An Interprofessional Collaborative Practice Model (IPCP) for Enhancing Population Health and Care Transitions

Saturday, 29 July 2017: 8:50 AM

Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAAN
School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
Connie White-Williams, PhD, RN, NE-BC, FAAN
Center for Nursing Excellence, University of Alabama at Birmingham Hospital, Birmingham, AL, USA


Changing requirements shifting the focus of care from an emphasis on value over volume demand delivery models that cultivate teamwork and collaboration across the healthcare continuum. Academic-practice partnerships represent a desirable vehicle to test innovative interprofessional collaborative practice (IPCP) models to enhance population health outcomes and care transitions.


This purpose of this presentation is to discuss early findings following implementation of an IPCP model used as part of an academic-practice partnership to enhance health outcomes and care transitions in a complex and underserved heart failure patient population. Leadership and partnership strategies used to facilitate IPCP and care coordination will also be identified.


An innovative IPCP model was implemented in a nurse managed heart failure clinic impacting health outcomes for an underserved patient population in an academic health center in the southeastern United States. Professionals from various disciplines including nursing, medicine, social work, health services administration, and health informatics worked together as a unified team to enhance the patient experience, health outcomes, and cost of care. Leveraging resources of a grant-funded opportunity and longstanding academic-practice partnership, the IPCP model incorporated transitional care coordination approaches to affect population health outcomes and care transitions across the healthcare continuum.


Two years of project data reflect positive outcomes. Patients reported enhanced access to care, availability of life-sustaining medications, superior experience ratings, and improved physical and mental health outcomes. Care transitions improved with a reduction in hospital readmissions for this complex patient population. Use of an IPCP model also demonstrated enhanced teamwork and collaboration amongst healthcare team members from multiple disciplines. The IPCP model also provided clinical placement opportunities for students from the various disciplines represented to learn about teamwork and build their competencies for IPCP, population health, and care coordination across transitions.



An IPCP model of care is an effective approach to improve health outcomes and care transitions in underserved patients with chronic diseases such as heart failure. Members of various health professions working together in a collaborative model can enhance teamwork that ultimately benefits patient outcomes. Working together, academic-practice partners can achieve impactful outcomes that one partner alone might not be able to achieve.