|Year : 2014 | Volume
| Issue : 1 | Page : 93-98
The REACH project: Implementing interprofessional practice at Australia's first student-led clinic
Ellen Buckley1, Tamara Vu2, Louisa Remedios3
1 Department of Physiotherapy, BPhysio(Hons), School of Health Sciences, The University of Melbourne, Melbourne, Parkville, Victoria, Australia
2 Final Year Student 2011, Melbourne Medical School, The University of Melbourne, Melbourne, Parkville, Victoria, Australia
3 Department of Physiotherapy, School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Parkville, Victoria, Australia
|Date of Web Publication||11-Jun-2014|
Physiotherapy, School of Health Sciences, The University of Melbourne Alan Gilbert Building, 161 Barry Street, Carlton, Victoria 3053
Source of Support: This project was partially funded by a grant under the Workforce Innovation Grant Program, Department of Human Services, Victoria, Australia., Conflict of Interest: None
Background: REACH (Realising Education and Access in Collaborative Health) is an initiative of students of the University of Melbourne to improve access to primary health care services. It is driven by the voluntary commitment of over 120 students and is built upon the principles of collaboration, interprofessionalism and client-centered care. Summary of work: The feasibility of student-led clinics has been demonstrated with the operation of over 100 such clinics in North America. Senior students from Medicine, Physiotherapy, Nursing and Social Work attended a student-run clinics conference in Jacksonville, Florida, USA in 2010. On return, research was conducted to identify a local underserviced community appropriate for a clinic. On review of the literature, it was determined an interprofessional model of care would best serve this community. The student body engaged a local community health service as a project partner. The model of care at the REACH Clinic was developed by senior students from the schools of Medicine, Physiotherapy, Nursing and Social Work and managed by an interconnected student committee structure. The final consultation model involves a triage process and simultaneous consultation by two disciplines. This model of care was successfully implemented during a 4-week pilot period in October 2011. Results: Several issues were identified during the REACH pilot, with dissonance between the at-times competing principles in health care of interprofessionalism, client-centered care and efficient care. Conclusions: An interprofessional model of care was developed and successfully implemented in a 4-week pilot student-run clinic within an established community health service. While providing a free health service, this model facilitated interprofessional learning at both a clinical and management level and highlighted logistical and ideological challenges that served as the basis for further refinement of this model of community service .
Keywords: Access, client student-run clinic, health access, interprofessional, interdisciplinary, model of care client-centered, model of care, student-led, student-run, student-run clinic
|How to cite this article:|
Buckley E, Vu T, Remedios L. The REACH project: Implementing interprofessional practice at Australia's first student-led clinic. Educ Health 2014;27:93-8
| Background|| |
REACH (Realising Education and Access in Collaborative Health) is a pilot project to develop a student-led clinic in inner Melbourne, Australia, providing medical, physiotherapy, nursing and social work services under the supervision of volunteer clinicians. It is an initiative of students of the University of Melbourne to improve access to primary health care services, in collaboration with the Faculty of Medicine, Dentistry and Health Sciences at The University of Melbourne (MDHS) and Doutta Galla Community Health Service (DGCHS). It is driven by the voluntary commitment of over 120 students and project partners and is built upon the principles of collaboration, interprofessionalism and client-centered care. The REACH Clinic is the cornerstone of the project, which also provides education, training and community engagement.
Student-led clinics were first developed in the United States, where well-documented problems with access to health care created a need for alternative methods of provision of health care services.  The client's clinical experience at a student-led clinic is similar to that of a student placement, insofar as they are attended to by a student under the supervision of a qualified practitioner; however, the student-led clinic is initiated and directed by students, from the identification of an appropriate facility, development of clinical procedures, and day-to-day operations.  The benefits of a student-led clinic are clear; for the client, increased access to health care services, and for the student, an opportunity to develop clinical skills within a supervised environment.  A student-led clinic also allows students to gain experience in policy development, practice communication and leadership skills, and to develop a professional network within the health care industry.
Student-led clinics have operated in the United States since the late 1960s.  A 2007 study reported that 49 of 94 US medical colleges operated a total of 111 student-led clinics servicing over 10,000 patients per year;  while the Society for Student Run Clinics reports 125 US-based clinics.  Many of these clinics provide medical services only, and those which offer allied health services often do so in a multidisciplinary rather than interdisciplinary paradigm. ,
Australia's health care system is fundamentally different to that of the US, with the Australian Medicare system providing funding toward medical consultations for all Australians.  Despite this, there remain sections of Australian society who have limited access to health care services, including people from low socioeconomic backgrounds, refugees, people who are homeless or newly arrived in Australia.  While community health services and other safety net providers partially fill this need, 22% of Australian adults surveyed reported cost-based access barriers to health care in the previous 12 months, the third highest rate among 11 high-income countries.  In addition, 25% of Australian physicians report affordability being a concern for their patients, second only to the United States.  Public health care funding remains heavily weighted toward medical services, with only five allied health visits funded per year, under stringent guidelines, and only under the auspices of a general practitioner. 
The aim of the trial opening was to confirm the feasibility of our model of care in its clinical application and to identify any issues that may arise during this period. Further, while student-run clinics have been shown to be theoretically feasible in Australia, we hoped to demonstrate this in our pilot.
Development of the Project
In January 2010, funding became available for eight MDHS students to attend a conference in Jacksonville, Florida, USA on student- led clinics. On return, a student committee was formed to explore the feasibility of such a clinic in Australia. The student committee identified a local underserviced community and identified and engaged with DGCHS, a community health centre in this community with values in parallel with REACH and a strong interest in leadership in community health and student education. Negotiations led by the student committee in concert with MDHS established an ongoing relationship with DGCHS, which provided significant and ongoing support for the project. This support took the form of policy and procedure development, risk management insurances, clinical governance, development of training packages to support students in logistical issues, advice on recruitment and credentialing Clinical Supervisors, identifying suitable clients and establishing referral pathways.
A literature review was conducted to develop a model of care that would provide the best outcomes for this community. It was determined that an interprofessional model of care would be most appropriate. Interprofessional education (IPE) occurs when two professions learn with, from and about each other to improve collaboration and quality of care.  The World Health Organization now recognizes IPE and collaborative practice as key to improving health outcomes around the world.  Multidisciplinary care can often be hierarchical, placing medicine above other disciplines; different professions can have differing intervention goals and management plans are not necessarily client-centered. , Interprofessional practice emphasizes respect and collaboration between professions with the client at the centre,  which empowers clients as active partners in their care.  Key to interprofessional practice is shared decision making, where the client plays an active role in directing their care. 
Limited examples of an IPE model exist in an Australian setting. At Curtin University, students currently gain experience in an interprofessional setting within a hospital as a part of their undergraduate training.  An interprofessional student placement has also been developed in a public community rehabilitation centre in association with Monash University. 
The REACH Model of Care
Development of the REACH model of care was a collaborative process between senior students across the four disciplines. The eventual design of the collaborative consultation was based upon the following principles: (1) expanding students' knowledge and understanding of interprofessional practice; ensuring students learn about, from and with each other, as well as from supervisors and clients, (2) considering the client at each stage of our consultation; providing client-centered care at all times, (3) providing holistic care to the client; considering opportunities to improve their health beyond their presenting complaint and (4) ensuring safety for clients and students, including appropriate clinical supervision.
The REACH student committee structure was key to the development and management of our model of care. Students across a number of committees focused on different aspects of the model, with a clearly defined structure facilitating communication between committees. Built into the student committee structure is a formal evaluation process for the model of care, ensuring any identified issues are promptly and efficaciously addressed.
The student committee structure involved 10 individual committees tasked with unique roles. Each of these committees was represented on the student Executive Committee, chaired by the Director of REACH, where project-wide issues were discussed [Figure 1].
The following clinical roles were developed:
- Shift Supervisor - A final year student of any discipline; the most senior role within the clinic. The Shift Supervisor's clinical role is to triage clients and select appropriate disciplines to assess the client. The Shift Supervisor also has a major non-clinical role in ensuring efficient running of the shift
- Student Clinicians - Senior students across the four disciplines, who were judged to have attained adequate clinical experience to safely consult a client under professional supervision. Students generally had to be in their penultimate or final year of study, though specific requirements varied between disciplines. The Student Clinicians carry out the interprofessional consultation
- Client Liaison - Junior students from any discipline. The Client Liaison establishes themself as the client's advocate in the clinic, introduces the client to the model of care, and is present during triage. They accompany the client while the Student Clinicians are discussing management with Clinical Supervisors, and distribute client evaluation forms
- Reception Staff - Junior students from any discipline. The Reception Staff greet the client on arrival and organize client follow-up
- Clinical Supervisors - Experienced clinicians across the four disciplines. The Clinical Supervisors' roles were in ensuring client safety and development of students' clinical skills.
When a client presents to reception, a Client Liaison is assigned to the client. The Client Liaison introduces the client to the REACH model of care. With the Client Liaison present, the Shift Supervisor triages the client and, in consultation with the client, assigns two or more Student Clinicians to assess the client. The chosen Student Clinicians together assess the client and develop a management plan. This plan is discussed with the Clinical Supervisors and the client, and then carried out with the client's consent. Following the consultation, the Client Liaison returns to the room, distributes evaluation forms, and ensures adequate follow up is arranged with the Receptionist.
Client safety is ensured at multiple points by the presence of the Clinical Supervisor. The level of supervision provided is similar to that received by students in their undergraduate clinical placements. The nature of the supervision was dependent on the client management strategies and techniques used by students [Figure 2] and [Figure 3].
Orientation and Opening
Prior to the opening of the clinic, all students attended a 1-day training session orienting them to the core values of REACH. Students were introduced to the principles of interprofessional practice, the roles of each discipline and worked through a number of case studies with reference to interprofessional assessment and management.
The REACH Clinic opened for a 4-week trial period, from 1 to 5 pm each Saturday, in October 2011. During this period, 31 clients attended the clinic; of these, 24 clients saw a medical student, 21 a physiotherapy student, 10 a social work student and 9 a nursing student. Two Shift Supervisors were present for each shift. Ideally, four Student Clinicians of each discipline would be present at each shift; in practice, there were only two to three Social Work and Nursing students at each shift. Three Client Liaisons and two Reception Staff were present for each shift. One Clinical Supervisor per discipline was present. Shift Supervisors and Student Clinicians were rostered fortnightly. Client Liaisons were assigned to clients and were required to attend the clinic when their client was present, and Clinical Supervisors were rostered on a case by case basis.
The total in-clinic time for some clients was over 2 h. Logistical issues such as unfamiliarity with policies and procedures, computer systems and the clinical site were the main contributors to this. By the final week, the total in-clinic time was reduced to a mean of 45 min.
Evaluation data was collected from clients, students, supervisors and other key stakeholders. This data focused on qualitative feedback from clients, learning experiences of students and logistical issues between REACH and DGCHS. No adverse events were recorded over the 4-week period. The feedback received was predominantly positive; however, this data has not been published.
| Discussion|| |
The REACH Clinic pilot opening successfully demonstrated the feasibility of an interprofessional model of care in a primary care, community health setting and the feasibility of such a clinic in Australia. As a result of the pilot, several specific tensions between competing healthcare principles were identified, three of which are discussed below.
Interprofessional Care Versus Client-Centered Care
Within REACH, emphasis is placed on interprofessional practice and client-centered care. While an advantage of an interprofessional model is that it can identify issues overlooked by other models, there will inevitably be some clients who will prefer the input of a single discipline; for example, a client with an upper respiratory tract infection who wants antibiotics, or a client who wants physiotherapy for an acute ankle sprain. To these clients, they had a single issue to be addressed; they did not always see value in discussing their social situation or in having a full health check, in keeping with the interprofessional model of practice. Clients were more familiar and more comfortable with traditional models of practice where they saw a single practitioner.
Some stakeholders have advocated for a two-tiered model of care, with a single discipline approach for those with relatively straightforward presentations, and an interprofessional approach for those with more complex presentations. It may be seen as paternalistic to impose an interprofessional model of care onto a client who wants the input of one discipline only for one specific issue. However, attending to single issues rather than the client as a whole challenges the notion of holistic care that REACH is guided by. There is a risk that students may fall into patterns of screening for a single discipline service and the interprofessional value of the clinic would be lost. There is no clear answer as to how to balance these two competing yet equally valid principles.
Continuity of Care Versus Realities of Student Commitment
In providing high quality health care, REACH endeavors to provide continuity of care for clients. Due to time pressures on senior students, Student Clinicians were rostered every fortnight only, which allowed a full complement of Student Clinicians for most REACH sessions despite heavy academic commitments. However, a client requiring weekly care then rotated between two Student Clinicians of each discipline. This lack of continuity can create inefficiencies among students and perpetuate client disengagement with the health care system.
This issue was addressed, in part, by assigning a Client Liaison to each client, who then arrives for a shift when this client has an appointment. This approach ensures at least one REACH volunteer will be a consistent presence for the client. It was deemed that, as junior students, Client Liaisons would have more flexibility with rostering. The REACH Clinic was linked closely to the existing weekday clinic provided by DGCHS, which serves to keep clients linked into this service system.
The REACH pilot was based on a service model of volunteers, and benefited from a large cohort of motivated students across all disciplines. Participation in the pilot was viewed as a learning opportunity for students to build on skills attained in their undergraduate courses. Students also developed a sense of ownership and responsibility for the project. In the longer term, sustainability of the project will depend on proactive recruitment and training of motivated student volunteers with adequate handover and succession planning through each generation of student leadership.
Learning in a New Model of Practice Versus Reinforcing Established Practices
The vision for the clinic was that of a horizontal hierarchy with equal representation of all disciplines in the clinic and all committees. The REACH pilot, however, attracted more medical students than students of any other discipline. This may be in part due to higher enrolment numbers in medicine than other courses within MDHS, or to other issues such as recruitment practices, timetabling challenges, undergraduate versus graduate students in each course, or actual experience once in the clinic. Some disciplines saw many clients per shift, while students from some disciplines could sit through a shift without seeing a client. Some student groups were confident in their knowledge, while others required encouragement to demonstrate their clinical skills and contribute to management plans in front of other students. All of these factors may reinforce traditional medical hierarchies within REACH.
While more clients received physiotherapy or medical services compared with nursing or social work services, it is not known whether this is an accurate representation of the clients' needs, or a reflection of the Shift Supervisors' ability to select appropriate disciplines for each client. The imbalance in involvement of these disciplines will be exacerbated if Shift Supervisors are prioritizing these disciplines when selecting Student Clinicians.
These issues were addressed at multiple levels. While medical students were disproportionately represented in some committees, the Director of REACH was a nursing student with strong interprofessional values, and all disciplines were represented on the student executive. The Training and Education committee spent significant time on enhancing students' awareness of IPE, and the Membership Services committee organized social events to facilitate interaction between students of different disciplines. Collaboration between students of different disciplines is an ongoing priority of REACH.
| Conclusion|| |
Students of The University of Melbourne have successfully opened a student-led clinic, which has continued to provide free health care to the local community. With an innovative model of care, the clinic is able to provide more holistic care than traditional models. Many important issues have been raised from the pilot opening, and the interplay between competing healthcare ideologies identified. While we believe there is no clear solution to these issues, identifying these conflicts allows future research to explore the interplay of these issues in different clinical contexts. In an environment where many are struggling to realize the practicalities of interprofessional practice, the REACH Clinic is an example of effective implementation of these principles.
| Acknowledgments|| |
The Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne and Doutta Galla Community Health Service for their ongoing support of the REACH Project, and the students of REACH for their commitment and dedication to the project.
The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of REACH, Doutta Galla Community Health Service or The University of Melbourne.
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[Figure 1], [Figure 2], [Figure 3]
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