The VHA Interprofessional Collaboration Competency Framework for Home Healthcare: Development and Implementation Requirements in Ontario,Canada

Abstract

There is a heightened focus on the need for interprofessional collaboration (IPC) to improve person-centered care. The unique challenges of the home healthcare context are not reflected in existing frameworks. The purpose of this work was to develop an interprofessional competency framework for home healthcare and to identify enablers and barriers to implementation. The framework was co-designed with home healthcare clients, providers and leaders through a 5-step process: a rapid literature review, “Design Day,” iterative co-design, shareback meetings, and refinement. Seven competencies were identified around the core value of patient-centered care, supported by 4 guiding principles. The framework was designed to promote individual-, team- and organization-level competency through identifying required elements at each level. Three months after clinical leaders were introduced to the IPCC Framework, 38 participated in workshops in which they provided insights on enablers and barriers to implementation. These were analyzed thematically with reference to the COM-B theory of change model. Major themes reflected capabilities to implement practice changes, opportunities enabling the integration of IPC, barriers to implementing IPC, and motivation to practice interprofessionally. Most identified barriers existed structurally at the team and organizational levels, limiting or disincentivizing interprofessional collaboration. This framework provides an approach that home healthcare organizations can use to guide the advancement of IPC, identifying how competencies may be enacted at the individual, team, and organizational levels within the relatively autonomous and geographically disparate context of home healthcare.

Introduction

Internationally, there is a heightened focus on the need for interprofessional collaborative practice to improve person-centered care. ¹ The World Health Organization defines interprofessional practice as the state in which “. . .multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, caregivers and communities to deliver the highest quality of care across settings.” ² This requires clear, efficient communication and collaboration between healthcare providers of different disciplines as they care for shared clients. ³ Without this collaboration, clients and families must assume responsibility for communicating clinical information with and between healthcare providers ⁴ – placing substantial burden on the client or caregiver, increasing the risk of inaccurate information sharing, and limiting opportunities for clarification and follow-up between healthcare providers. ⁵

Accordingly, there have been considerable efforts in many countries to study the contributing factors that may influence interprofessional collaboration (IPC) between healthcare team members, with theoretical frameworks or models developed in Canada^6,7 and Norway ⁸ based on reviews of the literature, and in Finland, ⁹ New Zealand, ¹⁰ the United Kingdom, ¹¹ and the United States ¹² based on primary data (interviews, group discussions, and observational studies with providers and leaders). These models have addressed factors at the individual through system levels that are required as facilitators of interprofessional practice. While they provide a broad understanding of concepts and relationships, further work is needed to support operationalization and measurement of IPC behaviors in practice. This practical step is advanced through 3 additional frameworks which explicitly identify measurable behaviors associated with specific competencies.^{13 -15} Common competencies identified across all 3 were shared decision making/collaborative leadership, communication, and knowledge of roles and functions; 2 frameworks^13,14 also contain a focus on inclusivity, interprofessional conflict resolution, and continuous quality improvement.

In Canada, as in many international contexts, there is also a growing focus on the potential contributions of home healthcare to broader health systems ¹⁶ – as the setting in which the vast majority of people prefer to receive care and as an opportunity to manage costs and improve access to care.^17,18 In Canada, 6% of the population receives home care and an additional 3% have been identified as needing but not receiving it. ¹⁹ Home healthcare encompasses a broad range of services, including nursing, personal support, and allied health services (e.g., occupational therapy, physiotherapy, social work, speech language therapy and nutrition/dietetics).

In the unique practice context of home healthcare, there are practical considerations for implementing interprofessional collaboration which extend beyond those seen in institutions. In Ontario, Canada, most publicly funded home healthcare is coordinated by a quasi-governmental organization which contracts individual homecare services to provider organizations on a fee-for-service basis. This structure can result in clients receiving home healthcare services from multiple organizations and limits the availability of paid hours to engage in indirect care activities. Even when a home healthcare client receives multiple services from 1 organization, the providers’ varying work schedules and lack of co-location create few opportunities for interprofessional collaboration. This challenge is not unique to the Ontarian or Canadian context; earlier work by Landers et al. ²⁰ identified similar challenges in communication and coordination across providers working within the US Medicare-funded system.

To date, comprehensive IPC frameworks have been developed for the practice contexts of acute and primary care settings, as identified above. However, as previously identified by Ritchie et al. ²¹ in their work to develop a care quality framework for home healthcare, while frameworks from other contexts serve as useful inspiration, there is a need for context-specific adaptation in order to ensure that developed frameworks are appropriate for and usable within a homecare context. Two studies presenting homecare-specific conceptual frameworks related to IPC focus more narrowly on communication ²² and shared decision-making, ²³ providing greater depth related to enabling these competencies in homecare contexts. Additional insights are provided by a qualitative study of home healthcare nurses, which found that collaboration was influenced by outreach and ongoing relationship maintenance, care coordination practices, and congruence between organizational values and nurses’ personal values. ¹²

In addition to the differences in practice context, there are also substantial differences in the composition of the home healthcare workforce as compared to acute and primary care settings. Current IPC frameworks have primarily been informed by engagement with physicians, physician assistants, nurses/nurse practitioners, midwives, or social workers. The inclusion of physical and occupational therapists, which disciplines each support over 30% of homecare clients, ²⁴ has been rarer. To our knowledge, only Légaré et al’s study of interprofessional decision making in homecare has included the insights of personal support workers, ²³ who provide >70% of paid homecare services in Ontario. ²⁴

Given the unique nature of the work context and workforce composition in home healthcare, and the current lack of comprehensive, homecare-focused interprofessional collaborative competency frameworks to support IPC, there is an opportunity to build on existing work by developing such a framework. This could be used to inform home healthcare provider organizations’ work to create the enabling conditions for successful implementation of interprofessional collaboration practices which are widely recognized as improving person-centered care.

Purpose

1. Develop an Interprofessional Collaboration Compe-tency Framework tailored to the unique context of home healthcare, and

2. Identify barriers and enablers for implementation into practice, from the perspective of clinical homecare leaders.

Phase 1: Framework Development

Background: This framework was developed at VHA Home HealthCare, a large provider of in-home nursing, allied health and personal support services in Ontario, Canada, as part of the “One Team Project” - a large organizational quality improvement initiative aimed at improving client and service provider experiences through greater interprofessional collaboration. The One Team Project Team consisted of leaders of clinical operations (4), best practice and education (3), human resources (1), and innovation (1), supported by 2 project managers plus senior sponsors from each Operations and Best Practice.

Development Process: Our participatory co-design process is depicted in Figure 1; detail on each step is provided below. Following a rapid literature review initiated in July 2022 (Step 1), framework development (Steps 2-5) occurred in April-August of 2023 and was led by the “Design Workstream,” a 12-person interprofessional team supported by an organizational design consultant. The team included a project manager and leaders from allied health, nursing, personal support, social support, operations, best practice, and innovation. These diverse leaders represented multiple geographic service regions and led teams that worked under 2 common funding and service delivery models: the traditional fee-for-service and emerging integrated care models. The Design Workstream developed the methods used throughout framework development and recruited interest holders to ensure representation of a broad range of interprofessional perspectives.

Figure 1.

Iterative participatory co-development process.

Step 1: Rapid Literature Review

A rapid literature review ²⁵ was used to identify evidence-based competencies and existing frameworks for supporting interprofessional collaboration. Details regarding the search, screening and data abstraction, conducted in Covidence^®, ²⁶ are available in Appendix A. Key findings (Table 1) highlight competencies of individual healthcare providers, the interprofessional team, and the provider organization that are required to support interprofessional collaborative practice. The majority of evidence-based competencies were reflected within the Canadian Interprofessional Health Collaborative (CIHC) Framework ¹³ and Sunnybrook’s Interprofessional Collaboration Framework. ¹⁴ Findings from this review, including the 2 identified example frameworks, provided an evidence-based foundation for future steps.

Table 1.

Literature-Supported Enablers (✓ and Barriers (✗) to Interprofessional Collaborative Practice at the Individual, Team and Organizational Levels.

Individual	Knowledge	✓ Individual team members’ familiarity/knowledge of standardized protocols for teamwork 27
	Skills	✓ The ability to negotiate and distribute knowledge and skills among interprofessional members based on care needs 11 ✓ Strong individual relationships between healthcare professionals, maintained through formal (e.g., co-learning) or informal means 11 ✓ Individual agency and autonomy for knowing how their own abilities and responsibilities meet care needs in the context of other professional practices. 11
	Behaviors	✓ Willingness to delegate or accept tasks outside of providers’ traditional perceived roles for the benefit of the team or patient28 -30 ✓ Individual team members’ adherence to standardized protocols 27 ✓ Mutual trust and respect for other healthcare providers 31 ✗ Failure to respect agreed upon procedures 32 ✗ Devaluing of professional contributions by another professional decreases trust and respect 11
Team	Structures	✓ Healthcare professionals with overlapping scopes of practice can support integration, collaboration, and cohesion33,34 ✓ Leader/management in-situ who empowers staff to autonomously exercise role negotiation 11 ✗ Professional silos and resistance to allowing other professions to perform activities perceived as belonging to one profession (i.e. gatekeeping) 35 ✗ Power dynamics reinforcing traditional healthcare hierarchies, particularly where these lead to friction and conflict between team members8,31,36 -38
	Processes	✓ Timeliness, responsiveness, and accuracy of information from colleagues8,11,29,38,39 ✓ Knowledge and awareness of other professionals’ tasks, workflows, and roles28,32,40 ✓ Implementation of team huddles, rounds, or joint consultations with clients to promote engagement and shared decision-making 41 ✗ Conflicts between professions resulting from one group claiming “ownership” over patient care and dismissing the contributions of others. 42
	Culture	✓ An explicit shared vision 7 and clear goals10,40,43 set by the team. ✓ Shared values of patient-centered care and engaging patients in informed decision-making.4,44 ✓ Equal recognition of the valuable expertise that each team member offers regardless of their professional background or designation 45 ✗ Unwillingness to be flexible to collaborative solutions6,11
Organizational	Structures	✓ Flexibility for healthcare professionals to modify their practices (i.e. role negotiation) in response to patient care needs. 11 ✓ Physical co-location of team members8,10,29 ✓ Formal adoption of structured tools to standardize facilitation of interprofessional team conferences (supports communication, teamwork, clinical problem solving, respect for the contributions of different professionals) 41 ✓ Integrated patient-record systems accessible by the interprofessional team9,39,46 ✗ Actual and perceived time pressures can limit opportunities for interprofessional communication and collaboration.6,38,39 These can result directly from financial/reimbursement models that do not protect time to engage in interprofessional information sharing and planning8,37 ✗ Team composition within models of care or geographies (i.e. rural settings) may limit access to other disciplines and opportunities for collaboration 6 ✗ Inadequate staffing and/or frequent turnover disrupts the growth of trusting relationships6,32
	Processes	✓ Sufficient time and resource investments toward interprofessional learning opportunities build team members’ collaborative skillset, knowledge of each other’s skills/roles, and professional relationships.47,48 This professional development should occur prior to the introduction of new interprofessional workflows. 8 ✓ Opportunities for synchronous (i.e. face-to-face, telephone/video-calls) and/or asynchronous (i.e. emails, text paging, electronic patient record review) communication39,47
	Culture	✓ A climate of psychological safety for all healthcare professionals 41 ✗ Incongruency between an organization’s stated commitment to interprofessional teamwork and their demonstrated actions that appear to prioritize other values (i.e. fiscal, time, workload constraints) over making resources available. 45

Step 2: “Design Day”

The foundational co-design event was a day-long “Design Day” which engaged 94 stakeholders to seek broad perspectives on core interprofessional collaboration competencies in home healthcare. Contributors included client partners (3); point-of-care providers of personal support (5), nursing (9), allied health (9) and social support services (1); clinical leaders and supervisors directly supporting each discipline (27); senior clinical leaders (8); scheduling coordinators (8); and specialists with expertise in information technology (3), clinical practice and education (4), quality (3), human resources (1), communication (3), innovation (2) and operations (8). Participants were introduced to the project vision to co-design the future of interprofessional home healthcare. As background, they were presented with an evaluation of the organization’s current state, the WHO’s definition of interprofessional care, ² 2 example interprofessional competency frameworks,^13,14 and a summary of literature-based interprofessional care concepts. Smaller (6-8 person) mixed-perspective groups then discussed values, competencies and practices that they believed were most important for interprofessional collaboration. Note-takers at each table recorded the ideas raised during these discussions, with a focus on interprofessional population health-based care, interprofessional competencies, and leadership competencies in interprofessional care. Synthesis of the notes from each group identified 13 priorities: team development, safety and care, collaboration and growth, a person-centered approach, organizational consistency, interdepartmental collaboration, culture shift and standardization, championing team investment, team empowerment, cross-disciplinary communication, service integration & access, skills development, and navigating high-pressure situations.

Step 3: Iterative Development

To create the draft framework, the Design Workstream team held 5 virtual meetings to prioritize and define key competencies based on the literature review, CIHC and Sunnybrook frameworks,^13,14 and Design Day findings. These were used to create an initial map of behaviors, actions and skills that participants identified as necessary for interprofessional collaboration. Design Workstream members used collaborative strategies including group discussion and asynchronous voting and ranking exercises to review, prioritize, rank, redefine, and customize these competencies to address the needs of the Ontario homecare context. The workstream leads (GP, JDS) synthesized the outcomes of these meetings and proposed 2 potential draft frameworks based on the identified priorities. These were discussed, compared to the CIHC and Sunnybrook frameworks, and iteratively refined. Throughout this process, meeting and asynchronous engagement records including minutes, presentations, collaborative documents (e.g., digital collaboration boards, spreadsheets), and iterative framework drafts were used to track team processes, reasoning and decisions. Twice during the development process, progress was reviewed with the One Team Project Team which provided oversight and direction.

Step 4: Shareback of Model

Shareback meetings with leaders throughout the organization were used to ensure resonance and support refinement of the framework language and definitions. Four large group meetings invited feedback from clinical leaders across all disciplines and regions (60); senior leadership of digital solutions, communications, research, finance and legal/privacy (6); and leaders from clinical practice (1), quality (1), and client engagement (1). Two One Team Project representatives also sought feedback directly from point of care through individual meetings with allied health (1), nursing (1) and personal support (1) providers and from 2 client and caregiver partners. Feedback from the shareback sessions provided confirmation that the proposed framework resonated, suggested opportunities to clarify language, and identified a preference to include 4 “guiding principles” in the graphic depicting the framework.

Step 5: Final Refinement

In the sixth and final meeting of the Design Workstream, this team reviewed feedback from shareback meetings, added the guiding principles, and adjusted the wording of the competencies and definitions. Final refinements and clarifications were approved by the leaders and senior sponsors of the One Team Project Team and Design Workstream.

Result: VHA’s Interprofessional Collaboration Competency (IPCC) Framework for Home Healthcare

VHA’s IPCC Framework for Home Healthcare (Figure 2) aims to enhance person-centered care – the core value at the center of the framework. This is supported by a commitment to 4 guiding principles that influence how the framework is applied: (1) creativity and innovation, (2) the quintuple aim, ⁴⁹ (3) diversity, equity and inclusion, and (4) best practice, research and education. The framework is designed to promote individual competency through clearly identifying requisite knowledge, skills and attitudes, and to promote team- and organization-level competency through identifying structures, workflows and culture that support interprofessional practice. The identified competencies for interprofessional collaboration in home healthcare are: (1) team development and empowerment, (2) collaborative decision making, (3) organizational consistency, (4) collaborative leadership, (5) interprofessional communication, (6) interprofessional conflict resolution, and (7) role clarity. These competencies are further defined in Table 2.

Figure 2.

VHA’s Interprofessional Collaboration Competency Framework for home healthcare.

Table 2.

Expressions of Each Competency at the Individual, Team and Organizational Levels.

Competency	Definition	Individualknowledge, skills and behaviors Individuals are able to. . .	Teamprocesses, dynamics and culture Teams are able to. . .	Organizationalresourcing, structures and culture Organizations are able to. . .
Team development & empowerment	Team members develop the capacity for understanding team dynamics, promoting trust and inclusion, and fostering a collaborative environment. Team members are further empowered to advocate for required supports to enable optimal team collaboration.	• Promote respectful and trusting relationships, recognize hierarchies, and challenge power dynamics that may impact effective collaboration • Negotiate and delegate tasks appropriately based on clinical knowledge, timelines for care, and what is best for the client	• Create coaching opportunities and mentorship relationships within teams to refine skills • Promote formal and informal opportunities to build collaborative relationships between colleagues • Leverage debriefing and reflective practice to develop resiliency and cohesion amongst team members	• Create a culture of shared learning by investing in dedicated opportunities with protected time for professionals to develop their collaborative skillset together • Empower all members by shifting culture toward shared, collective accountability and responsibilities to meet client goals
Collaborative decision making	Client-centered decisions are informed by interprofessional team members contributing their profession-specific knowledge and insights in collaboration with the client, taking into consideration client goals and priorities.	• Engage in care planning and decision-making that incorporates client, family, and interprofessional team member perspectives • Discuss differences of opinion openly with the client and care team, and respect mutually agreed decisions.	• Implement processes (e.g., team huddles or joint consultations) with clients to promote transparency and shared decision-making • Generate a climate of trust, inclusivity, openness, and willingness to collaborate	• Cultivate a culture of shared planning & decision-making that incorporates perspectives across professional groups • Establish decision-support processes and organizational tools that measure team performance and collaboration
Organizational consistency	A universal commitment to interprofessional collaborative practice is championed and practiced across all layers of an organization. This common element is woven throughout an organization’s policies, expectations of its employees, standardized operating procedures, and culture.	• Actively role model collaborative practice competencies and seek opportunities to develop colleagues • Feel empowered to use collaboration experiences as the basis to propose enhancements to existing workflows and protocols with a continuous improvement lens	• Champion inclusive, psychologically-safe spaces and explicitly communicate shared team vision, goals, and values for how interprofessional members are expected to collaborate • Encourage, share expectations, and create opportunities for interprofessional learning (i.e. job shadowing, mentoring, attending available education)	• Foster a culture where all professions have equal access to information and opportunities to inform organizational priorities, develop professionally, and participate in decision-making • Create inclusive policies and guidelines which promote opportunities for shared practices • Advocate for funding models that recognize benefits of collaborative care organized around interprofessional teams
Collaborative leadership	Leaders are accountable for creating an environment that fosters teamwork between all members in the circle of care, including clients and caregivers. They acknowledge their strengths and learning gaps, continuously working to improve collaborative leadership skills.	• Self-reflect to identify skills promoting and behaviors inhibiting team engagement and collaboration • Demonstrate a growth mindset, inviting different perspectives • Take responsibility for contributions to decision-making and follow through on commitments	• Actively promote diverse professional perspectives to contribute toward shared goals on client care outcomes • Call-out observed behaviors that are harmful to collaboration such as professional gatekeeping, dismissive comments, or devaluing attitudes	• Support the development of digital tools, communication pathways, or infrastructure (e.g., committees) that enable visible collaborative and interprofessional leadership • Address inherent power dynamics to consider models of care where team members are optimally positioned to foster collaboration
Interprofessional communication	Teams ensure a common understanding, engage in reciprocal knowledge exchange and leverage expertise from diverse perspectives. They prioritize timely and effective communication within and across teams, supported by appropriate processes and tools.	• Communicate with colleagues from all professions in a collaborative, responsive, and responsible manner. Actively seek clarification to develop a common understanding. • Commit to continuous learning of the organization’s digital tools that support communication	• Build proficiency and appetite for synchronous and asynchronous communication between professionals through structured and standardized processes • Commit to promoting timely, responsive, and accurate information exchange (including via client care documentation) when colleagues seek information.	• Set an expectation that interprofessional communication is an essential component of care. • Provide appropriate physical spaces for face-to-face communication. • Provide e-infrastructure to connect the circle of care, enable virtual communication, and support access to shared health records
Interprofessional conflict resolution	The use of positive conflict resolution strategies to address anticipated or developing conflict situations that arise between interprofessional team members.	• Demonstrate an open-minded approach and actively listen to understand others’ perspectives to reach mutual agreement including clients/caregivers • Discuss, mobilize, and escalate issues through appropriate channels when mutually agreed-upon solutions cannot be reached	• Pre-emptively address anticipated or developing conflict situations in a timely manner through a structured approach that promotes psychological safety of all participants • Apply an ethical framework to ensure that conflict resolution does not cause moral distress	• Provide access to training and practical resources on conflict resolution, including opportunities to practice skills. • Establish escalation pathways to ensure conflict management and resolutions are consistently documented. This may include interprofessional advisory councils for inclusive mediation support.
Role clarity	Team members understand their own professional scope/ expertise as well as those of other team members. They acknowledge role interdependencies, with a goal to optimize each member’s scope within integrated models of care.	• Explain their own/colleagues scope of practice and how each contributes to client care and safety • Understand that clients’ and families’ perceptions of different professional roles may impact what information is shared with each	• Regularly seek opportunities to leverage each other’s full scope through ongoing consultation, communication, and review of interdependencies • Promote open discussion for negotiating tasks when there is role overlap between professions	• Ensure that organizational assets such as job descriptions clearly define roles and responsibilities for each profession • Create opportunities for team members to learn and highlight their scope of practice alongside areas of intersection with others

Phase 2: Clinical Leadership Perspectives on Implementation Requirements

To prepare for organization-wide implementation of the IPCC Framework, clinical leaders were provided with comprehensive training and education. To assess practice readiness and identify barriers and enablers of framework implementation, these clinical leaders were surveyed immediately after the training and invited to participate in 3-month follow-up workshops.

Recognizing that adoption of the IPCC Framework would require practice change from all individuals at the organization, the COM-B theory of change model ⁵⁰ was used to map leaders’ insights regarding: perceived Capabilities (C) surrounding individual-level knowledge and skills, and team- and organization-level structures and processes related to the IPCC Framework; Opportunities (O) for enabling interprofessional competencies within the home healthcare context; and Motivation (M) to practice interprofessionally – all of which are required to influence the intended Behavior change (B) of practicing interprofessional collaboration.

Methods

Education: Blended education to introduce the framework comprised a 30-minute eLearning module, pre-reading materials, and two 3-hour training sessions. Training sessions included small group activities to promote reflection on current practices and the identification of strategies for operationalizing each competency.

Data collection: Following training, the clinical leaders completed brief surveys rating the expected ease of incorporating each competency within their teams. Survey questions related to the expected ease of implementing each competency (on a 5-point Likert scale) were adapted from the Collaborative Practice Assessment Tool ⁵¹ and mapped to each competency identified in the VHA IPCC Framework (3-7 questions per competency; 32 questions in total). In 1-hour virtual workshops held 3 months after the initial training, leaders shared their reflections on how elements of the framework aligned with their practice and factors likely to influence framework implementation. Each of the 3 workshops was audio-recorded and transcribed verbatim prior to analysis.

Data analysis: Survey responses were averaged within each competency, across participants. Workshop transcripts were analyzed using the 5 phases of the team-based Rigorous and Accelerated Data Reduction (RADaR) Technique ⁵² and deductive thematic analysis. ⁵³ RADaR is a rapid qualitative analysis technique which organizes and systematically “reduces” the data so that only the most concise and relevant text is available for analysis and timely reporting. ⁵² In the first stage of analysis, 3 researchers (SN, TC, PW) collaboratively reviewed and annotated the all-inclusive data table; a predetermined coding scheme had been developed using the COM-B model and IPCC Framework competencies. The data table then underwent iterative data reduction in which 2 researchers (TC, PW) coded meaningful segments of the raw text to analyze for embedded meaning. Following review by a third researcher (SN), data not relevant to the evaluation was removed to create a new table, moving toward a narrower focus and deeper interpretation of the data. In this evaluation, 2 phases of data reduction occurred. Data were then analyzed thematically to develop themes in accordance with the COM-B model. Consensus around developed themes and subthemes was achieved through collaborative decision-making amongst the full research team. In all stages of analysis, team meetings allowed for researcher reflexivity and facilitated collaborative decision-making.^50,52

Results

Post-training surveys

In post-training surveys (n = 52), clinical leaders from nursing (n = 10), personal support (n = 10), allied health (n = 27) and social support (n = 5) reported that they expected most competencies to be relatively easy to adopt within their teams (Table 3). The greatest challenges were anticipated with respect to interprofessional conflict resolution, interprofessional communication, and organizational consistency.

Table 3.

Clinical Leaders’ Perceptions of the Ease of Adopting Each Competency in Their Teams.

Competency	Perceived ease of adoption (average)Scale: 1 (very difficult) to 5 (very easy)
Team development & empowerment	3.7
Collaborative decision making	3.9
Organizational consistency	3.5
Collaborative leadership	3.7
Interprofessional communication	3.5
Interprofessional conflict resolution	3.3
Role clarity	3.7

Post-training workshops

Three workshops were held with a total of 38 clinical leaders representing nursing (n = 5), personal support (n = 8), allied health (n = 21) and social support (n = 4) services. Clinical leaders across the workshops identified enablers and barriers to framework implementation at the individual, team, and organizational levels (Table 4). Most leaders perceived individual-level strengths in capability and motivation, while discussion of team- and organization-level factors had a greater emphasis on structural barriers or factors which disincentivized interprofessional collaboration.

Table 4.

Summary of Clinical Leaders’ Perceived Enablers (✓) and Barriers (✗) to Applying VHA’s IPCC Framework.

Capability
Individual-level	Team-level	Organization-level
✓ Applying collaborative leadership competency through meetings to share strategies ✓ Confidence in personal skills and knowledge of VHA’s IPCC Framework ✓ Technology-literacy to use EMR as a parallel but key capability required to facilitate interprofessional collaboration ✗ Workload demands impede development and retention of skills	✓ Leaders able to facilitate educational discussions and share learnings among team members ✓ Capacity building through team meetings ✗ Teams not yet aware of IPCC Framework ✗ Team leaders’ workload demands limit time/capacity to share learnings ✗ Limited access to material resources (e.g., training slides) ✗ Collaboration time not perceived to be part of care	✓ Cross-disciplinary support (e.g., professional practice) & resources as helpful in skill-building across teams ✗ Concurrent organizational changes compete with efforts to socialize framework and skill-build around interprofessional practice
Motivation
Individual-level	Team-level	Organization-level
✓ Strong intrinsic desire and excitement toward further learning about & integrating VHA’s IPCC Framework into practice ✓ Benefits of interprofessional communication with colleagues ✓ Intrinsic desire to be a collaborative team member ✗ Belief that interprofessional care is an “add-on” rather than a core part of work	✓ Intention to shift culture toward interprofessional practice as routine & expected ✓ Setting team-based reminders about integrating interprofessional collaborative practices ✗ Limited engagement in IPCC discussion from team members during team meetings	✓ Culture shift toward more integrated care and ways of working in the home healthcare sector ✓ Co-design & bottom-up approach supports implementing & scaling IPCC Framework across organization ✗ Home healthcare’s funding model and contracted provider framework limits incentives ✗ Workload demands limit prioritization of IPCC
Opportunity
Individual-level	Team-level	Organization-level
✓ New framework aligns with many existing practices ✓ In-person/face-to-face encounters ✓ Professional responsibilities/scope has role clarity built-in ✓ Some are already using visit time to integrate interprofessional communication ✗ Challenge of balancing clinical tasks and interprofessional contact within a single visit ✗ Workload management detracts focus from IPC	✓ Joint visits facilitate integration of IPCC into practice ✓ Team meetings a venue for interprofessional communication ✓ Participating in cross-professional team meetings ✗ Regional teams’ interactions limited to locally-available professional groups ✗ Care plans not harmonized across professions ✗ Challenge for leaders in dual roles (clinician & leader) to protect time to facilitate interprofessional collaboration	✓ EHR chat feature facilitates communication for some providers ✓ Inclusion of scheduling coordinators in collaborative-decision making ✗ Ontario’s home healthcare system aligned with practicing autonomously ✗ Culture driven by fee-for-service funding-model ✗ Some disciplines use different EHRs ✗ Inconsistency in team structures, standards, guidelines across professional groups ✗ External organizations have different standards and practices ✗ Concurrent organizational changes impeding ability to focus on new practice change

Note, A ✓ indicates an enabling condition, and an “X” indicates a perceived barrier.

Theme 1: Capability to Implement Practice Change

Most leaders reflected on their experiences implementing strategies from the framework to build capacity within their point-of-care teams. They shared how their teams applied competencies such as collaborative leadership, interprofessional communication, and role clarity through interprofessional team meetings at the team and leadership levels. In those meetings, team members shared personal learnings and healthcare providers from different professional teams were invited to speak about their roles:

We come together as leaders on that [geographic] team and share ideas and supports and learn from each other about ways to support our teams and collaborate and it’s actually been really helpful. (Allied health leader)

Some allied health leaders shared how their teams were adjusting their workflows to leverage features within the electronic health record (EHR) platform that facilitated interprofessional communication:

[In my team,] we were able to focus on some of the strategies on interprofessional communication wherein we could use the [EHR] chat function to communicate with other members. So that was received very well by the team. (Allied health leader)

Some leaders whose teams had struggled to make progress on implementation shared a need for practice-based learning resources (e.g., presentation slides, booklets) to support socialization of the framework and encourage interprofessional practice. Similarly, others suggested client-facing resources to clarify provider roles:

I know one of the things that we’re talking about is the [client-facing web interface]. . . possibly [we could include] a blurb about our roles for clients and families because I think that’s also helpful. (Personal support leader)

Additionally, some leaders shared that they had not yet worked with their teams on implementing the IPCC Framework due to competing demands related to other ongoing organizational changes.

Theme 2: Opportunities Enabling Integration of IPC

Many leaders shared environmental factors which enhanced their ability to facilitate IPCC Framework implementation. Several competencies, such as role clarity and interprofessional communication, were viewed as more innate and built into clinical care, providing natural opportunities to engage. In these cases, the framework validated approaches to interprofessional practice such as conducting client visits jointly with other care team members, including scheduling coordinators in collaborative decision-making, and participating in cross-professional team meetings:

We’ve always worked in collaboration with our other multi-disciplinary teams, but now that it’s official and you know that it’s recommended, . . . It wouldn’t be viewed as a waste of time because all of us are working for the same client who’s in the center of all. (Allied health leader)

Allied health leaders specifically highlighted the organization’s digital communication platforms, including the EHR’s chat feature, as valuable in-workflow tools for interprofessional communication.

Theme 3: Barriers to Implementing IPC

Various elements of the organization of home healthcare work, team workloads, and the time required to change practices were identified as barriers to creating a work culture that prioritizes interprofessional collaborative practice. The majority of leaders expressed that these barriers were often driven by the conditions of the dominant home healthcare sector fee-for-service funding model, which generally encourages a narrower task focus within time-limited visits. This model was perceived to exacerbate the siloing of care delivery and disincentivize interprofessional collaboration. Several leaders shared the perception that the opportunities for point-of-care healthcare providers to practice interprofessional communication were not built into the timing of clinical encounters; instead, providers felt that they needed to cut care visits short or contribute unpaid time after client visits to practice interprofessional collaboration:

I’m still really challenged with this area because ultimately the system is not there to support this interprofessional collaboration . . . For me to communicate with the nurse that’s involved . . . I don’t even know who the nurse is. . . there’s certainly no remuneration associated with that extra work. (Allied health leader)

Additionally, organizational consistency to enable collaborative decision-making was noted by most participants to be lacking between professional groups; specifically, difficulty identifying all care team members, a lack of harmonized care plans in a centralized EHR, and inconsistent scheduling practices across discipline-specific teams were identified as limitations of the existing team and organizational structures.

I feel like we are missing that opportunity for the nurse and the occupational therapist to reach out to each other instead of going through a supervisor. [Who is assigned to a client] is available in [the nursing EMR], but our [allied health] providers don’t have access to it . . . there needs to be a mechanism for more direct communication with [all] service providers. (Nursing leader)

Lastly, several leaders shared their difficulties collaborating interprofessionally with members of the client’s care team from external provider organizations – a challenge which stemmed from differing processes, standards, and scopes of practice across organizations:

It’s very hard to navigate across multiple organizations and [the funder] has a different process than care coordinators and it’s just hugely difficult (Allied health leader)

Theme 4: Motivation to Practice Interprofessionally

All leaders were intrinsically motivated to practice interprofessional collaboration and believed that their teams shared this motivation. Some leaders shared optimism that the IPCC Framework could contribute to sector reform in ways that would minimize siloed work, while others shared their strong desire to see IPCC Framework competencies embedded into day-to-day practice:

Giving [interprofessional practice] more visibility so that the nurses know this is an option and the direction we’re going as an organization. And not to feel like this is extra work because this is what you would be expected to be doing. This is not just a ‘by the way’ but actively seeking those opportunities for collaboration. (Nursing Leader)

However, previously discussed challenges relating to capability and opportunity also affected team- and organization-level motivation. Most participants discussed how perceptions of current workplace processes, priorities and compensation models disincentivized implementation of the IPCC Framework at an individual level.

The culture hasn’t changed, it’s still very much driven by the funding model . . . Client care is really important and it’s the bulk of our work . . . I can see a client or three clients, compared to me sitting in the whole day of a workshop. (Allied health Leader)

Discussion

This paper presented the development of VHA’s Interprofessional Collaboration Competency Framework for Home Healthcare. Inspired by the Sunnybrook framework ¹⁴ and the Canadian Interprofessional Health Collaborative Competency Framework, ¹³ VHA’s IPCC Framework incorporates insights from home healthcare clients and providers. It identifies 7 competencies required at the individual, team and organizational levels to support interprofessional collaborative practice. In addition to previously identified competencies, the framework contains an emphasis on organizational consistency, which must be fostered very deliberately in this relatively autonomous and geographically disparate context (c.f., Chow et al ⁶ ). To this end, VHA’s IPCC Framework emphasizes the structural advantage of organizing work such that teams include point-of-care providers across disciplines rather than reinforcing professional silos, as has also been proposed for hospital-based care. ⁵⁴

In considering IPCC Framework implementation, clinical leaders identified existing strengths, practices that could readily be integrated into team workflows, and anticipated barriers. Leaders perceived an intrinsic desire from point-of-care providers to be collaborative practitioners, reflecting a broader shift away from task-focused approaches toward team-based, holistic care. ⁴ They also shared some existing structures and practices, such as cross-disciplinary supports and EHR chat features, which facilitate the application of IPCC Framework competencies. Identified barriers largely centered on team and organizational structures which would need to change in order to align workflows and fully implement the IPCC Framework. Leaders also identified elements of broader health system structures that impact how completely the framework can be implemented.

Existing strengths of individual providers aligned with many identified competencies – particularly interprofessional communication, role clarity, and collaborative leadership. Individual-level barriers were identified related to high workloads, limited time with clients, and challenges balancing time for direct clinical care with interprofessional communication. These were exacerbated by a commonly held perception that interprofessional activities, while important, are not a core part of a client visit. This barrier was attributed to the contracted fee-for-service model which dominates home healthcare provision in Ontario; however, this prioritization challenge exists across healthcare settings (c.f., Allen et al ⁴⁶ ). Within the fee-for-service model, there is a potential to support a shift in perception by ensuring that all parties – including clients and families – understand that interprofessional communication is part of the services expected within a client visit. Such a shift must be supported by organization- and health system-level recognition that allows appropriate time and resources for clinical collaboration.^6,8 Concurrently, the broader adoption of interprofessional communication tools embedded within providers’ workflows (e.g., within the EHR) is a common recommended enabler of interprofessional collaboration ³⁹ that may reduce the time required for effective communication.

Paid team meetings were understood to be important professional development and learning opportunities. Participants highlighted that more such opportunities were needed. For client cases requiring more extensive interprofessional communication, interprofessional joint visits have been highlighted in the present work and by Kushner and Strasser ⁴¹ as important for enabling shared decision-making; similarly, case-focused interprofessional huddles or rounds have been identified as useful opportunities to support collaboration. ⁴¹ Creating and engaging in these interprofessional opportunities requires time and coordination from healthcare providers, emphasizing a need to ensure that organizational expectations recognize and account for this time.^6,8

At the organizational level, leaders identified some progress toward socializing IPCC Framework concepts, while highlighting a need for structural change. A particularly high priority, reinforced by the literature, was the availability of an integrated patient record/EHR system accessible by all members of the interprofessional team.^9,39,46 A shared EHR would also provide a platform for the creation of care plans that could be harmonized across professions, enhance the utility of in-workflow tools for interprofessional communication, and enable transparency regarding all healthcare providers’ scheduled visits to each client.

While these organizational measures would address many barriers to interprofessional collaboration within a service provider organization, the current reality that a client may receive home healthcare from many organizations may limit their impact. If care integration at the broader system level could be designed in a way that is sensitive to required organization-level IPCC Framework competencies, this could help to bridge current challenges and create shared expectations for communication and collaboration. ³

Strengths and Limitations

VHA’s home healthcare-specific IPCC Framework is grounded both in the academic evidence base and in extensive consultations with home healthcare clients, care providers, and leaders. The rapid review which informed the model development was limited to articles published in English since 2015 found within the Ovid MEDLINE database and would not have captured earlier literature or works not indexed in MEDLINE. All parties involved in the framework’s development were from a single large provider organization which provides service within southern Ontario, Canada. Developers reflected the organization’s experience in delivering care under both traditional fee-for-service and diverse integrated models of care. Allied health and nursing leaders were most vocal in sharing their perspectives on enablers and barriers to implementation; further work to elicit the perspectives of personal support and social care leaders may help to identify additional existing strengths and opportunities specific to those groups. Similarly, increased engagement with point-of-care providers could uncover further practical insight into enablers and barriers that may affect implementation. Broad consultation within the originating organization has supported the framework’s face validity in this context; perspectives from outside the organization are necessary to validate its potential generalizability. Work to date has been largely conceptual; rigorous evaluation of future implementations will support further understanding of its utility.

Current Status of the Framework

Since the creation of VHA’s IPCC Framework in 2023, the organization has made a deliberate effort to implement the Framework, build capacity, and embed the 7 competencies in its culture and operations. Pilot projects to create an enabling context and culture for interprofessional collaborative practice at the team and organization levels are being designed, implemented and evaluated. Examples include an integrated interprofessional care model, interprofessional rounds, shared scheduling and a digital coordinated care plan. Plans for scale and sustainability are under development.

Implications for Homecare Policy and Practice

The importance of enabling IPC is being emphasized across many health systems, including in Ontario, Canada where this framework was developed.^1,2,55 VHA’s IPCC Framework provides a blueprint for home healthcare organizations to follow in pursuit of enabling interprofessional collaborative practice. It identifies and describes competencies to present a target for updating collaboration approaches within organizations. Current interest in reforming homecare and moving toward more integrated care models presents an opportune time to test the changes required to implement the framework as a strategy for enhancing IPC.

Conclusion

As a home healthcare-specific product, VHA’s IPCC framework provides an approach that home healthcare organizations can use to guide the advancement of interprofessional collaborative practice. As the first home healthcare-specific interprofessional collaboration framework, it contributes insights on how competencies may be enacted at the individual, team, and organizational level within the relatively autonomous and geographically disparate context of home healthcare delivery. This framework provides guidance on how interprofessional care can be advanced within an organization while highlighting opportunities to address system-level barriers in the creation of new models of integrated care.