The IMPACT clinic was developed collaboratively by an interprofessional team of clinicians, educators, and researchers. Several strategic partnerships were established with local community-based health and social care agencies. The IMPACT practice model () comprises family physicians, a community nurse, a pharmacist, a physiotherapist, an occupational therapist, a dietitian, and a community social worker. In addition, the model is designed to accommodate trainees from each of the various disciplines.
All members of the interprofessional team attended the weekly clinics, which were scheduled for the full day on Fridays. Each member assumed 3 unique roles in the project: 1) as clinician, providing clinical care for patients and families in the weekly interprofessional clinic; 2) as educator, providing information, guidance, and support both to new trainees and to practising clinicians; and 3) as innovator, contributing to the ongoing refinement and evaluation of the interprofessional practice model.
Patients were referred to the IMPACT clinic by their regular family physicians in the Family Practice Unit. The eligibility criteria were as follows: 65 years of age or older; 3 or more chronic diseases requiring monitoring and treatment (or 2 chronic diseases when 1 is frequently unstable); 5 or more long-term medications; a minimum of 1 functional limitation on activities of daily living; and not homebound or institutionalized.
Referred patients were provided in advance with a description of the IMPACT clinic and then invited to attend. Patients were encouraged to bring the following to their appointment: any family members or paid caregivers involved in their care; all of their current medications (both prescription and over-the-counter medications); and a list of their current concerns. Patients were scheduled for an extended appointment (1.5 to 2 hours), during which a diverse range of medical, functional, and psychosocial issues were investigated by the full team.
The IMPACT clinic protocol evolved over time through an ongoing process of interprofessional collaboration and teamwork (). At the visit, the patient and family members were met by the family physician and a family medicine resident. After being introduced to the team, the patient and family were brought to an examination room, where the resident conducted a 20-minute quality-of-life interview that was designed to “unpack” the patient’s circumstances and concerns. This initial interview, which did not involve any physical examinations, was observed by the full team via closed-circuit television. This model allows for real-time information sharing and collaboration among all members of the team. Upon completion of the initial interview, the resident returned to the team for debriefing and discussion.
During each visit, there were 3 formal discussion periods in which the full team assembled to identify patient- and family-centred priorities, to share assessments and insights, and to develop collaborative strategies for care management. At the outset, a facilitator was appointed from within the team to ensure that the clinic remained on track and ran smoothly. Informal discussion in smaller groups occurred routinely throughout the visit. During the first formal discussion period, patient and family priorities and team concerns were discussed and clarified in order to plan the sequence of clinical assessments to follow.
Once the visit plan was in place, members of the team met with the patient and conducted interprofessional assessments. The assessments were typically led by 1 member of the team with participation from 1 or 2 other members, as appropriate, while the rest of the team observed via closed-circuit television. Knowledge and perspectives were continuously being shared among team members and were often incorporated into the assessment of another practitioner from a different discipline. When the assessments had been completed, the team reassembled for the second formal discussion period in order to draft the interprofessional care plan.
Drawing from the interprofessional care plan, a patient-friendly “to-do list” was created for the patient and family to take home. This formed part of the IMPACT information package, which included a complete and up-to-date medication list and other relevant educational information and resources. Any necessary referrals and follow-up appointments were arranged, and these details were included in the information package.
Next, the care plan was finalized in collaboration with the patient and family. The family physician and resident returned to the patient and family to review the care plan with them, as well as the medication list and any other resource materials being provided. The patient and family were encouraged to raise concerns, ask questions, and discuss the specifics of the care plan with the family physician and resident.
At the end of the visit, the team came together for a final debriefing and discussion. During this time, a follow-up plan of care was developed for the family physician, who would resume ongoing care of the patient. The follow-up plan included a list of the issues identified and addressed at the IMPACT visit, as well as any outstanding concerns and a proposed management plan for these concerns that the family physician could refer to at the patient’s next regular family practice appointment.