U.S. Department of Health and Human Services

Interdisciplinary Education and Training of Professionals Caring for Persons with Disabilities: Current Approaches and Implications for a Changing Health Care System

Executive Summary

Christopher DeGraw, Michael Fagan, Marion Parrott and Susan Miller

George Washington Univeristy Medical Center

December 1996

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This report was prepared under contract #182-92-0040 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the George Washington University Medical Centers, Center for Health Policy Research. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Kathleen Bond.

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EXECUTIVE SUMMARY

The Center for Health Policy Research of The George Washington University Medical Center conducted a project to examine innovative and interdisciplinary education and training programs for professionals serving people with disabilities under a contract from the Office of Disability, Aging and Long-Term Care Policy (ODALTCP), Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. The Office of Disability, Aging and Long-Term Care Policy is particularly interested in the development of effective "systems" of care for persons with disabilities across the life span; if such coordinated systems of care are to be achieved, training of providers of services is a key issue from both policy and program implementation perspectives. Providers of services to persons with disabilities must be knowledgeable about the range of service needs of their clients, about the abilities of various disciplines to best provide those services, and with regard to how professionals from an array of disciplines can work together to achieve a coordinated system of care that meets those needs. Such issues may be particularly relevant within the rapidly changing context of a health care environment which places a growing emphasis on managed care and capitated financing mechanisms. People with disabilities of all kinds are increasingly likely to be faced with participation in a managed care system for receipt of at least some of the services they require to lead healthy, independent and productive lives.

The primary purpose of the project was to identify innovative and interdisciplinary education and training programs for professionals caring for persons with disabilities, and through case studies of these programs, describe how students and working professionals are trained regarding the needs of persons with disabilities, and how settings and programs are organized to encourage interdisciplinary and integrated approaches in education and training. The project was to focus on the unique aspects of training in an interdisciplinary environment.

The full report is presented in three sections. Part I is the Summary Report. This part presents the project goals and methodology; a brief overview of the demographics of disability; and trends in service delivery for persons with disability, including managed health care. Concepts and approaches to interdisciplinary education and training are reviewed, as are examples of how these approaches have been integrated into the education and training of professionals to serve persons with disabilities. The findings presented are based upon information gathered through the case studies and literature review. Conclusions are the interpretations of project staff, based on their analysis. Finally, a series of recommendations is offered.

Part II presents nine case studies of education and training programs which take interdisciplinary approaches to preparing professionals to serve persons with disabilities. The case studies present both objective information concerning the structure and implementation of the programs, as well as the subjective observations of those individuals involved in planning, implementing or participating in the programs. Interviews were conducted with professionals from various disciplines involved with each program, students and other trainees, representatives of community-based organizations involved in the training programs, and where possible, individuals with disabilities, parents or other family members linked to the programs.

Part III is a review of the literature as it specifically pertains to interdisciplinary education and training of professionals to serve persons with disabilities.

Study Methodology

The scope of the project included convening a Technical Advisory Group, conducting a literature review, nine case studies (six conducted by site visits; three by telephone interviews) and this final report. The project team consisted of health services researchers from the Center for Health Policy Research and faculty members from the Departments of Health Care Sciences and Neurology of The George Washington University Medical Center.

Parameters to guide the nine site selections and the scope of the literature review were developed in consultation with the Technical Advisory Group. The initial criteria employed required that the sites: 1) be targeted explicitly to persons with disabilities; 2) employ a coordinated interdisciplinary team approach; and 3) include a focus on comprehensive community-based services. Beyond the initial criteria, an attempt was made to include programs from a broad array based on:

• age of the primary target populations to be served by the professionals trained by the program, ie. 1) infants, children and adolescents with disabilities, 2) working age adults with disabilities, and 3) the frail elderly;

• differing types of disabilities represented in the target populations;

• programs that are university-based, community-based, or a combination of the two;

• programs doing preservice training, inservice training, or a combination; and

• programs that could represent a range of potentially relevant training models--formal and less formal, programs adapting more traditional approaches and those taking new approaches.

An attempt was made to include sites that represent an array of approaches, differing target populations, a variety of organizational structures, and potentially interesting and useful perspectives on interdisciplinary training in the changing health care environment.

Broad research questions included the following:

• How is an interdisciplinary approach to professional education and training being implemented to meet the range of service needs of persons with disabilities?

• Are there unique considerations to be taken into account when training professionals to function as members of interdisciplinary teams to provide services to persons with disabilities?

• What has been the experience of the program in training professionals to function effectively to provide services to persons with disabilities in an interdisciplinary manner at the community level?

• How is the training program addressing the delivery of services to persons with disabilities within the growing environment of managed care?

Demographics of Disability

Most Americans will experience disability at some point during their lives, either themselves or within their families. Some 49 million non-institutionalized Americans have disabling conditions that interfere with their life's activities; the other 200 million Americans can expect to experience a disabling condition at some point in their lives. The demographics of disability illustrate this point:

More than nine million people have physical or mental conditions that keep them from being able to work, attend school, or maintain a household;

• more than half of the 4-year increase in life expectancy between 1970 and 1987 is accounted for by time spent with activity limitations;

• disabilities are disproportionately represented among minorities, the elderly, and lower socioeconomic populations;

• of the current 75-year life expectancy, a newborn can be expected to experience an average of 13 years with an activity limitation;

• annual disability-related costs to the nation total more than $170 billion.

Although the percentage of people with a disability increases with age, disability is found throughout the age spectrum. Furthermore, at different ages the nature of the conditions that cause disability varies. For example, for younger adults disability is more likely due to mobility limitations resulting from spinal cord injuries, orthopedic impairments, and paralysis, whereas for older adults, chronic diseases predominate as causes of limitations. A significant trend with implications for service providers and their training needs is the growing number of people with a wide array of significant physical, mental, and cognitive disabilities that are living and participating in the community.

Trends in Service Delivery for Persons with Disabilities

Several notable trends have relevance for the education and training of providers of acute and long-term services. Perhaps the trend with the most far-reaching implications has been the disability rights movement, which, according to a recent report from the National Council on Disability, has made steady progress in the last decade in empowering people with disabilities to achieve the goals of equality of opportunity, full participation, independent living, and economic self-sufficiency. As more and more persons with disabilities of varying severity are integrated into the community, they require health care and related services that are accessible and that support their inclusion. This has been accompanied by increasing advocacy for the "demedicalization" of certain services, especially those required for long-term support.

Dramatically increasing numbers of Americans are receiving medical and health-related services through managed care arrangements which involve some degree of "gate-keeping" or case management, an emphasis on primary care, restrictions on provider choice, and which may or may not be financed in a prepaid, capitated manner. By the end of 1993, more than 44 million people were enrolled in 566 health maintenance organizations and an additional 55 million in preferred provided organizations. More and more, privately-insured persons with chronic illnesses and disabilities, and those who will develop disabling conditions, will be receiving their health care under some sort of managed care arrangement.

The managed care phenomenon is not limited to the privately insured. By 1995, nearly one in four Medicaid beneficiaries--7.8 million persons--were receiving their health care through a managed care arrangement. Currently, some 32 percent of Medicaid beneficiaries are covered under managed care risk contracts.

Persons with developmental disabilities have traditionally received long-term care in institutional settings; recently, however, states have begun to significantly expand their use of Medicaid 1915c home and community-based waivers, enacted by Congress in 1981, to provide alternatives to institutional care for this population. While increasing the number of persons whose long-term care is financed by Medicaid, the waiver program permits states to meet the needs of many persons with developmental disabilities by offering them a broader range of services in less restrictive settings such as group or family home, rather than institutions.

According to a recent report from the General Accounting Office, few states have significant experience with prepaid care for beneficiaries who qualify for Medicaid on the basis of disability. While states can make prepaid managed care plans available for Medicaid beneficiaries who wish to enroll, federal waivers of Medicaid rules are necessary before a state can require such enrollment or restrict individuals to specific plans. Increasingly states--motivated by the fact that Medicaid beneficiaries with disabilities account for only about 15 percent of all Medicaid beneficiaries but over one-third of all Medicaid expenditures--are directing more attention to using managed care for this population.

The Medicare program provides health care coverage for almost all persons over age 65, as well as persons under age 65 who are receiving cash benefits on the basis of disability, or who have end-stage renal disease. In 1996, Medicare Part A hospital insurance will cover an estimated 37.5 million aged and disabled persons. Although still fundamentally a fee-for-service (FFS) system, in 1983 Congress authorized payment to qualified "risk contract" health maintenance organizations (HMOs) to enroll Medicare beneficiaries. Today, approximately 10 percent of Medicare beneficiaries are enrolled in HMOs, and a variety of legislative proposals in Congress aim to expand the managed care options available to Medicare beneficiaries and increase the overall percentage of Medicare beneficiaries in managed care plans.

Interdisciplinary Service Delivery

Interdisciplinary service delivery models have appeared in the social services and health-related literature for several decades, but it is generally conceded that a gap has existed between the conceptualization of interdisciplinary service delivery, as opposed to the multidisciplinary model more prevalent in practice, and its actual implementation. Many authors have offered definitions of interdisciplinary service delivery, which share common elements including: cooperation and collaboration among professionals of different disciplines, coordination, communication, a collective team identity that supersedes individual disciplines, an interactive process, and client-centered goals.

A team approach to assessment and to the delivery of services has been advocated as especially advantageous for providers of care to persons with disabilities. Specific skills that are considered important in making decisions in the context of interdisciplinary practice include identifying and prioritizing problems, information gathering and sharing, generating and evaluating solutions, moving toward consensus, and implementing and evaluating decisions. Additional personal and professional skills desirable in team members include the ability to listen, to trust, to be open, and to communicate clearly and effectively, as well as a willingness to give feedback, to live with uncertainty and ambiguity, to take personal and professional risks, and to share power and expertise.

Interdisciplinary Training

Interdisciplinary team training can be broadly defined as the education and training of an array of professionals from different disciplines in the provision of coordinated services by an integrated team of professionals. A key element of interdisciplinary training is conveying an understanding and appreciation of the unique perspectives, knowledge, skills, values, and purposes of each of the professions represented on the team. A defining characteristic of training is learning how to work interdependently and collaboratively with other members of the team.

The Pew Health Professions Commission has identified some of the advantages of the interdisciplinary approach to training for both students and educators as: giving trainees the opportunity to study multiple health care paradigms; fostering appreciation and understanding of other disciplines; allowing students to model strategies for future practice; promoting and fostering participation by students from each of the disciplines involved; and, by challenging the norms and values of each of the disciplines, making students and educators more aware of their own, as well as those of their colleagues.

Interdisciplinary education and training of professionals to serve people with disabilities is the particular knowledge base, systems and professional disciplines involved. The goal of such training is to develop the trainees' capacity for interdisciplinary collaboration and to form teams around the needs of clients and populations being served. From this standpoint, "interdisciplinary" is a function of content of the curriculum and how the content of the curriculum is delivered; it is not necessarily dependent on whether the learner group itself consists of more than one discipline. Others take a more service-oriented approach, and believe that interdisciplinary education and training should reflect the service delivery model, with interdisciplinary team assessments and collaboration as the sine quo non of interdisciplinary training. Under this approach, training would incorporate multiple disciplines into the structure and content of the training program itself, training a variety of disciplines together.

The provision of early intervention services for infants, toddlers and young children with disabilities or at-risk for disabilities has created a focus on interdisciplinary service delivery and interdisciplinary personnel preparation of professionals serving this age group. The early intervention field has promoted the concepts of family-centered care, family-professional collaboration, and culturally-appropriate care, in some cases leading to the incorporation of family members as participants in the interdisciplinary training of professionals.

The field of medical rehabilitation is the field most closely identified with the care of working age adults with disabilities that are of acute or sudden onset, such as those that are trauma-related, as opposed to more chronic, insidious conditions, for instance, multiple sclerosis. Interdisciplinary care--the "team approach"--has been a key part of the traditional, in-patient medical rehabilitation culture. In 1992, however, the American Congress of Rehabilitation Medicine recognized a lack of formalized training in interdisciplinary team functioning that "is significant in that failure to acquire skills needed to work in an interdisciplinary fashion can affect patient care outcomes negatively and have an adverse impact on the rehabilitation effort." Residents in rehab medicine and other health professionals working in rehab medicine training facilities--nurse specialists, physical therapists, occupational therapists, speech/language pathologists, social workers--are "immersed" in the interdisciplinary service model, which they learn "through an acculturation process" that is very strong.

In the field of mental health, there has been some recognition that serious mental illness and substance abuse are so complicated that they reach beyond the purview of any one discipline. It should be noted though that some current practices in parallel training of professionals in these fields impede taking a collaborative approach to service delivery.

The current aging of the population has drawn increased attention on the care of the frail elderly. A recent review of the state-of-the-art in geriatric medicine points out that the goal of care of the older adult is to prevent or reduce disability. It is also noted that the concept of continuity of care, in which patients are continuously reassessed, is emerging as an important issue in the care of older adults. Another trend has been the provision of assessment and continuing care in the home setting, rather than in the hospital or nursing home. These trends all have implications for the training of providers of services to the elderly with disabilities or at-risk for disabilities. In addition to the frail elderly, the aging of the population of adults with developmental disabilities has created a sub-population of elderly persons with unique functional, social, emotional, and physical needs.

Across professional fields and ages of clients and patients served, it has been noted that one factor hindering interdisciplinary education in academic settings is the lack of qualified faculty, as well as a lack of appropriate role models for students who actually practice interdisciplinary care in clinical training sites.

FINDING

The nine site studies (see Table) detail what programs are doing regarding interdisciplinary training, how they are going about doing it, as well as the perspectives and opinions of those involved regarding issues faced by the programs, specifically, and by interdisciplinary education, generally. The site studies present a rich source of information about interdisciplinary education and training with a disability focus. Similarities, differences, and "lessons learned" can be compared and contrasted among the nine programs along many different dimensions. Several of these are highlighted in this section. The reader is referred to the site studies themselves for more detailed information. Some of these programs are longstanding; others have begun only recently. All are continuing to evolve. Some have their base in an academic institution, where they contrast with the more traditional, and often more established and predominant, unidisciplinary training programs. A number of training programs have grown out of successful service models, and these present unique challenges. Many programs, while concentrating on either the preservice preparation of professionals or outreach to practicing professionals, do both; in either case, there is an increasing recognition that today's training must have a strong community-based component. In most cases, there is a recognition that education and training programs must continually evolve if they are to continue to produce professionals who can successfully meet the needs of persons with disabilities while responding to the challenges of a health care system that is in flux.

The nine programs vary considerably with regard to objectives, scope, target populations of individuals with disabilities to be served by the professionals trained by the programs, and on other parameters; this reflects the lack of consensus to date on any one or several models of interdisciplinary education and training. Interdisciplinary education and training is still in its infancy. Nonetheless, the programs also demonstrate a number of similarities, both in terms of components and structure of the programs and the competencies being conveyed, as well as regarding the issues, facilitating factors, and barriers which the various programs have faced or continue to face.

There is unanimity among the programs concerning the value of interdisciplinary training for professionals serving people with disabilities of different ages, with different types of disabilities, and with differing functional capacities and service requirements. At the core of these interdisciplinary training programs is the realization that providing services to people with chronic illnesses and disabilities, many of whom have complex conditions and functional limitations, cannot be done appropriately by one discipline alone. To help the consumer/client/patient and their family access and utilize an array of necessary services in an efficient and effective manner requires a coordinated effort among several disciplines. It is also emphasized that such a "team" effort does not come naturally, but requires education and training to develop specific knowledge and skills necessary to function as a team.

The nine programs represent a complete spectrum in the degree to which managed health care is addressed by the content of the curriculum or other educational components of each program. At one end of the spectrum is the On Lok program, in which service delivery and training actually take place within a framework that is totally based on a managed care model in which On Lok is fully responsible for the health and social needs of its clients. Staff and trainees learn to appreciate the ability to balance participant care demands for an array of services with the human capital and organizational resources required to meet those needs. But this "full immersion" model is unusual. Other training programs have only begun to address managed care as it affects professionals serving people with disabilities. At the Seattle program, the core seminar series for all trainees covers some managed care issues, and the realities of managed care for individual clients are discussed more and more in case conferences. There is evidence that managed care organizations themselves are beginning to look at the training needs of their own providers related to interdisciplinary team service delivery and even with regards to serving populations of persons with disabilities. The Henry Ford Health System, a large, vertically integrated health care delivery system that provides both primary and specialty care in the Detroit area, has been a leader in this area.

Most of the training programs studied are grappling with the changing delivery systems that have resulted from the growing prevalence of managed and capitated care. Although for a few of these programs the discussion is removed from their related delivery of services, for most the realities of managed care mean preparing professionals to work in an environment where fewer patients are referred for specialized services, and resources are tightly controlled. At one program, managed care has had very different effects on the two "core" clinics where much of the training takes place. One clinic, which serves children with very complex needs, has not seemed to be affected to a great extent; however, another, which does follow-up of high risk infants, has been "devastated." Other programs have been similarly affected; at one program based in a rehabilitation hospital, the penetration of managed care is adversely impacting the patient pool, while many of the patients who do come often have their care very tightly monitored by their managed care plan.

The perceptions of individuals associated with these programs vary. One faculty member believes that "managed care is threatening training"; training more and more has to be measured against some sort of "efficiency stick" that may not take into account the complexity of the clients being served. An associate of another program expressed the uncertainty many feel in the face of managed care. Noting that many of the services needed by people with disabilities or at-risk--social services, early childhood education, nutrition, assistive technology--are not viewed as "health" services by some, and not usually reimbursable, managed care organizations may not feel they should be concerned that their clients receive such services. On the other hand, if managed care evolves into a more "consumer-driven" system, then there may be more opportunities for interdisciplinary service delivery. "More and more, with managed care, the issue is--you get what you need."

Adequate funding is critical to support interdisciplinary education. According to one faculty member, "Just keeping the interdisciplinary process functioning takes an incredible amount of energy and time." The source, scope and duration of funding offers a great deal of insight into a program's capacity to build and sustain an interdisciplinary training program. Funding sources for training have a significant impact on the degree of structure and formality of interdisciplinary training programs. Programs that have dedicated sources of funding tended to have more formalized curricula and program infrastructure. Within programs that had some dedicated, some non-dedicated training funding, the dichotomy was evident.

Some of the programs studied had no dedicated source of revenue to conduct training. These programs relied upon the financial resources provided by their service delivery component. In some instances, the programs were state or county institutions, dependent on public revenues. Others received third party reimbursement including Medicare, Medicaid, and private insurance. In the case of On Lok, the program receives capitated payments for service delivery under Medicare and Medicaid waivers, as well as some private insurance capitated reimbursement.

Some interdisciplinary programs stressed the importance of financial support for trainees. According to one program director, "Stipends can solidify a training program, but the funding is not always available." Without stipends, an interdisciplinary program may have to rely on trainees being carried through their home academic department; in such a case, the interdisciplinary program may lose control of trainees' time for educational experiences, impacting the overall interdisciplinary educational experience.

Most of the programs studied are fundamentally rooted in the notion that exemplary service delivery programs are the base for exemplary education and training. Some programs, like Wisconsin's PACT, began with service delivery as their primary mission, from which the educational component evolved. Others, such as Craig Hospital in Colorado, continue to see their primary mission as service delivery, although a significant amount of training takes place. On Lok, which began in 1973 as the first adult day health center for frail elderly, began providing training to students and professionals in the early 1980s, and its education component continues to expand and evolve. Likewise, although both the service delivery and educational components are new, the Health and Education Collaboration Project in Hawaii was basically added on to the service delivery component of the Healthy and Ready to Learn Center.

CONCLUSIONS

A new generation of service providers is needed who view service delivery as grounded in the interdisciplinary process to promote effective, efficient and quality care while assisting persons with disabilities of all ages and their families to access the services they need to live healthy, productive and fully integrated lives in their communities. Both preservice education of new professionals and inservice education and training will be key to building this workforce.

The primary focus for professional training and service delivery is to meet the clients' needs. There is increasing consensus that, in many cases, this cannot be done effectively and efficiently by one discipline alone. While not every client may require assessment and service delivery by a "team" as such, it is evident that professionals from different disciplines and working in different "systems" will more and more be called upon to work interactively with one another and with the client with a chronic illness or disability and his/her family members and associates.

If education and training is, indeed, the "third leg" of managed care, then, at least as far as it pertains to serving persons with disabilities, managed care could be building on a precarious base.

While many excellent academic and community-based programs are training providers to serve persons with disabilities, it appears that, in many instances, issues specifically pertaining to managed care are being addressed only peripherally by curricula, and opportunities for trainees and students to learn and practice interdisciplinary skills and disability-specific content within a managed care context are limited. It is also quite likely that, to a large extent, managed care organizations have little appreciation for the specific knowledge, attitudes and skills needed by providers to appropriately serve people with disabilities.

RECOMMENDATIONS

The following recommendations are offered to address the needs to expand the scope of interdisciplinary education and training opportunities for professionals serving persons with disabilities, and to ensure that the content of such education and training is relevant to the on-going changes in health care and other systems affecting the delivery of services to persons with disabilities.

Promote linkage

Promote opportunities for continuing dialogue between managed care organizations and their representatives and persons with disabilities, the professionals who serve them, and those educating and training the next generation of service providers or re-training current providers. Such a dialogue will be critical to:

• inform managed care of the service needs of persons with disabilities and the variety of ways in which these service needs can be met;

• inform managed care about the competencies needed by professionals serving persons with disabilities;

• inform persons with disabilities, providers and educators/trainers about managed care and its potential to help meet the service needs of persons with disabilities; and

• promote the establishment of critical linkages between academic/community-based education and training programs and managed care organizations that will result in new and innovative approaches to professional training that incorporate the rich tradition of interdisciplinary training in the disability field with the new realities and potential promise of managed care.

Create incentives

Create incentives, through established mechanisms and programs supporting professional education and training or through new initiatives, to:

• encourage the establishment of linkages between academic/community-based professional education and training programs and managed care organizations to enhance preservice and inservice education and training of providers serving persons with disabilities and to enhance the provision of services to people with disabilities under managed care;

• promote further integration of academic-based education and training programs with community-based organizations and providers to 1) enhance preservice training by increasing opportunities for community-based experiential learning, and 2) enhance inservice, continuing education of professionals already working in the community;

• facilitate linkages between innovative community-initiated education and training programs and academic institutions with a similar mission 1) to enhance preservice training, ensure a stream of preservice trainees for the community-based training programs, and enhance the long-term viability of community-based training programs, and 2) to increase the transfer and incorporation of innovative, community-based approaches to training into academic curricula; and

• foster and facilitate the wider incorporation of interdisciplinary approaches to education and training by institutions of higher education into curricula at all levels --undergraduate, graduate and post-graduate--with a special emphasis on exposing students to interdisciplinary concepts, approaches and experiences early in their educational experience.

Support research

Support research to:

• investigate the causal connections between interdisciplinary professional education and training, interdisciplinary provision of services, access to care, quality of care, and positive outcomes for persons with disabilities. This research should focus on different models of interdisciplinary education and training and different models of interdisciplinary provision of services for persons with disabilities within the context of managed care;

• further the understanding of the pedagogy of interdisciplinary team training and to develop outcomes measurements for interdisciplinary training in order to help determine the effectiveness, and ultimately the efficiency, of such training models; and

• investigate options and incentives for private sector and public sector funding of interdisciplinary professional education, and mechanisms for how funding mechanisms could leverage interdisciplinary training programs. This would contribute to the broader context of policy discussions and options regarding the future course of Graduate Medical Education.

Disseminate information

Partner with appropriate players in the field (institutions of higher education, managed care organizations, community based organizations) to disseminate information regarding:

• interdisciplinary curricula and approaches;

• innovative use of community sites for training by academic-based programs;

• community-initiated and community-based education and training programs;

• linkages between education and training programs based in academic institutions and those based in the community;

• how managed care issues can be infused into curricula and other components of training;

• innovative models of education and training that link managed care organizations, academic institutions, community-based providers, and persons with disabilities and their families; and

• sources of funding to support interdisciplinary training.

It will be important to ensure that information is disseminated across different sectors serving different populations of persons with disabilities and training different disciplines. For example, models and experience gained by educators and practitioners in the fields of geriatrics and gerontology could inform those working in programs serving other age groups, such as rehabilitation or early intervention, and other conditions, such as developmental disabilities or the sequelae of trauma. Building on the case studies presented in this report, it has been suggested that HHS consider the development and dissemination of "how-to" manuals addressing steps to implement interdisciplinary education and training programs based on the experiences of innovative and successful programs. It has also been suggested that there is a need to foster the development of software for training and to foster communication among team members.

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SUMMARY OF SELECTED CHARACTERISTICS OF EDUCATION AND TRAINING PROGRAMS STUDIED
Program	Disciplines Represented by Trainees	Type of Training Offered	Setting(s)	Target Population for Service	Formal Curriculum	Primary Funding Source for Training
Clinical Training Unit, Center on Human Development and Disability, University of Washington	DPeds; Aud; Adm; Ntr; N; OT; PT; LS; SW; Psych	Preservice, Inservice	Academic center and community-based	Children (and adults) with developmental disabilities	Yes	MCHB (LEND Program)
Interdisciplinary Related Services Education Program, Virginia Commonwealth University	N; OT; PT; Psych; SW	Preservice	Academic center and community-based	Infants/young children with disabilities	Yes	OSEP
Health and Education Collaboration Project	Peds; SW; NP; N; OB; ECE	Preservice, Inservice	Community-based	Infants/young children at-risk	Yes	MCHB
Program for Assertive Community Treatment (PACT)	Rehab Psych; SW; N; OT; Human Res	Preservice, Inservice	Community-based	Schizophrenics with substance abuse issues	Partial	State; NIMH
Craig Hospital	PT; OT; SW; PMR; SL; VR; RecT	Preservice, Inservice	Community-oriented	Adults in rehabilitation	Partial	Implicit in payor costs
Community and Academic Partnership to Train Interdisciplinary Health Teams for Underserved Populations	OT; PT; N; DH	Preservice	Academic center and community-based	Homeless persons	Yes	BHPr
On Lok, Inc.	M; N; APN; OT; PT; Ger; SW; Ntr	Preservice, Inservice	Community-based	Frail elderly	Under development	Implicit in capitation
Geriatric Health, Education and Research Center, Rancho Los Amigos Medical Center	PT; M; OT; N; APN; PA; Clin Pharm	Preservice, Inservice	Community-oriented	Frail elderly and aging disabled	Partial	County; NIDRR
Washington DC Area Geriatric Education Center Consortium	SW; N; M; Rehab; MH; Ger; Adm; Ed; Others	Inservice	Academic and community-based	Frail elderly	Yes	BHPr
KEY: DPeds = developmental pediatrics; Peds = pediatrics; OB = obstetrics; PMR = physical medicine and rehabilitation; M = medicine; PT = physical therapy; OT = occupational therapy; N = nursing; NP = nurse practitioner; APN = advanced practice nursing; Ger = gerontology; SW = social work; SL = speech/language pathology; ECE = early childhood education; Ntr = nutrition; Aud = audiology; Psych = psychology; Rehab Psych = rehabilitation psychology; Human Res = human resources; VR = vocational rehabilitation; DH = dental hygiene; PA = physician assistant; Clin Pharm = clinical pharmacology; MH = mental health; RecT = recreational therapy; Adm = adminstration; Ed = education; MCHB = Maternal and Child Health Bureau; OSEP = Office of Special Education Programs; BHPr = Bureau of Health Professions; NIMH = National Institute of Mental Health