University of Washington School of Public Health
A Team Approach to Combating the Wounds of War
Today, almost half of recently deployed veterans get their health care outside the 1,700 facilities managed by the U.S. Department of Veterans Affairs. That number of users increases to 75 percent when applied to all veterans, and many female veterans choose not to access care from the VA at all.
That means no matter where they practice, tomorrow's health practitioners are likely to be caring for veterans at some point in their careers. With 22 million veterans nationwide, including more than 600,000 in Washington state, this community's health needs continue to grow.
Whether combating symptoms such as fatigue and memory loss or facing more complex mental health issues such as depression and post-traumatic stress disorder, one of the most effective treatment plans for post-combat veterans is enlisting a team of cross-disciplinary health providers who know how to work together and who value a collaborative approach.
"In social work, we've known for years the importance of an interdisciplinary approach," says J'May Rivara, a lecturer in the University's School of Social Work. "In the last decade, the finances of health care have forced us to look more at prevention and ways to keep people healthy. Teamwork ensures better outcomes for patients and lower costs for everyone."
The idea of a team-based, cross-disciplinary, integrated approach to health care is at the core of a new initiative launched last year at the University of Washington. Known as Interprofessional Education, IPE uses curricula and training opportunities to educate and engage health sciences students from six disciplines—dentistry, medicine, nursing, pharmacy, public health and social work.
The goal is to help future health practitioners understand the services that each discipline brings to the table, to value individual skills and perspectives, and to work together now as students so they can function more effectively later when they are practicing in the field.
During the past academic year, a series of six IPE sessions flipped the classroom experience, allowing students from the health sciences schools to learn from each other and encouraging faculty to teach in new ways. "Faculty's role was not to take over but to ask questions," said Rivara. "To observe and be very strategic but not to drive the conversation."
Each of the sessions was sponsored by a professional health sciences school and centered on a different health issue. The School of Social Work organized the last session in April, which focused on medical issues affecting returning veterans. About 600 students in total participated, meeting in six different lecture halls and classrooms at UW Medicine. Following presentations, the students broke into smaller cross-professional groups for discussion.
Many health providers are not trained to ask about military service, so common health concerns might get overlooked, which could have long-term negative impacts on health. At the IPE session focused on veterans, students learned how to ask about past military service as well as how to solicit information on health concerns and potential exposure risks. The session also included four documented case studies and involved several student and faculty veterans who framed post-combat health issues in real-world terms.
One of the case studies revolved around Leon, a 28-year-old retired Army veteran who suffered four significant head injuries while serving two tours of duty in Iraq. Following his discharge, he was on multiple medications to treat traumatic brain injury, post-traumatic stress disorder, seizures and disabling migraines.
The students used Linoit, an online "sticky note" service, to post their ideas and share feedback. Faculty members, fellow students and practicing social workers circulated among the groups to facilitate discussion. "Students were asked to use their own discipline's perspective to identify treatment options and resources," says Rivara. "We encouraged everyone to be as innovative and participatory as possible."
The discussion at one table focused on what medications to give Leon, according to Susie Ryan-Coy (MSW '14), a student facilitator. "That made sense since the group had two pharmacy students, a nursing student and several medical students," she said. "But I felt they also needed to look at psychosocial issues. That's where social workers get involved."
Gurminder Hothi (MSW '14), another student facilitator, echoed Ryan-Coy's experience. "I helped guide the conversation at my tables," he said, "trying to encourage students to consider other facts. For example, if the team wanted Leon to change his medications, they also needed to consider how he was going to get the new medications refilled or how he would get to the hospital for follow-up visits."
Both Ryan-Coy and Hothi credited the IPE exercises with raising awareness about the role of social workers in the health care system. "It was refreshing to see students consider a variety of precipitating factors, such as what behaviors led to a certain illness," said Hothi. "Combining students from all the professional schools allowed discussions from different viewpoints."
The collaborative technique, so central to Interprofessional Education, is not just for classroom use. The approach reflects the way that health care services are being delivered today, according to Ana Fisher (MSW '05), a cancer care navigation team social worker who has worked at the Department of Veterans Affairs for nine years.
"When vets come to the VA, they receive more than just health care," she said. "We look at all factors, whether medical, psychological or psychosocial. Maybe there are mental health issues, family problems or drug addiction. If they are facing financial hardships, a social worker can help them apply for disability. If they cannot drive to their appointments, a social worker finds them transportation. All of these services will impact their treatment and recovery."
Fisher, who was a presenter at the IPE session, believes this unique approach can transform the way that faculty teach and students learn, ultimately benefitting patients and their families. "Fighting disease is not easy. Everyone must be on board for us to succeed," she said.
"Each week, I sit down with a team of doctors, nurse practitioners, physician assistants, speech pathologists, dieticians and others," Fisher continued. "We all focus on how to meet the needs of this one individual. It's a beautiful thing."
Ryan-Coy has also witnessed IPE principles in action during her eight-month advanced practicum at a VA hospital. A case manager in the renal dialysis unit, she recently worked with a veteran who wanted to quit dialysis. Determined to seek other advice, Ryan-Coy called together members of his medical team, which included nurses, nephrology fellows and other care providers. After multiple discussions with the patient, the team learned for the first time that the dialysis was exacerbating the veteran's chronic pain symptoms.
"It was so helpful for us all to hear the same information at the same time," said Ryan-Coy, "and together we developed a treatment plan. Getting to the bottom of things took many months but I felt we positively affected this veteran's health and his future."
As the delivery of health care services continues to evolve, one thing will remain constant: The importance of health professionals working cooperatively in a team setting. "IPE is not just an academic discipline," said J'May Rivara. "It's real. Interprofessional teams and a collaborative approach are the wave of the future in health care."