Collaborative Care Planning for Residents in Long-term Care Facilities: An Interprofessional Clinical Learning Activity

TTUHSC Interprofessional Practice and Education (IPE) Experience

Title of the Interprofessional Practice and Education Experience

Collaborative Care Planning for Residents in Long-term Care Facilities: An Interprofessional Clinical Learning Activity

Experience Status


Approval Date Range

3/28/2022 - 1/27/2025

Criteria for Registering the IPE Experience

  • Opportunities to learn about, from, and with one another.
  • Significant interactivity between participants.
  • Involvement of two or more professions.
  • Teaching and/or learning about interprofessional practice and education is intentionally integrated into the activity. Interprofessional practice and education constructs are targeted with IPE learning objectives are also discussed, trained, reviewed, and/or assessed as part of the learning activity.

Type of IPE Experience

  • Clinical observation and/or professional interview
  • Case-based and/or problem-based learning
  • Experiential and/or clinical learning

IPEC Core Competencies Targeted by this IPE Experience

  • Communication: Communicate in a responsive, responsible, respectful, and compassionate manner with team members.
  • Roles and Responsibilities: Use the knowledge of one’s own role and team members’ expertise to address individual and population health outcomes.
  • Teams and Teamwork: Apply values and principles of the science of teamwork to adapt one's own role in a variety of team settings.
  • Values and Ethics: Work with team members to maintain a climate of shared values, ethical conduct, and mutual respect.

Quintuple Aim Strategic Goals Discussed in this IPE Experience

  • Improving patient and/or population health outcomes
  • Enhancing the experience of care
  • Advancing health equity

Detailed Description and Purpose of the IPE Experience

Multimorbidity is common in older adults in institutional long-term care and skilled nursing facilities. Older adults with multimorbidity impairments in care facilities are affected by the complexity of more than one chronic disease, are known to have poorer quality of life, an increased risk of functional decline, and increased morbidity. To be able to provide the best and safest care possible, interprofessional collaborative care is critical and necessitates an approach that enables optimal collaboration between health care professionals from various professional disciplines. The purpose of this IPE learning activity is to improve student preparedness for working as part of an interprofessional team in a long-term or skilled nursing care setting.

This IPE will involve students from Medicine, Nursing, Health Professions, and Pharmacy. The activity will begin at the Mildred & Shirley L Garrison Geriatric Education & Care Center in Lubbock and expand to other Lubbock local nursing homes.

Description of the event: Faculty in each of the TTUHSC schools will coordinate an interprofessional team of learners to attend a patient care plan at the LTC faculty. During the care plan conference, learners will observe team collaboration around resident-centered care with Garrison staff (social worker, DON/ADON, dietary manager, Director of Rehab, and Activities Director) and LTC family members. Learners will also be encouraged to ask questions and engage in suggestions for care planning. Following the care plan discussions, the interprofessional team of learners will actively participate in a facilitated debrief with TTUHSC faculty to reflect on teamwork, communication, roles and responsibilities of the healthcare team, and values/ethics in this population.

Aims/Learning Objectives:
1. Integrate the complex care of LTC residents into clinical practice.
2. Reflect on the multiple interprofessional roles required to provide patient-centered care for older adults in the LTC setting.

Level of IPE Integration

  • 1. Foundations Level: Consists of introductory learning activities that provide learners with the opportunity to interact and learn from professionals and peers from disciplines beyond their own. The desired outcome for activities offered at this level is that learners will gain a deeper understanding of their profession while gaining an appreciation for the perspective and roles of other professions.

Attendance or Participation in the IPE Experience

  • Voluntary basis
  • CV credit
  • Certificate of Attendance

Frequency of the IPE Experience

  • 07. Bi-weekly
  • Care plan meetings are weekly. Select students and faculty will attend the Care Plan meetings twice during a month with one debriefing meeting at the HSC.

Duration and/or Timeline of the IPE Experience

  • 02. 1 to 3 hours

Campus and/or Location of the IPE Experience

  • Lubbock
  • Clinical or experiential rotation - Long-term Care and Skilled Nursing Facilities

Average Number of Learners Participating in the IPE Experience

  • 01. up to 50

Target Audiences

Graduate School of Biomedical Sciences Audiences

  • Biomedical Sciences, MS
  • Graduate Medical Sciences, MS
  • Pharmaceutical Sciences, MS

School of Health Professions Audiences

  • Addiction Counseling, MS
  • Audiology, AuD
  • Clinical Mental Health Counseling, MS
  • Healthcare Administration, MS
  • Healthcare Management, BS
  • Occupational Therapy, OTD
  • Occupational Therapy (Post-Professional), OTD-P
  • Physical Therapy, DPT
  • Rehabilitation Science, ScD
  • Physician Assistant Studies, MPAS
  • Rehabilitation Science, PhD
  • Speech, Language, and Hearing Sciences (Second Degree), BS
  • Speech, Language, and Hearing Sciences, BS
  • Speech-Language Pathology, MS

School of Medicine Audiences

  • MS 3
  • MS 4

School of Nursing Audiences

  • RN to BSN
  • Second Degree BSN
  • Traditional BSN
  • Veteran BSN

School of Pharmacy Audiences

  • P3
  • P4

School of Population and Public Health Audiences

  • Public Health, Certificate
  • Public Health, MPH Traditional


IPE Learning Objectives for the Experience

Values and Ethics

  • VE01. Promote the values and interests of persons and populations in health care delivery, One Health, and population health initiatives.
  • VE04. Value diversity, identities, cultures, and differences.
  • VE06. Collaborate with honesty and integrity while striving for health equity and improvements in health outcomes.

Roles and Responsibilities

  • RR05. Practice cultural humility in interprofessional teamwork.
  • RR03. Incorporate complementary expertise to meet health needs including the determinants of health.
  • RR04. Differentiate each team member’s role, scope of practice, and responsibility in promoting health outcomes.


  • C03. Communicate clearly with authenticity and cultural humility, avoiding discipline-specific terminology.
  • C04. Promote common understanding of shared goals.
  • C05. Practice active listening that encourages ideas and opinions of other team members.
  • C07. Examine one’s position, power, role, unique experience, expertise, and culture towards improving communication and managing conflicts.

Teams and Teamwork

  • TT03. Practice team reasoning, problem-solving, and decision-making.
  • TT07. Share team accountability for outcomes.
  • TT06. Reflect on self and team performance to inform and improve team effectiveness.
  • TT04. Use shared leadership practices to support team effectiveness.

Type of Learner Assessment Administered

  • Self-reflection with facilitated debrief

Formal Assessment Protocol used, if Applicable

Type of Program Evaluation Administered

  • Facilitated debrief with planning committee

Provide Details on the Potential Sustainability of the IPE Experience

  • Dedicated personnel
  • Engaged community partners

Provide Dedicated Funding Sources:

  • No dedicated funding

Roles of Faculty/Staff in the IPE Experience:

  • Assessors of student learning
  • Facilitators
  • Instructors and/or preceptors
  • Leadership team members
  • Mentors
  • Planning committee members
  • Faculty are members of the Garrison Coordinating Council

Additional Information About the IPE Experience, if Necessary

IPE Experience Organizer

  • Garrison Coordinating Council

Contact Person(s) and Contact Information for the IPE Experience

Alyce S. Ashcraft PhD, RN, CNE, ANEF
Professor and Associate Dean for Research and Scholarship
TTUHSC School of Nursing

John Culberson MD
Associate Professor
TTUHSC School of Medicine