AACN Essentials Domain 6: Interprofessional Partnerships

“Focuses on interprofessional collaboration in healthcare” (AACN, 2021, p. 42).

Domain 6: Essential Knowledge

To meet the objectives for Domain 6, knowledge is required in:

• Role and scope of other mental health professionals
• Working collaboratively with other mental health professionals
• Clinical supervision, collaboration, and oversight in psychiatric practice
• Variations in interprofessional collaboration in psychiatric and mental health treatment settings across the continuum of care
• Understanding team dynamics and fluid leadership based on the care context
• Knowledge of IPE core competencies and frameworks

Domain 6: Leveling of the AACN Essential Objectives

Domain 6: Teaching/Learning Strategies

Examples of Classroom and Clinical/Practicum Strategies

Case scenarios across the lifespan (child, adolescent, young adult, adult, and older adult) are included and could be created as individual assignments, team assignments, discussion boards, or developed as simulations.

Example 1: Case Scenario – Interprofessional Partnership with Adolescent

Sally is a 14-year-old female who lives with her parents. She is an only child. Sally is a straight-A student who loves basketball, volleyball, track and field, figure skating, and golf.

Sally reports ongoing depression, anxiety around people, and panic attacks when told that she has to do something she does not like (i.e., going on bedrest or getting a feeding tube). She says that she has PTSD from her psychiatric hospitalizations. She considers herself abused by her parents since they did not listen to her when she initially told her she was depressed and not doing well. A week ago, she was discharged from a psychiatric hospitalization and had a current PHQ-9 of 20 and a GAD-7 of 13.

During an annual physical last fall, Sally first expressed anxiety over her weight and food intake. After experimenting with her eating, she felt better taking in fewer calories. She was restricting her food intake while playing all her sports in addition to her workouts. Her primary care physician (PCP) recommended that she go to therapy. Sally went to two therapy sessions in the fall; her mother stopped taking her when Sally reported that the treatment was not helping. Sally. started removing the servings from her dinner plate in December.

Sally was brought to the emergency room in late January after a fainting episode. She had a heart rate of 40, blood glucose of 80, weighed 100 pounds (at 5’8″), and had no menses since August. Once stabilized in the ICU, she was admitted to the psychiatric hospital for two weeks.

She was hospitalized for a month in March. She started on Reglan and Zyprexa. Eight weeks of residential treatment was recommended at discharge.

Sally is on exercise restriction and cannot do any sports right now. Her PCP will sign off when she can go back to her sports. She sees both a therapist and dietitian twice a week. She does not want to go to residential treatment. The dietitian is adding protein to her food plan and taking blind weights.

Goals:
1. A.C. is to weigh 120# in 6 months.
2. A.C.is to follow the food plan 80% of the time.
3. A.C. is to start back on one sport once she weighs 110# as long as there is no associated weight loss.

Roles of the team:
Individual – cooperates with medication management, therapy, food plan, PCP orders, and parents.
PMHNP – manages psychotropic medication. Communicate with the therapist, dietitian, and PCP regarding progress.
Therapist – assists the individual in developing a positive body image and decrease anxiety around food.
Family therapist for parents – assist the parents in setting appropriate limits on the individual. Discuss the case with the individual’s therapist.
Dietitian – develop ongoing food plans, track blind weights, and communicate with the school nurse and PCP regarding weights.
Primary care physician – orders labs as needed; recommend weight-based exercise regimen.
School nurse – speak to the dietitian and/or PCP to communicate with coaches and physical education instructors regarding exercise and sports participation restrictions.
Parents – report to PMHNP, therapist, and dietitian on individual behavior, eating patterns, and mood.

Example 2 Case Scenario – Interprofessional Partnerships with a Young Adult

Sally is a 25-year-old female presenting for an initial individual assessment and evaluation. Her fiancé accompanies her and permits her fiancé to attend the session. Sally is animated, talkative, and challenging to redirect to obtain a history. She is easily distracted, gets up frequently to pace, and calls various people on her cell phone. Her fiancé reports that the individual has not slept for two weeks. She has nightmares about events in her childhood. She works full-time as a stockbroker, and then, after returning home, she calls individuals throughout the night. Her fiancé reports that although this recent behavior is out of character, there have been several times when the individual exhibited the same behavior but to a lesser degree.

Additionally, Sally has maxed out several of her credit cards, creating a debt of $20,000. Her finance reports that over 50 packages have arrived at the house due to her shopping spree. Sally interjects frequently. She says that Wall Street will be awarded broker of the year and selected as a year person by Time magazine. The fiancé reveals that Sally is estranged from her family.

Sally was raised by her mother, who was neglectful and physically and verbally abusive. Her mother would often disappear for days, leaving the individual to care for her younger sister. Her mother misused alcohol and had numerous boyfriends who molested her and her sister. Sally’s mother had several psychiatric admissions. Her fiancé reports that she avoids talking about her childhood. She finds it difficult to remember, but what she recalls is exceptionally distressful, and she becomes angry.

After identifying one event of molestation, she threw her laptop across the room at work, almost resulting in her termination. Sally thinks she is terrible and feels guilty for not protecting her sister. She denies suicidal/homicidal ideation, plan, or intent. She has no legal problems. Her boyfriend reports she has made poor decisions at times and has limited insight into her behavior.

Sally has no children and is estranged from her family. She is an only child. Family history of Bipolar (Father and Maternal GF), multiple cousins, and dx with ADHD/ADD. No family suicides. History of hypertension and bipolar disorder. NKDA. No past hospitalizations

Goals:
1. Management of mood instability.
2. Referral for therapy due to poor insight and judgment.
3. Rule out ADHD/ADD, Bipolar I

Roles of the team:
Individual – attend follow-up appointments, medication compliance, participate in the program of care
PMHNP – manage referrals, manage medication, diagnosis, and medication education; explain avenues for treatment; coordinate care with team members; order testing as needed
Therapist – trauma PTSD therapy, referral for PTSD and veteran support groups, referral for AA
Family therapists – start family therapy with finance once acute symptoms have been stabilized.
Primary care clinician – management of diabetes II, physical, labs
Family members – collect collateral information and involvement in the plan of care with the consent

Example 3: Case Scenario Interprofessional Partnerships with an Adult

John is a 42-year-old male Army Veteran presenting with complaints of insomnia and anxiety. His spouse accompanies him. John has been deployed three times. John was a noncommissioned officer and an infantryman and spent much of his time deployed on patrols “beyond the wire.” When asked about traumatic events he had experienced, John answered, “many.” He does not like talking about his experiences because they make him feel sick. His heart starts to race, and he becomes sweaty and nauseous. One incident that stands out was coming upon a mass grave site where multiple bodies of women and children were uncovered. John feels guilty because he lost two soldiers killed by sniper fire.

His spouse reports that he was not the same when he returned from the war. He no longer participates in family activities. His spouse reports that he is moody and angry. John admits to drinking up to a 6-pack of beer nightly. His spouse has found several marijuana joints in his car and several firearms in the house. His spouse found him sitting with a gun to his head one time in the past. He insisted that she not call 911. John shouts at the television if any news comes on about war, punches holes in the wall, and throws things. His spouse reports incredible frustration and wants to end the marriage. John does not want to end his marriage but feels distant from his spouse. Although he had tried very hard, he feels empty and no longer feels any loving feelings toward her since he feels numb most of the time.

John has nightmares about incidents that occurred while being deployed. His spouse no longer sleeps in the same bed because he thrashes about and unknowingly punches his wife during a nightmare. He prefers to avoid crowds, noisy restaurants, malls, and loud noises. Recently, he dropped to the ground during a Fourth of July celebration, crawling to cover because he was “back in combat.”

He wants to return to college but needs help concentrating and focusing. Since leaving the Army, he has had several jobs but was fired because of his angry behaviors. He has been married for 12 years, has no children, and enjoys exercising and reading.

Family history is positive for generalized anxiety disorder and alcohol use disorder.

Past medications include alprazolam and diazepam for anxiety and temazepam for sleep. He asks for the restart of these medications. He had been in psychotherapy, “exposure or something like that,” but stopped after a few sessions. He has a history of PTSD, diabetes II, and substance use disorder.

Goals:
1. Management of acute PTSD symptoms and suicidal ideation
2. Management of substance use disorders
3. Treatment of Insomnia and Anxiety
4. Consider Individual referrals, therapy referrals, support groups

Roles of the team:
Individual – attend follow-up appointments, medication compliance, participate in the program of care
PMHNP – manage referrals, manage medication, diagnosis, and medication education; explain avenues for treatment; coordinate care with team members; order testing as needed
Therapist – trauma PTSD therapy, referral for PTSD and veteran support groups, referral for Alcoholic Anonymous
Family therapists – start family therapy with his wife once acute symptoms have stabilized.
Primary care clinician – management of diabetes II, physical, labs
Family members – collect collateral information and involvement in the plan of care with the consent

Example 4: Case Scenario Interprofessional Partnership with Older Adult

John is a 67-year-old male complaining of poor energy, crying spells, and anhedonia. His wife died about eight months ago, and he has been living alone with his German Shepherd. He hasn’t been attending his weekly family outings or church on Sundays. He reports that he has noticed an increase in his sleep and appetite. He only recalls feeling this way once, about 30 years ago, after he lost his job. He reports that the symptoms lasted about a year. Exercise, a steady routine, and family support were helpful in the past. He completes a PHQ-9 at intake, with a score of 16.
He doesn’t report any history of psychosis or paranoia. He also reports that he typically has no sleep or energy problems. He has no history of substance abuse or trauma.

He grew up with his mom, dad, and eight siblings. He completed high school and started working as a carpenter. He worked until he retired at age 65. He married his wife at 18, and they raised four children together.

Last year, he had a heart attack. He has been taking Lisinopril for HTN and Lipitor for elevated cholesterol. His BP is 136/89 at today’s appointment, Pulse 69, RR 16. NKDA. There is no history of surgeries or hospitalizations.

He has never had any psychiatric medications in the past. His mother and father both suffered from depression. His father attempted suicide several times before dying in a car accident.

He wants to improve his mood and return to his normal activities. His children are supportive.

Goals:
1. Management of Severe Depression Symptoms
2. Referral for Grief Therapy
3. Management of HTN/Elevated Cholesterol

Roles of the Team:
Individual – attend follow-up appointments, medication compliance, participate in the program of care
PMHNP – manage referrals, manage medication, diagnosis, and medication education; explain avenues for treatment; coordinate care with team members; order testing as needed
PMHNP/Therapist – grief therapy, referral for grief processing groups
Primary care clinician – management of HTN/elevated cholesterol, physical, labs
Family members – collect collateral information and involvement in the care plan with consent. Provide family with information about depression through NAMI to assist with support.

Example 5: FNP/PMHNP OSCE Scenario

A 57 y/o married female had been seen as a new individual by the FNP two weeks ago. The individual’s chief complaint was burning on urination, frequent urination, and back pain. She also complains of difficulty sleeping and changes in moods, lack of appetite in the last two weeks. The physical exam was unremarkable except for low back tenderness. Lab results showed abnormal urinalysis results, bacteria 5+, WBC >10, + nitrate and an A1C – 7.2%. Urine Culture and sensitivity were positive for staphylococcus saprophyticus. The treatment consisted of fluoroquinolone for seven days and scheduled for a return date to the clinic.

PMH:

• Poorly controlled DM.
  • Metformin 1000 mg bid
  • Glipizide 10 mg bid
• Well-controlled HTN on Lisinopril 10 mg daily.
• Dyslipidemia is well controlled: Atorvastatin is 10 mg daily.
• Depression in the distant past, not currently on medication.

Social History: Non-smoker, one glass of wine nightly, no illicit drug use
Family History: Mother A&W, age 85: diabetes, HTN, dyslipidemia, father deceased, age 85 with MI/CVA history. 2 siblings, both A&W, not sure of any medical issues.
Screenings: mammogram one year ago regular, PAP (1 year ago) normal, has never had a colonoscopy, yearly optometry exam (wears glasses for reading).
The last routine labs were done one year ago, and other than her three-month A1C being high, she’s still determining other results.
Immunizations: Tetanus, Diphtheria, Pertussis 2 years ago, thinks she had childhood immunizations; up to date on COVID-19 vaccinations (has had booster).
Allergies: none
VS: BMI 23.0, 128/72, P68, R 16, T 98.6
PHQ9 – Score 15
Audit C – Score 0
No physical findings are noticeably abnormal, except for mild CVA tenderness on the right side.
Plan: Discontinue Glipizide; start Invokana 100 mg daily, start Sertraline 50 mg daily, Metformin 1000 mg bid, Invokana 25mg daily, Lisinopril 10 mg daily, Atorvastatin 80 mg.
Return to clinic in 4-6 weeks.

START OF PMHNP/FNP/FNP OSCE:
Ten days after the last clinic visit (the pt had no further urological complaints), the FNP was contacted by the individual’s husband, who stated, “What did you do to my wife?” When queried further, the husband went on to describe how his wife has not been sleeping more than 3 hours/night, getting into arguments with their neighbors, was arrested by police for not pulling over after speeding (going 70 mph in a 35 mile zone), having rambling and bizarre conversations, and cleaning the house at 4 am. When asked if he had witnessed such behavior, the husband responded, “Yes, twice before when they were first married.”

Meds: Sertraline 50 mg daily, Metformin 1000 mg bid, Invokana 25mg daily, Lisinopril 10 mg daily, Atorvastatin 80 mg.

The FNP works in a Collaborative Care model practice, sets up an appointment at the clinic for the next day, and calls the PMHNP who works in the same practice to seek a consultation.

The OSCE will start with the FNP presenting the case to the PMHP.
After debriefing with the PMHNP, the FNP will write a short reflection on collaborative care practice. What are the takeaways from the experience for the FNP?

Objectives:
1. Develop an understanding of the role of the PMHNP as a consultant.
2. Demonstrates a collaborative dialogue with the PMHNP.
3. Assess areas where an FNP can work independently with individuals who display psychiatric signs and symptoms and when to confer/refer to the PMHNP.
4. Identify at least three resources that the FNP can utilize post-OSCE.

Domain 6: Resources

Articles/Textbooks

Arora, S., Geppert, C. M., Summers Kalishman, D., Dion, D., Pullara, F., Bjeletich, M. B., Simpson, G., Alveson, D. C., Kuhl, D., & Scaletti, J. V. (2007). Academic health center management of chronic diseases through knowledge networks: Project ECHO. Academic Medicine: Journal of the Association of American Medical Colleges, 82(2), 154-60.

King, H. B., Battles, J., Baker, D. P., Alonso, A., Salas, E., Webster, J., Toomey, L., & Salisbury, M. (2008). TeamSTEPPS™: Team strategies and tools to enhance performance and individual safety. In K. Henriksen, J. B. Battles, & M. A. Keyes (Eds.), Advances in patient safety: New directions and alternative approaches (Vol. 3. Performance and Tools). Rockville (MD): Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK43686/

Websites

Agency for Healthcare Research and Quality (AHRQ). Team Stepps
American Interprofessional Health Collaborative (AIHC)
Australian & New Zealand Association for Health Professional Educators (ANZAHPE)
Canadian Interprofessional Health Collaborative (CIHC)
Centre for the Advancement of Interprofessional Education
The European Interprofessional Education Network
Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC
IPEC Core Competencies: 2023 Update
The National Center for Interprofessional Practice and Education
Nordic Interprofessional Network
Telehealth Resources: University of New Mexico, School of Medicine, Project ECHO