Development and Evolution of a Model Interprofessional Education Program in Parkinson ’ s disease : A Ten-year Experience

Ruth A. Hagestuen, Elaine V. Cohen, Gladys González-Ramos, Celia Bassich, Denise Beran, Elaine Book, Kathy P. Bradley, Janice L. Briggs, Julie H. Carter, Hillel W. Cohen, Mariann Di Minno, Joan Gardner, Monique Giroux, Sandra Holten, Susan Imke, Ricky Joseph, Denise D. Kornegay, John C. Morgan, Patricia A. Simpson, Concetta M. Tomaino, Richard P. VandenDolder, Maria Walde-Douglas, Rosemary Wichmann


Introduction
There is widespread consensus that healthcare professionals are not adequately prepared to meet challenges in today's healthcare system (Cuff et al., 2014;Institute of Medicine, 2001;National Academies of Science, 2016;World Health Organization, 2010; Interprofessional Education Collaborative (IPEC) Expert Panel, 2011& 2016 Update).A recent global workshop on interprofessional education (IPE) (National Academies of Science, 2016) points to a continuing "chasm" between what health professions students are being taught and a healthcare system that has shifted focus from acute to chronic care, and from single-profession to an integrated, team-based approach (National Academies of Science, 2016;World Health Organization, 2010).The knowledge explosion in healthcare has only deepened this "chasm." Medical information, reported in 2010 to have doubled every 3.5 years, is now projected to double every 73 days by 2020 (National Academies of Science, 2016).Thus, busy practicing clinicians have a dual challenge: staying current with evidence-based best practices in their profession and learning skills to collaborate/coordinate with other professions to address complex chronic illnesses.
Although initially identified in 2001 (Institute of Medicine, 2001), the need for improved professional education in evidence-based, interprofessional (IP) collaborative practice remains important even now (IPEC Expert Panel, 2011& 2016 Update).To keep current, healthcare practitioners are urged to (a) become lifelong learners who "upskill and retrain" (Clark, Draper, & Rogers, 2015) through continuing professional development and (b) attend IPE programs, widely viewed as the best path to becoming "collaborative-practice ready" (National Academies of Science, 2016;World Health Organization, 2010;Breitbach et al., 2013;Graybeal, Long, Scalise-Smith, & Zeibig, 2010; The Association of Schools of Allied Health Professions, 2015;IPEC Expert Panel, 2011& 2016 Update).

Responding to Need: The Start of ATTP
In 2002, the National Parkinson Foundation (NPF) 1 initiated development of a Parkinson's disease (PD)based IPE for practicing healthcare professionals to learn about best practices in collaborative PD care.Key drivers were as follows: (a) Leaders across PD Centers of Excellence identified the need to educate healthcare professionals in the complexities and current best practices in PD care, (b) new NPF leadership embraced the Institute of Medicine (2001) dual national agenda to train the healthcare workforce in IP teamwork and evidence-based, patient-centered care, (c) NPF Centers of Excellence leaders also identified the need to develop IP-PD care teams, including educating communitybased healthcare professionals about collaborative PD care, and (d) NPF leadership received a Health Resources and Services Administration (HRSA) grant to launch Allied Team Training for Parkinson (ATTP).

Literature Review
The focus on IPE is, by now, a global movement with a steady growth of IPE curricula, particularly in academic settings seeking to prepare health professions students to work collaboratively on IP teams (Cox, Cuff, Brandt, Reeves, & Zierler, 2016;Olaisen, Marisca-Hergert, Shaw, Macchiavelli & Marsheck, 2014;Shrader, Kern, Zoller, & Blue, 2013;Grymonpre et al., 2010).In the past few years, the focus has turned to also improving the IP teamwork and collaboration skills of post-licensure practitioners already in the workplace.Robben et al. (2012) demonstrated improved team skills, knowledge of other professions, and collaborative behaviors for primary care practitioners in the Netherlands who were exposed to three brief IPE workshops.Bain, Kennedy, Archibald, LePage, and Thorne (2014) showed that high levels of satisfaction and improved self-assessed IP collaboration competencies were sustained one year after IPE training workshops for arthritis specialty teams in Canada.Sargeant, MacLeod, and Murray (2011) used role play with trained actors to successfully teach practitioners in cancer care how to improve communication skills.Until development of ATTP, there were no known IPE programs in the PD field, de-spite recognition that IP collaboration is the preferred model for effective, integrated PD care.
Despite the wide diversity in IPE programs developed (e.g. in design, duration, mix of professions, clinical settings, etc.), the vast majority have been shown to be effective in improving learner teamwork skills and decision-making, understanding of the role and responsibilities of other professions, confidence, selfefficacy and skills in IP collaboration, job satisfaction, and ability to transfer knowledge and skills to the workplace (Breitbach et al., 2013;Zwarenstein, Goldman, & Reeves, 2009;Cox et al., 2016;Malcolm, Shellman, Elwell, & Rees, 2017;Ward et al., 2016).In some studies, IPE has been associated with improved patient outcomes (Cuff et al., 2014;World Health Organization, 2010;Ekmecki et al., 2015;Lawrence, Bryant, Nobel, Dolansky, & Singh, 2015).Even so, there are repeated calls for more rigorous evaluation methodology, supported by data beyond learner self-report (Institute of Medicine, 2015;Reeves et al., 2010b;Reeves, Perrier, Goldman, Freeth & Zwarenstein, 2013), to establish a robust link between IPE, IP collaboration and "… patient, population and health outcomes" (Cox et al, 2016, p.1).
Projected increases in the prevalence of chronic illness in an aging population (Dall, Gallo, Chakrabarti, West, Semilla, & Storm, 2013) have spurred the movement to build IP teamwork and collaboration skills in the healthcare workforce, largely through IPE.Parkinson's disease (PD) is an example of a complex, chronic, neurodegenerative disease significantly impacting the diagnosed person, caregiver, and family over many years.As the second most prevalent neurodegenerative disease, PD is estimated to affect 1 million in the U.S. and 4-6 million diagnosed worldwide (Hassan et al., 2012), with projections of a 68 percent increase between 2010 and 2030 (Dall et al., 2013).PD affects virtually every aspect of a diagnosed person's life over time.Motor symptoms typically include tremor, slow movements, rigidity, impairment in gait/balance, and impaired activities of daily living.Non-motor problems include anxiety, cognitive impairment/dementia, autonomic disturbance, sleep problems, fatigue, constipation, apathy, and a high prevalence of depression, often associated with decreased social participation (Pfeiffer, 2012;Pfeiffer, 2016;Hassan et al., 2012;Begat, Wu, Pei, Schmidt, & Simuni, 2014).As the disease burden increases, quality of life is significantly affected, both for the person diagnosed and for their caregivers and families (Carter et al., 1998;Van Uem et al., 2016;Peters, Fitzpatrick, Doll, Playford, & Jenkinson, 2011).It is now widely accepted that comprehensive assessment and treatment of PD requires specialized knowledge and involvement of multiple professions working closely together to realize optimal integrated care.

Purpose
The IPE literature has largely focused on outcomes rather than the processes critical to success (Clark et al., 2015).This paper, a companion to the ATTP outcomes article (Cohen et al., 2016), describes key processes in developing, implementing and sustaining NPF's IPE program, ATTP, as well as learner reactions and outcomes not reported elsewhere.It focuses on three program evaluation questions: (a) How was ATTP developed and designed, including evolution and implementation challenges?(b) What were learner reactions to the program?(c) Is ATTP a potentially replicable or adaptable IPE model?

Methods
Our mixed methods evaluation includes Part I, a qualitative case study review of ATTP program development, implementation, and evolution over a ten-year period (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013), and Part II, report of quantitative measures of learner reactions and pre-post outcome measures [adding to previously reported ATTP outcomes (Cohen et al, 2016)].An independent research/ program evaluation consultant observed all training events and faculty planning meetings/calls and collected all survey data.

Ethical Considerations
NPF established an independent IP Institutional Review Board (IRB) that reviewed and approved ATTP evaluation consents/protocols.Curriculum modules for each of 26 training schedules were entered into an Excel database for comparative analysis of module changes.Qualitative text data were analyzed using content and thematic analysis guided by grounded theory (Charmez, 2006).Through review of initial program grants and relevant literature (Oandasan & Reeves, 2005a, 2005b

Specific ATTP Team Training Modules
• Day 1-Understanding Interdisciplinary Care Teams--introduces trainees to the benefits and characteristics of successful IP teams, stages of team building and key concepts for building a successful IP team.3(3):eP1151 | 8 2. Building the Curriculum:

• Day 1-Models of IP
a. Ensuring faculty "buy-in" Joint planning, ensuring faculty "buy-in" and "ownership" of the curriculum, was key.At several in-person meetings, the entire faculty developed the Mission Statement, Program Objectives, and, in Table 2, Team Values and Guiding Principles, given to trainees at the start of training.The latter highlighted an atmosphere of respect toward other professions and broadening of the team to include patient/family care priorities.NPF assumed responsibility for administrative functions (e.g.fund-raising, developing marketing materials, host site recruitment, site logistics, etc.).
Faculty also jointly designed all ATTP plenary curriculum modules (attended by all professions) during the initial six-month grant period (July-December 2002).
Curriculum planning sought to maximize cross-profession interaction.PD case videos and vignettes were created to illustrate greater complexity of management and caregiver challenges in culturally diverse scenarios at progressive PD stages (early, middle and advanced stage PD).Each faculty member individually developed his/her profession-specific module, which was then peer-reviewed by two independent same-profession experts.

b. Team Training:
The ATTP team training combined didactic and interactive approaches.As can be seen in Table 3 (Evolution of ATTP) the IP Team Training component underwent significant change, beginning in 2006.Trainee and faculty feedback suggested the need to hire a dedicated team specialist.A specialist in team training, who was also a social worker, was brought onto the faculty and developed several new modules focused on teaching about the elements of successful teamwork and team-building (see • The patient as an active partner in their own treatment team Individualize care, such that: • Care will center around client -considering their ethnicity, spirituality, family dynamics and patient choice • Care options will reflect client needs within the continuum of disease process • Care will be holistic addressing physical, emotional, cognitive and spiritual life of patient, care partner and support system III.Recognize that a team of allied health professionals is needed to provide quality care to persons with Parkinson's.In order for the team to be successful, there must be cross-disciplinary* awareness of the scope of services within each discipline*.This will allow collaboration and identification of the interventions, at a given point of time, that best addresses the patient/ family's priorities, their physical, cognitive and emotional energy and available health care resources.
IV. Promote hope and dignity in relationship-centered care by: • Fostering an atmosphere of hope and possibility

I. Interdisciplinary to Interprofessional Teamwork and Coordination
• Preferred model for integrated PD* care: IP* team with regularly scheduled team meetings • The IP team remains core to an expanded PD care delivery model across settings and over time, with emphasis on intentional building of IP collaborative relationships throughout the continuum of care, on-site and in the community.

II. Curriculum Enhancements
• Some joint care planning & team exercises (e.g.puzzle-solving) • Live patient demonstrations or case videos for discussion by IP groups

III. Faculty Enhancements
• Team overview module taught by discipline faculty • Team specialist hired to design and teach 4 new team modules (Understanding IP Teamwork, Team Learning, Team Mechanics, Team Troubleshooting) to complement collaborative IP activities throughout the course  to practice on return to the workplace.In this regard, faculty also encouraged "at least one" practice change on return to the workplace.

Focusing on applied and collaborative practice:
Emphasis on IP collaboration in practice was embedded throughout the course.ATTP faculty consisted of experienced clinicians versed in "the priorities of practice" (Clark et al., 2015) and need for ongoing IP communication in PD care.Toward that end, faculty presented material that was based on the latest evidence-based research applicable to collaborative practice.

ATTP Implementation Challenges
Implementation challenges for ATTP included: (a) tensions when profession-specific module time was reduced to increase team training, (b) resource-intensive recruitment to enroll work teams and certain professions (e.g.primary care physicians, physician assistants, nurse-practitioners) being asked to attend a 4½ day program, and site logistics planning, necessitating commitment of local leadership and an assigned "administrative point-person" at the host site, (c) difficulties associated with teaching trainees at widely varying experience levels, (d) variable funding environments from year to year necessitated continued monitoring, and (e) evaluation of a complex and multifaceted IPE program that was evolving over time as program learning occurred, necessitating a "real-world" evaluation approach that relied on the stability of program structure, program objectives and faculty mix over time (Clark et al., 2015;Mackenzie, O'Donnel, Halliday, Sridharan, & Platt, 2010;Bamberger, Rugh, & Mabry, 2012).

Sustainability of ATTP
Funding and commitment are essential to sustainability of an IPE program (Graybeal et al., 2010;Oandasan & Reeves, 2005a, 2005b;Willgerodt et al., 2016).Through HRSA funding, the initial eight trainings were offered without fee.After 2006, NPF sustained the program initially (adding a modest fee) while continually seeking other support.Clearly there is both a need and desire for the training among healthcare providers.Beyond need, the commitment of NPF, the pharmaceutical industry, other sources of support, and of the faculty were essential to continuation of ATTP.

Part II: Quantitative Data Collection and Analysis
Enrollment logs and demographic questions documented the number of participants in each profession, hours of training completed, the number of work teams attending each training event and other trainee characteristics.
Trainees rated the effectiveness of the overall program at the end of each day.5=very effective) for 14 trainings.For ease of interpretation, trainings 15-25 changed to a 6-point rating scale (1=strongly disagree to 6=strongly agree).Curriculum effectiveness was rated at the end of each day on the 5-point 1=very ineffective to 5=very effective rating scale for 14 trainings and changed to the 5-point (1=poor; 2=fair; 3=good, 4=very good; 5=excellent) rating scale for the remaining 12 trainings.Data from each of these scales are analyzed and presented separately.Trainees rated the following in a subset of regions: (a) Self-perceived knowledge change in key curriculum domains, at the end of training and at 6-month follow-up (1=not at all, 2=a little, 3=a good amount, 4=very much, 5=a great deal) (b) Amount of New Information rated daily and for the week on a 5-point scale (1=almost none to 5=almost all) (c) Willingness to recommend ATTP to other healthcare professionals (1=strongly disagree to 5=strongly agree), at the end of training (d) Self-reported on-the-job practice changes at 6 month follow-up (e) Self-perceived confidence in working with people with PD, and with caregivers, on a 10-point scale (1=no confidence to 10=complete confidence) before and after the training, and (e) Self-perceived team skills, before and after the training, on a 5-point scale (1=poor to 5=excellent), using the validated 17-item Team Skills Scale (TSS).The latter measures a team member's self-rating of his/her team functioning, communication, collegiality and cooperation as a team member.Items on knowledge of other professions' contributions to patient care, patient-centeredness in care planning and ability to resolve conflicts are included.Higher scores denote a more positive view of teamwork skills.Prior study yielded a single factor with good reliability (Cronbach alpha at 0.95) and validity (Heinemann & Zeiss, 2002).
Quantitative data were entered into SPSS, version 22, and analyzed using descriptive and nonparametric (Wilcoxon Signed Rank Test) and parametric statistics (paired t-tests).To account for multiple testing, the alpha level was set at p<.01 and only consistent and robust results (rather than isolated, non-meaningful or spurious findings, even if statistically significant) are reported.Conceptually similar curriculum modules were aggregated, with an average score computed for each trainee.An average score was also computed for each trainee for the TSS.For all scores created as an average of items, missing items were excluded from numerator and denominator to assure scaling consistency for all participants.

Training and Participant Characteristics
There were 26 ATTP programs offered from 2003-2013, enrolling 1519 trainees.Those who were in the eligible targeted professions and who completed the program evaluation (n=1395) provided the quantitative data for this paper5 .Trainees were predominantly female (86%) and had six or more years of practice in their profession (69%) (Table 4).Most (93%) reported having team experience and "some" experience working with people with PD (79%).Rehabilitation professions (OT, PT and SLP) constituted the largest trainee group (65%), with the top work settings being outpatient (42%), acute care (29%), and home care (10%).Ninety percent of eligible trainees completed the multi-day program.
Approximately 2/3 of trainees attended with a work team.A total of 246 healthcare work teams (defined as two or more professions from the same institution) enrolled in ATTP; 65% of these included three or more professions.Of the 457 sending institutions, 7% were located in federal-designated rural regions.Fifty sending institutions were NPF-affiliated Centers or Chapters (11%), 34 of which were repeat senders.

Overall Program and Curriculum Module Effectiveness
Overall program effectiveness ratings were very high.
From 95-97% reported effective or very effective ratings on the 5-point scale, and from 98-100% expressed agreement about training effectiveness on the 6-point rating scale, for all training days.
Effectiveness ratings for the curriculum modules (which map to the Curriculum Domains in Figure 1) were very high, with slight improvement for later trainings (using Scale 2: 1=poor to 5=excellent).While 81-89% reported effective ratings for the Learning to Work in Teams modules in earlier trainings (using Scale 1), they were considerably improved in later trainings, ranging from 96-98% (using Scale 2), after hire of the team specialist faculty member.Patient and Caregiver panels, Medical Overview of PD and MT (Music Therapy) on the Team modules were consistently highest rated in effectiveness across trainings, regardless of rating scale used.Nearly all trainees (99.3%) indicated that they would recommend ATTP to other healthcare professionals.All days and week ratings showed a median of 3.0 (IQR: 3.0, 4.0).Figure 2 (week ratings) shows that, except for MD and NP professions, 73% or more of trainees across professions reported at least half of the week's content as new to them, even for rehabilitation professionals (OT, PT, SLP).While MD and NP professions included more experienced PD practitioners, a substantial number (68% and 58% respectively) reported at least half of ATTP content as new.
Figure 2. Proportion of professions rating half or more of ATTP information for the week as new (n=808) 4. Self-perceived Knowledge Change (1=not at all, 2=a little, 3=a good amount, 4=very much, 5=a great deal) Table 5 shows ratings of perceived knowledge increase to be high at the end of training [Med posttest =5.0 (IQR: 4.0, 5.0 and Med posttest =4.0 (IQR: 4.0, 5.0 for IP teamwork and profession-specific PD treatment].Although the 6-month follow-up was significantly lower (p≤0.001), it was nonetheless still high (Med follow-up : 4.0; IQR:4.0,5.0 and 3.0, 5.0 for all, with Health Literacy IQR follow-up : 3.0,4.0).

Discussion
To   Inclusion of patient and caregiver panels conveys that patients and caregivers are important members of the overall team and appears to be a particularly effective teaching and experiential approach in healthcare education.
Our case study also confirms the following four critical factors for IPE success outlined by Clark et al. (2015) and others (Ekmecki et al., 2015;Oandasan & Reeves, 2005a;2005b): Organizational support and leadership were evident at multiple levels.The NPF vision established the foundation for IP collaboration in PD care and long-term commitment to IPE for its Centers of Excellence.Varied funding sources also demonstrated commitment and interest through multi-year funding.Many NPF Centers viewed hosting ATTP as their opportunity to develop a regional PD-informed, IP referral network for ongoing collaboration.Healthcare facilities enrolling workplace teams in ATTP, despite significant travel for some, showed commitments to building or strengthening a culture of integrated, IP-PD care.
Partnerships are considered the "golden thread" (Clark et al., 2015) in continuing professional development.
Joint faculty curriculum planning and respecting faculty and evaluation feedback for program improvements, ensured that the program was "embraced rather than imposed" (Graybeal et al., 2010) and created strong faculty "buy-in" and camaraderie.The close collaboration between NPF and host sites working out logistics was equally important.Many host site leaders became IPE champions, promoting robust team and individual enrollment, and demonstrating a commitment to IP collaboration and coordination in PD care.Institutions sending employees who volunteered supported a worksite expectation for trainees to disseminate their new knowledge to colleagues and/or improve care delivery.The "continuous feedback loop" in the post-training debriefs fostered an "emergent responsiveness" centered on learner needs (Bain et al., 2014;MacDonalad, Archibald, Puddester, & Bajnok, 2011) Positive practice changes are outlined here and in a previous publication (Cohen et al, 2016).ATTP encouraged trainees to define their own needs and areas for practice change, including program or service development, IP collaboration and teamwork or workplace inservice levels.Further research is needed to untangle which of the many ATTP processes were key in promoting practice changes.
The IPE literature encourages accelerated replication of successful IPE programs (Graybeal et al., 2010;Bain et al., 2014;Josiah Macy Jr. Foundation, 2013).It is hoped that, through this detailed description of the development, implementation, and evolution of a disease-spe- Limitations: There may be a self-selection bias since the majority of trainees were volunteers and likely more interested in either PD and/or integrated team-based IP care.Whether or not these findings can be generalized to targeted professions in the larger healthcare community is unknown.Self-report is subject to social desirability bias and learner reactions in IPE programs across the continuum tend to be very positive (Bain et al., 2014;Curran, Sharpe, Flynn, & Button, 2010;Hadjistavropoulos et al., 2010).Like all questionnaire data, these data were self-report and we believe accurately reflect the participants' perceptions.While it is reasonable to expect participants' perceived gains in knowledge would translate into improved practice and clinical outcomes, this study was not able to assess that through direct observational methods.However, confirmatory evidence from multiple ATTP trainee cohorts and data sources and objective measures (Cohen et al., 2016), provide added confidence for these self-report findings.While multiple testing could contribute to Type I errors, our more stringent alpha level of p<.01 was used to address this.Consistency of findings across trainings further reduces the likelihood of Type I errors based on multiple testing.
Strengths: There was a high (96%) participation rate in the program evaluation, including a cross-section of trainee professions, experience levels and work settings.ATTP data were collected in sequential waves, from 26 ATTP trainings, in different geographic regions over a 10-year period, thus lending greater confidence in the findings.There continues to be disagreement about how to effectively evaluate IPE programs.Clark et al. (2015) point out the "considerable conceptual and methodological challenges" (p.389) in IPE evaluation.They conclude that more rigorous methodologies (e.g.randomized controlled trials) are not suitable for studying IPE programs where there are often difficult-tocontrol or undefined variables preventing conclusions about a firm causal link between IPE and collaborative practice change or improved patient outcomes.In this regard, we believe our mixed methods approach contributed to the contextual and process understanding of the program and its evolution, while inclusion of a practice change measure enabled understanding of the differential impact of the program on attendees.

Concluding comments
ATTP is currently the only known IPE program in the PD field.Our evaluation has shown ATTP to be an effective IPE curriculum in PD for trainees from a range of professions, geographic regions, work settings, and experience levels, yielding improved PD knowledge, team skills, confidence in working with PD, and positive practice changes.Its processes are supported by the literature associated with successful IPE programs.These findings, and the successful iterations over ten years, suggest that the ATTP model could be replicated and adapted to other settings and other neurodegenerative and chronic illness areas, although the results of any replications or adaptations should be independently evaluated and assessed.With its positive outcomes, the ATTP model may well represent a next practice (Chandarana, 2017), teaching IP collaborative practice by embedding IP experiences and concepts within a disease-specific topic.

Corresponding Author
Elaine V. -The ATTP faculty member in each respective discipline designed the core content of their respective curriculum area (e.g.profession-specific)… and presented to the entire core faculty for review and discussion of its integration into the entire curriculum.
-Each morning (Days 2-4), the entire allied health faculty taught as a team.Motor, non-motor and caregiver aspects of PD will be taught from a collaborative perspective across professions.
-Trainees moved into profession-specific modules to learn assessment and treatment techniques for their profession.
-The faculty developed 5 videos of persons with PD and their caregivers, including diverse client populations (Hispanic, Asian and African-American) and diversity in stage of disease and challenges posed.Active Learning Methods -Joint faculty teaching; engaged learning strategies; practice in teams; transfer of knowledge through reflective learning -Imparted a knowledge base about teams, teamwork and outreach strategies to the underserved and rural communities.
-The core faculty taught as an interdisciplinary team, thus modeling the very concepts being taught.
-Faculty continued to refine their joint teaching modules, developing specialized interdisciplinary training in psychosocial and mobility issues, and cognitive assessment and treatment.
-…Engaged learning through team-based, problem solving with "live" patient demonstrations/ case vignettes.
-Faculty continued to move the curriculum toward more interactive, interdisciplinary and problem-centered teaching.Toward that end, plenary cross-profession sessions were developed on End of Life, Dealing with Depression and Understanding the Role of Each Profession.
-…Teaching methods were designed to encourage trainee critical reasoning and participation.-Evidence-based tools/ protocols for immediate application in professionspecific practice.
-Bridged gap between education and practice by placing all trainees in teams where they could immediately practice new skills.
-Trainees were assembled into teams for integrated care planning in "team labs"...illustrating the stage of disease being discussed that day (e.g.Early, Middle or Late PD) -Trainees worked in their teams to discuss how to apply the training at their workplace by "doing things differently".Teams shared their ideas with the larger group, encouraging suggestions about how to deal with challenges to teamwork and outreach at their work site.Engaging/ Promoting Networks -Creating partnerships with community healthcare facilities or providers to build capacity for PD-informed community-based network.
-Host site building of regional network of PD-informed providers in community & across care continuum.
-At some training sites, local funders sponsored a reception for trainees to network with each other and with local health providers.
-Over time, local host site teams presented their structure, mix of professions, how they functioned and unique challenges.Some presented how they built their PDinformed regional community network -In a continuous quality improvement environment, the core faculty incorporated trainee suggestions for improvement, although the curriculum overall has rather consistently received high marks from trainees.

Program Evolution
Interdisciplinary** to IP Teamwork and Coordination -Shift from the initial focus on interdisciplinary teams on-site to a broader network of coordinated PD providers across the continuum.
-Initial ATTP trainings focused on interdisciplinary** teamwork as the preferred model of integrated PD care.Although building collaborative relationships in the community was valued, the on-site interdisciplinary team was emphasized.Later trainings taught about network building and IP coordination across the continuum.Curriculum Enhancements -Reframing PD curriculum to Early, Middle and Advanced stages -Increasing team interactive activities and varied case material.
-Adding curriculum modules on role and responsibilities of different professions -ATTP faculty teams re-designed the curriculum to fit into the Early, Middle and Late stage Parkinson's disease format recommended by the curriculum consultant.
-The faculty Team expert finalized curriculum modules on Team Self-Learning, Team Mechanics and Team Troubleshooting.
-With the team expert, faculty jointly developed the Team Lab segment where trainees practiced interdisciplinary care planning in teams, learning about PD, team dynamics and successful team meeting strategies.Faculty Enhancements -Hire of new faculty (movement disorder neurologists, RN's; Care in PD--outlines rationale for IP team care in PD, team member qualities and successful PD team care models • Day 2-Team Learning, Leadership & Values--didactic & interactive approaches convey how teams learn; how to start an IP team, develop effective ground rules, develop consensus and collaborative climates in IP teams; forms of team leadership, unique contributions of other professions.• Day 3-Team Mechanics & Tools--review tools to assist team function, communication styles/ skills (active listening; nonverbal communication), understanding differences in culture and its impact on communication in teams.• Day 4-Team Trouble-shooting & Implementing New Skills--reviews ways to develop effective implementation plans, team benchmarks for success, troubleshoot team problems, proactively recognize conflict and utilize effective team conflict resolution strategies • Days 2,3,4-Modeling of IP Team in PD care -faculty models IP collaboration in integrated care planning at early, middle and late stage PD, illustrating role of each profession • Days 2,3,4-Understanding the Role of each Discipline-through faculty and trainee IP teams, role of each profession is highlighted; Discipline* Mixer module allows each faculty member to engage in Q & A session with trainees about his/her role on IP-PD team • Day 5-Building IP**PD Care Partnerships/Community Networks--presentations by PD Centers that successfully built community partnerships/ networks; emphasizes view of community-based providers as IP team collaborators in offering seamless and integrated PD care across the continuum.• Day 5-Linking Knowledge Back to Workplace--convenes existing work or assigned IP teams (for individual attendees) to collaboratively plan next steps for transferring knowledge to improve IP teamwork on return to work.
Supportive learning environment: ATTP Team Values and Guiding Principles, developed early in the program (2002), set the stage for respectful IP communication, and listening at each training event.They reflect one of the IP Collaboration Core Competencies (Values and Ethics) identified in 2011 by an IPEC Expert Panel.
teams; transfer of knowledge through reflective learning; commitment to change practice.

Table 1 .
Generic Training Schedule for ATTP and Specific ATTP Team Training.All modules are plenary IP sessions except discipline-specific; *Original program terminology reflecting IP collaboration; **IP=Interprofessional; ***PD=Parkinson's disease

Table 1 )
, thus augmenting the team-based experiential component of ATTP.At its very first meeting, the Allied Team Training for Parkinson core faculty developed a list of values and guiding principles that would serve as the underpinning for the training program being developed.What follows represents what we believe to be some of the most critical elements in relationship-centered teamwork and patient care.I. Value an attitude to learning, patient care and community approaches which: • Encourages openness, creativity and adaptability • Builds in continuous feedback and "big picture" reviews to renew and refresh approaches to care delivery • Embraces new learning and development through continuing education and collaboration with others II.Partner with clients in providing care by emphasizing: • Safety in choosing care options on client's own terms and timing • Being a professional care partner who provides the "right information at the right time in the right amount" c. PD Interprofessional EducationWith the exception of the Medical Aspects of PD lectures on Day 1, the ATTP program sought to combine PD and IPE by embedding cross-profession team exercises in care planning using PD case studies, videos and vignettes.PD content focused on the latest evidencebased understanding of symptoms and treatment/ management of PD in early, middle and advanced PD stages, from profession-specific and IP team perspectives.With the exception of adding new evidence/ studies as they became available, the basic PD curriculum content largely remained stable over the course of ATTP.4 Use of the term discipline instead of profession reflects original ATTP program terminology predating changes in terminology in the IPE field.H IP & ISSN 2159-1253 Health & Interprofessional Practice | commons.pacificu.edu/hip3(3):eP1151 | 9

Table 2 .
Team Values and Guiding Principles: ATTP

Table 3 .
Key Features of Program Evolution: ATTP & ISSN 2159-1253 Health & Interprofessional Practice | commons.pacificu.edu/hip3(3):eP1151 | 11 networks: ATTP considered building/strengthening community care partnerships an essential part of IP collaboration.Host PD Centers of Excellence worked with local leaders to enroll area providers in ATTP and to build sustainable PDinformed, IP collaborative networks in that region.Enrollment at each training event extended far beyond the local host site region, an unexpected outcome.Many NPF Centers also sent new hires to future trainings to "jump start" their knowledge of integrated and collaborative PD care.

Prior experience working w/persons w/ Parkin- son's (PD) and/or PD caregivers
ISSNHealth & Interprofessional Practice | commons.pacificu.edu/hip3(3):eP1151 | 13 *Other trainees (trainees not in ATTP-eligible professions-n=73) were only enrolled on a case-by-case basis (e.g. if they were the leader or a member of an enrolled work team).These Other enrollees are excluded from all quantitative analyses.

Table 5 .
Self-perceived Post-training Knowledge Change: ATTP **Reflects original terminology when Team Skills Scale items were developed ***Paired t tests

Table 6 .
Pre-Post Trainee Self-Ratings on the Team Skills Scale (TSS): ATTP IPEC Expert Panel, 2011 & 2016 Update) are embedded and reinforced throughout the course and particularly in the Learning in Teams modules.

Table 7 .
Trainee-Reported Practice Changes at 6-month follow-up ATTP* The Social work core faculty member presented an outline for the cross-cultural component to ATTP faculty… that included "voices from the community" of different cultures regarding healthcare experiences…effects of culture on health beliefs and help-seeking behavior.-Everycorefacultyreviewed the accepted standards on cultural competence within their discipline,…teaching those as well…-Trainees requested more information & examples of how to do community outreach and reach diverse populations not served.Recruitment has proven to be a time-consuming effort, given that it requires personal visits to faculty of five initial ATTP different professions in different Universities in each training region.Additionally, the recruitment of social work students and practitioners proved difficult.The broader vision of social work, which is incorporated in the ATTP curriculum, is not yet widely enough disseminated nor is it yet a reality in many health care facilities.During initial trainings, faculty expressed concern, in debrief calls, about reduced time with own profession trainees, requesting increased profession-specific teaching time.Similarly, in later trainings, reduction in team teaching time, based on trainee feedback and change to a 3½ day program, resulted in concerns about insufficient curriculum time.Loss of HRSA funding for all U.S. training programs was a turning point, solidifying NPF leadership commitment to continued funding of ATTP trainings until other funding sources could be located.-Reduction of pharmaceutical support in later years resulted in re-shaping ATTP into a blended shorter 3½ day program -Plans for several related initiatives (Annual 1-day Update Conference for ATTP graduates; Post-training Team Coaching sessions; Maintenance of database of ATTP graduates for referral) were not completed due to shortage of resources (staff time and funding).The evaluation plan was ambitious but could not be fully implemented due to limited resources e.g.resulting in very small unmatched control group; need to reduce paperwork; *Italics represent actual text.Non-italics represents interpretive comments; Abbreviations: PD=Parkinson's disease; IP=Interprofessional **ATTP documents use original terminology (e.g.interdisciplinary vs. interprofessional) ---Health & Interprofessional Practice | commons.pacificu.edu/hip3(3):eP1151 | 25 --