we will email her the resource after our phone call.

Operational challenges

There were three operational challenges observed in the startup of this virtual innovation. Learners, providers and preceptors described the: inadequate development of learner professional processes for telehealth and the lack of face-to-face orientation with providers; inadequate technology for optimal communications, and the challenges of long term sustainability of VIP learning and continuity of IP care for patients.

Learners experienced challenges due to the need to develop and adjust to virtual professional structures and relationship building. Two specific learner challenges were the lack of standardized appropriate mechanisms for interprofessional student confidential documentation, and the lack of face-to-face onboarding and orientation. Learners expressed that the lack of opportunities for face-to-face orientation with providers, nurses and residents was challenging in developing collaborative relationships with providers and learning communication preferences. A provider also noted, “there was a little bit of uncertainty sometimes in terms of when people would be at huddles and not … having a clear (communication) plan.”

Inadequate technology for VIP communications was at times challenging, a student shared “(we) had a difficult time hearing a lot of the team meetings, so we had challenges communicating or jumping in on something … . It was hard to collaborate just based on those Zoom calls where everyone was in person, but we were the only ones online.”

Sustainability of VIP care in FM and consistent access to interprofessional learners to support this innovation were described as challenges by providers and preceptors. During COVID the coordination of IP learner experiential placements was disrupted due to program delays associated with COVID. For patients, these disruptions resulted in delays in access and loss of continuity of care. The primary organizational issue impacting sustainability of the VIP model was the lack of direct access to licensed OTs and PTs assigned to the clinic to support ongoing OT and PT care for patients and supervision of OT and PT learners.

Facilitators of enacting VIP care in FM

VIP care in FM used a learner-centered model. In this setting learners worked in a collaborative academic FM community clinic context and VIP care was enacted through IP collaboration, participation, and dialogue. Four main facilitators were identified: virtual team huddles to promote dialogue and collaboration; use of technologies for interprofessional and patient communication; learner and physician direct collaboration as well as learner to learner collaboration.

Virtual team huddles provided an innovative platform for dialogue and to promote collaboration in VIP care for all learners. In person team huddles were held prior to the COVID pandemic but were adapted during the pandemic to allow for synchronous virtual meetings for all team members including OT and PT learners. Clinical Team members met virtually prior to each clinical session using a synchronous video platform (Zoom) so that members could participate without being in the same physical location. OT and PT learners were invited to join the virtual team huddles to promote IP learning and communication regarding patient care. One learner shared that attending

the virtual physician meetings every morning (made) me feel part of the interprofessional team. And then I felt like I could ask questions to the physicians in the morning to better serve our clients moving forward.

Another learner agreed and expanded:

those huddle meetings with the physicians … allowed me to understand more about the OT responsibility… the difference between our service and the PT and the other health provider services. It gave me a better sense about why the clients are referred to us.

Using technologies to optimize and expedite IP communications supported learners in delivering VIP care. Learners and providers had access to a range of virtual technologies for synchronous communication: phone, Zoom, or Microsoft Teams for remote virtual meetings with team members and preceptors and for patient care. Learners also interacted with patients and preceptors asynchronously through e-mail and EMR a messaging system Findings show the phone was used most often to interact with patients. All learners expressed the ease of access to other IP learners for discussions to promote quick conversations, coordination and timing of assessments, interviews, and to discuss plans and issues raised by patients together. Learners also agreed that they:

had some positive experiences using telehealth services … some of the phone calls made it easier with older clients and it also allowed for weekly check-ins,… giving us a better idea of what their daily routine was looking like.

The practices involved in this initiative utilize an electronic medical record system (EMR) (MedAccess) that has several options to facilitate asynchronous communication and collaboration between providers. Progress notes are recorded in the EMR with each patient encounter; there is an internal electronic messaging system within the system and providers can send tasks within the EMR directly to specific team members. One preceptor noted that one of the facilitators that expedited collaboration and communication was the use of EMR to communicate with physicians and make recommendations to support VIP care:

(learners) can easily hop on and be a part of conversations (with physicians and nurses) … there’s definitely collaboration … … . (the) EMR has been great for like creating tasks to ask a physician to have a conversation with us so we (preceptors and learners) can be a part of that treatment plan for the client.

A provider summed up the experience of using technologies as a facilitator of VIP care, “the dashboard on the MedAcess (EMR), we communicate back and forth with that, and sometimes with e-mail. I think that’s been very appropriate … … . Those ways always seem to be the right form of communication for the need.”

Opportunities for synchronous and direct collaboration were facilitated through learners and physicians working virtually together. In the Intellectual Disability/Development (IDD) clinic the preceptor noted that this specialized context it offered:

interprofessional conversation between the learners and the physicians … … . the physicians do inquire about kind of OT related questions … and the students can ask the physicians opinion at those (virtual) meetings … … . the students have expressed that they have gained more appreciation of (the work of the physicians in the ID clinics) and I think that helps the clients and the learners.

A student shared how this supported VIP care:

I did work with one of the family physicians quite a bit. We collaborated on what my role would be as the occupational therapy student and what we can provide to the client and how they can support me and (I) take over some of the responsibilities.

A provider shared more about working together and how it supported IP care, they described it as:

the collaborative leadership, I think that seems to be a bit organic, even though they were in a student role, they seem to take the leadership when it’s there for them to take. And otherwise, the other professionals are taking the leadership.

Experiential learning outcomes and benefits of VIP care in FM

Patients, learners, preceptors, and providers shared their perspectives regarding the value of VIP as a modality for patient care. The outcomes and benefits are based on the reflections of participants as to what they felt they gained. Outcomes are grouped into Patient Care and interprofessional Competencies Acquisition.

Efficiencies in accessing virtual care for patients included decreased reliance on transportation, decreased cost for travel, and the convenience and comfort in accessing care in the home virtually. A learner offered insights,

Telehealth is a quick phone call, there’s no travel time (for patients). There’s no waiting. Often times you say (to a patient) your appointment’s at 1:30 and it happens at 1:30.

A patient offered their insights on the benefits,

virtual care … on the phone, (they were) talking to me about what the issue was how it came to be injured. I thought it … (was) a door opener to the actual physical meeting. So that people were on board with the information and there were no surprises.

A provider shared:

it’s been very convenient for family and patients. You can have multiple people at the visit, which is efficient. With people with intellectual disabilities, they can have their caregivers present, and they don’t have to travel and access (transportation). … for convenience and for repetitive teaching it’s been very good for that population.

The practices already functioned in an interprofessional collaborative manner with family physicians, family practice nurses, medical learners (postgraduate residents in family medicine, and undergraduate medical students), other medical professionals (pharmacy, mental health providers, dietician) and medical specialists (internal medicine, pediatrics, palliative care). Expanding the learner-centered model to include OT and PT learners in community-based primary care FM provided an opportunity to expand the breadth of comprehensive care for patients and families in their medical home. One learner shared,

I think even from a patient perspective it’s not just us (the learners) more informed, but the patient gets a whole comprehensive treatment plan and it’s the same amount of time they would have spent with one practitioner. I find when an OT student learner and I interview people together, they get the chance to tell their story once, they pick out their details, I pick out mine, and it gives you a much better picture rather than having to relay the super important points, you might miss something that’s important to them.

Virtual care afforded opportunities for improved patient self-management through developing knowledge of online skills, and potentially more confidence with technology. The learners were able to provide patients with tablets and exercises or information electronically that they could use to work on interventions. One learner shared:

I felt it also gave opportunities for us to teach some clients how to use zoom and telehealth as well, which they could extend beyond just what we’re doing with them.” A patient shared that he felt that he was going to be able to “look for something a little better now that I know what I need. Because I keep hitting my (elbow) and it keeps getting sore, I just need to isolate it a little bit more than what I’m doing right now.

VIP care experiences provided more options for how care was provided. Some patients preferred in person, “I like to be in physical touch with the person who’s going to help me. The call was a nice set-up for that … I’m not a big virtual, Zoom person. One-on-one or two-on-one in person is a preference.” Others found virtual more suited to their health needs or preferences. One patient explained:

the only time, we went into the city was for doctor’s appointments. So therefore, I had a number of telephone appointments with the various physiotherapy students that I was a lot more comfortable having rather than to go into the city.

A provider elaborated on how having the option of virtual care provides options for patients:

for some people to come in (to the clinic) is a huge hurdle, especially when they don’t already have a relationship or a promise of help. I think that the advantage of the virtual care has allowed those people to connect with OT and PT and not having to jump that first hurdle. Once that relationship is established, OT and PT are able to say: ‘This is what we can offer you, let’s bring you in.’ I think it sort of makes the initial hurdle small which means that next time they have to go that hurdle it’s more worth it to them in a way.

Enacting this VIP care strengthened IP competencies for learners and providers. Collaboration, communication, role clarification, time management and advocacy were identified across the interviews and focus groups. A student shared an experience with role clarification, they said:

having the opportunity to work with an OT partner … (with a patient) who was dealing with carpal tunnel syndrome … I didn’t know that OTs made splints. Having a partner who was able to make a splint for this patient was obviously beneficial for the patient and (a) helpful complement to the PT treatment. The patient was then able to do their physiotherapy exercises and have a splint they can wear to do with other activities of daily living or to wear at night to minimize their wrist being in compromising positions. I think being able to understand the roles of different professions was also very helpful

Another student emphasized the competencies surrounding communication and collaboration:

those are super clearly demonstrated with this initiative. We are constantly communicating with each other, with the physicians through our documentation, making it clear that everyone who’s involved understands what’s happening with us, what’s happening with the physician… and everyone is clear on the care plan. And then similarly, with collaboration, everyone is working together for the same goal.

Providers also strengthened IP competencies through having IP learners as part of the VIP care. Greater role clarity was gained, a provider shared:

we get a sense from listening to one of the OT students speaking to another practitioner about their problem solving, you get ideas to how that might help some of your own patients. But also, they’re listening to our huddle and listening to what we do as family docs as well. So that goes in both directions

Another shared:

I think I have had less of a handle on what occupational therapy does, and I think that as I listened to the students reporting on the patient that they’ve recently seen, and I’m learning a lot about the breadth of occupational therapy. I think that I wasn’t as clear on before.

Further to this a provider said “I always thought of PT and OT as solving a physical problem, but just thinking that they can also help with different aspects of emotional and mental well-being has been a shift for me.”

The learner-centered model in this study was situated in primary care and the experience sensitized OT and PT learners to the scope, complexities, and reality of the FM context. OT and PT Learners shared they learned about FM through, “being able to partake in rounds.” In rounds, “seeing how they collaborate with each other to discuss care plans and who is taking which patient, what day and what they’re doing. Specifically seeing how everyone is kind of looped in on what everyone else is doing” helped them understand more about FM and how it operates. A learner also said it was invaluable experience, “to see the process (in FM in this setting) we could see where we could directly (send patients) instead of (patients) having to do that kind of run around.”

The experience of VIP care sensitized OT and PT learners to telehealth practice legalities in preparation for entering practice. One learner summed up the benefit of the learning:

for this to be our first experience with clients … in the direction that healthcare is going. I think it’s been super interesting and very informative, especially with (learning) all of the legal standards and the specifics of confidentiality when it comes to telehealth. I’ve become very aware…and I feel like that’s just not information that I would have thought I would have.

OT and PT Learners developed professional capacities through their placements in VIP care. They learned how to become more adaptable, flexible and to practice self-direction in preparing to enter practice. Learners shared the benefits and ways they improved professional capacity, one learner said, “the placement definitely has its merits and it’s definitely forced me to think on a more global level like what’s important, because you can’t just schedule this person in 3 days a week to see you.” Another shared, “I think it’s definitely increased our adaptability to certain situations. Going in with a completely open mind saying I’ll try this and if it doesn’t work.” The nature of VIP care for learners meant “we’ve had to take on self-directed learning a bit earlier … as healthcare professionals in the future we’re going to have to stay up to date with different treatment approaches and keeping up with our research. I’ve had to do that a lot more, just finding …answers on my own.”

Discussion

Participants in this IPE experiential opportunity provided key perspectives that can inform the emerging practice of VIP care and virtual clinical education in primary care. Perspectives from the participants involved contributed to IPE learnings, opportunities for aligning virtual care with patient needs, as well as ways to strengthen interorganizational and interfaculty collaborations to make VIP more feasible beyond the COVID pandemic. The strengths-based approach in this inquiry provided a basis for understanding what was learned and how organizational systems can do more to support authentic opportunities for learners to deliver VIP in FM that can have a positive impact for patients. Learnings are discussed for the advancement of IPE and IP competencies for medicine, OT, and PT learners and providers, curricula development and learner professional preparations for virtual practices, considerations for more inclusive patient access to comprehensive community-based VIP care and strengthening interorganizational and interfaculty academic collaboratives in future VIP initiatives.

Advancing IPE and IP competences for medicine, OT and PT learners and providers

Learning opportunities for authentic practice-based development and reflection on IP competences for health care providers was facilitated through this learner-centered approach. In this pilot both providers and learners advanced capacity, and knowledge beyond what is learned in undergraduate and graduate health care education. For instance, the virtual collaborative team huddles, direct and virtual interaction with students, and electronic communications regarding patient outcomes supported providers in gaining a deeper understanding of the realm of OT and PT scopes of practice. In real time, the students also learned about the complexities of primary care and the role of FM and were able to advocate for patient needs. As well, students learned more about the scopes of other student professions where the opportunity for working interprofessionally exists. These findings suggest that the learning environment of collaborative community-based clinics provides a space where ongoing IP development can transpire for both providers and all students.

Advancing curricula for VIP care

Provision of VIP care for learners was novel for many health professions during the COVID pandemic. Findings from this study identified some of the challenges and gaps that providers and students experienced using this approach for patient care. These included challenges with communication, developing relationships with providers and patients, and a lack of virtually appropriate assessment tools.

While learners in OT and PT involved in this pilot completed virtual care IP training modules as part of IPE, their feedback and insights have implications for the development of curricula for preparing for virtual or telerehab placements and practice. For instance, areas for development of virtual training modules that are needed include how to communicate with patients effectively using phone or on video platforms, how to engage collaboratively with other professions in assessments, how to think and plan to convey information, and how to ask questions to inform care in a timely manner.

There are opportunities to develop simulated IPE cases for virtual assessments and interactions with patients which has potential for better preparing students entering into clinical placements where virtual or combinations of virtual and in person care are required. Beyond this, there are opportunities to develop best practices in VIP care. For instance, in this pilot OT and PT students shared the initial assessment questions when interviewing patients and then drew on their specific practice tools and knowledge base. There is a need to develop appropriate IP assessment tools that can be part of virtual best practices for conducting assessments, check-ins, and follow-ups. In the future, research into the development of clinical virtual IP practices and tools may lend to furthering this emerging area of practice and support student-learners in engaging more competently in virtual care.

Advancing access to comprehensive community-based FM care for patients

The findings in this study concur with Miller et al. (2019) that all perspectives are needed to promote optimal IP care and learn more about how to advance IPE approaches. This pilot study highlighted that VIP learner-centered care provided patients with access to more comprehensive care given that it involved OT, PT, and Medicine learners. This added to the existing teams’ complement of providers in the setting. While there were some challenges noted by patients with regard to timing and prioritizing of care of calls and appointments organized virtually, there were also benefits. For instance, there were opportunities for patients to access IP knowledge and receive it while living at home, and VIP care was viewed as more efficient and comprehensive for patients in having OT and PT work collaboratively on initial assessments and coordinating interventions that aligned with patient goals. For some patients, virtual care provided better alignment for patient needs (addressing mental health concerns), preferences (more efficient to access virtual), and resources (lack of transportation). These initial findings point to the potential strengths of VIP care in delivering primary care in FM that may be used to inform this emerging area of practice. VIP offers more inclusivity and choices for patients and expands the potential of delivering primary care.

Strengthening interorganizational and interfaculty academic collaboratives for VIP care in FM

The introduction of the VIP care approach and including OT, PT and medicine learners into collaborative FM clinics provided a foundation for patients to access and benefit from FM and IP virtual practice in the community where they live. Positive outcomes and benefits of VIP realized across patients, students, providers, and preceptors from three professions concurred with previous IPE initiatives in the Atlantic provinces, and they have added insights to inform the development of VIP care as an emerging practice (Moores, 2020; Tzenov et al., 2021). For instance, co-leads provided leadership to create and sustain this interfaculty academic collaborative, they garnered and tapped resources such as instructor time, preceptors for students, access to electronic technologies and communication equipment, communicated within and across organizations the value and benefit to organizations and the health system, wrote proposals for funding and research, and engaged a community of participants in an evaluation. Moving forward the findings from this study can be used to strengthen the development of IPE curriculum related to dimensions of delivering IP care in academic professional programs, to forge strategic agendas for academic collaborative partnerships in primary care FM that are inclusive of the rehabilitation health sciences, and to support the development of authentic IP tools for use in virtual care.

Limitations

One limitation of the study was the number of participants who contributed to the study. Focus groups were small and there was especially little representation from FM residents. Future studies could benefit from more participants to warrant a boarder perspective of the VIP service. The limitations of this initial pilot study were that the perspectives of participants occurred at different stages of implementing the program through the COVID pandemic. Further study is needed to understand how this approach can be implemented and evaluated post-covid pandemic that offers interprofessional learning when virtual and in person learning approaches can work together.

Conclusion

The emerging VIP practice in community-based FM has potential to: 1) expand the breadth of comprehensive care for patients through increased access to professionals through a learner-centered model; 2) support the acquisition of interprofessional competencies for providers and learners; 3) expand the options for types of care for patients; and 4) enhance the knowledge of new learners about the role of FM in primary care.

Acknowledgments

Carmel O’Keefe contributed to the proposal, implementation, and preceptorship of the pilot. Beverly Lawson contributed to the proposal and implementation of the pilot. Jonathan Harris contributed time to review and support the pilot.

Disclosure statement

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

Additional information

Funding

This work was supported by the Living Lab Research Fund at Dalhousie University under Grant [REB File #: 1026636].

Notes on contributors

Joanna Zed

Dr Joanna Zed is an Associate Professor and Associate department Head with the. Dalhousie University Department of Family Medicine in Halifax Nova Scotia. She practices collaborative, comprehensive family medicine at the Dalhousie Family Medicine at the academic teaching clinic in Halifax. Interests include clinical teaching, office based primary care and office based procedures.

Lynn Shaw

Dr. Lynn Shaw is a Professor and Director of the School of Occupational Therapy at Western University. She holds a PhD in Rehabilitation Science. Dr. Shaw is an occupational therapist and occupational scientist who contributes to ongoing research and partnerships to address work transitions, work disparities, work disruptions and structural/systemic inequities needed to create opportunities for Decent Work, social inclusion, the promotion of occupational participation, and workplace health and well-being. Other key areas are in health transformation through Interprofessional academic collaborative approaches and workplace innovations, along with systematic reviews in occupational therapy, chronic pain, assistive technologies, and chiropractic. Areas of new focus in work include a focus on equitable work mobility and technological disruptions on the impact on future work.

Danielle Domm

Danielle Domm is a registered Occupational Therapist with experience and interest in providing care for primary care patients. Her research interests are in strengthening primary care and the health system, which involves synthesizing current research and implementing projects to impact policy.

Helena Piccinini-Vallis

Dr. Helena Piccinini-Vallis MD (Dalhousie University, Canada), PhD (Western University, Canada), is an Associate Professor in Family Medicine with cross-appointment in Obstetrics and Gynecology at Dalhousie University. Her quantitative and qualitative research explores issues pertaining to pregnancy-related weight changes from the perspective of women and healthcare providers, and she strategically integrates the Patient Centred Clinical Method as a framework for providing a primary care lens in her work.

Katherine Stringer

Dr. Katherine Stringer is a South African born medical graduate of the University of Cape Town. She worked as a community family physician before joining the Discipline of Family Medicine, Faculty of Medicine at Memorial University in 2009. She is a strong supporter of medical education and has held many leadership positions in medical education in Canada including currently the Department Head of Dalhousie Department of Family Medicine and the Chair of the Family Medicine Specialty Committee at the CFPC. Clinically she practices comprehensive family medicine with a special interest in Care of the Elderly and adults with Developmental Disabilities.

Appendix

Appendix 1. VIP Study Patient Interview Guide:

1. What would you like to tell us about your experience in having virtual care by the Occupational Therapy (OT) and Physiotherapy (PT) students? (Discovery) Prompts: What went well for you? What didn’t work well for you? Can you describe the service(s) that you received? What was helpful? How was the service delivered (e.g. video/telephone)?

2. What did you like about this service (virtual care)? (Strengths based) Prompts: Technology (ease of use), timing of service, receiving the care in your home? Access to care?

3. How could this service (virtual care) be improved? (Dream Design) Prompts: Technology (ease of use), timing of service, receiving the care in your home? Would you have self- referred to team if you were aware they were available?

4. What do you think OT and PT students need to learn to be effective in delivering virtual care through the clinic? (Dream Design). Prompts: technology, communication skills? Practical skills?

Appendix 2. Focus Group Guide:

1. What do think of the approach of using virtual care? (Strengths) Prompts: for patients students, families, practitioners?

2. What would you like us to know about the strengths of this Virtual Integrated Interprofessional Access (VIIA) for learning about Family Medicine and team- based approach to Primary Care? (Strength Discovery)

3. How were the demonstrated interprofessional education competencies experienced? (Strength Discovery)

4. How do you feel the aspects of the VIIA approach have strengthened IP knowledge? (Strength)

5. How can we build on and enhance this education and FM collaboration experience? (Design) Prompt: next year iteration?