Developing and Implementing Interprofessional Collaboration for Older Persons with Decisional Capacity

1. Interprofessional Collaboration on Behalf of Older Persons With Compromised Decisional Capacity: Developing and Implementing Core Professional Competencies Marshall B. Kapp, JD, MPH Florida State University Tallahassee, FL marshall.kapp@med.fsu.edu

2. Introduction • Issues arise about cognitive and emotional decision making capacity of older persons in many contexts. • Balance between autonomy and protecting against risk of harm requires accurate capacity assessments. • Interprofessional (medicine & law) collaboration often is desirable.

3. “Capacity determination is a complex, cross-disciplinary process that ideally involves a range of professionals. It requires knowledge of medicine, ethics, and the law.” • (Skelton, Kunik, Regev, & Naik, 2010)

4. Agenda • Strategies for developing core educational competencies • Public policy as facilitator of such development • Public policy addressing impediments to implementation of core competencies

5. Compromised Decisional Capacity • Lots of decisions • Presumption of autonomous decision making • Problem of decisional incapacity • Affects individual, plus those who have or are contemplating personal or professional relationships with the individual

6. Capacity is decision-specific • Capacity depends upon ability to: • Make and communicate a choice • Give reasons for the choice • Factually understand the alternatives • Appreciate the personal consequences of the choice

7. Need for Professional Involvement in Capacity Assessment • Attorneys (ABA Model Rule of Professional Conduct 1.14) and physicians independently • Attorneys and physicians collaboratively • Poor educational preparation for this task* But see Amer. Bar Assn. & Amer. Psychological Assn., Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers (2005) and British Medical Association and Law Society, Assessment of Mental Capacity:A Practical Guide for Doctors and Lawyers, 3rd ed. (2010).

8. Delineating Professional Competencies • Competency-based professional education • Outcome/skills oriented, not focused on process inputs or recitation of information • Premise: Teaching can improve performance • Assessing decisional capacity is a core competency that attorneys and physicians should be able to demonstrate

9. Delineating specific competencies • Build on General Competencies of Accreditation Council for Graduate Medical Education (ACGME) • Interpersonal and Communication Skills • “…work effectively as a member or leader of a health care team or other professional group.” • Professionalism

10. Build on Interprofessional Education Collaborative (IPEC) (organizations of health education institutions), Core Competencies for Interprofessional Collaboration Practice (2011). Did not address working with attorneys. • Core competencies: • Values/ethics • Roles/responsibilities • Communication • Teams and teamwork

11. Roles of Public Policy • Encouraging and Facilitating the Development and Implementation of Core Competencies • Government grants (e.g., NIA, HRSA, AoA) to support educational innovations, at least demonstrations, leveraged with private foundation support • Medicare payment to physicians for interprofessional capacity assessments under Part B, factor cost of this service into payment rate offered by CMS to Medicare Advantage plans

12. Integrate expectation of interprofessional capacity assessments into legal standard of care for physicians through Clinical Practice Guidelines (whose development and dissemination is supported through grants from the Agency for Healthcare Research and Quality [AHRC]). Integrate expectation of interprofessional capacity assessments into legal standard of care for attorneys through changes in ABA Model Rules of Professional Responsibility.

13. Government or private grants (e.g., HRSA) to support and encourage certain medical specialty boards to incorporate demonstration of relevant core competencies into specialty certification examinations. • Government or private grants to support and encourage organizational and state Bar legal specialty designation boards to incorporate demonstration of relevant core competencies into specialty certification processes.

14. Removing or Mitigating Barriers to Implementation of the Core Competencies • Clarify/modify Health Insurance Portability and Accountability Act (HIPAA) to facilitate information exchange and interprofessional communication involving medical information • Clarify/modify ABA Model Rules of Professional Responsibility to facilitate information exchange and interprofessional communication involving information known by the attorney

15. Discussion?