Interprofessional Collaboration on Behalf
of Older Persons With Compromised
Decisional Capacity: Developing and
Implementing Core Professional
Competencies
Marshall B. Kapp, JD, MPH
Florida State University
Tallahassee, FL
marshall.kapp@med.fsu.edu
Introduction
 Issues arise about cognitive and
emotional decision making capacity of
older persons in many contexts.
 Balance between autonomy and
protecting against risk of harm requires
accurate capacity assessments.
 Interprofessional (medicine & law)
collaboration often is desirable.
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“Capacity determination is a
complex, cross-disciplinary process
that ideally involves a range of
professionals. It requires knowledge
of medicine, ethics, and the law.”
– (Skelton, Kunik, Regev, & Naik, 2010)
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Agenda
Strategies for developing core
educational competencies
Public policy as facilitator of such
development
Public policy addressing
impediments to implementation of
core competencies
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Compromised Decisional Capacity
Lots of decisions
Presumption of autonomous decision
making
Problem of decisional incapacity
– Affects individual, plus those who have
or are contemplating personal or
professional relationships with the
individual
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Capacity is decision-specific
Capacity depends upon ability to:
– Make and communicate a choice
– Give reasons for the choice
– Factually understand the alternatives
– Appreciate the personal consequences
of the choice
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Need for Professional Involvement in
Capacity Assessment
 Attorneys (ABA Model Rule of Professional
Conduct 1.14) and physicians
independently
 Attorneys and physicians collaboratively
 Poor educational preparation for this
task*
But see Amer. Bar Assn. & Amer. Psychological Assn.,
Assessment of Older Adults with Diminished Capacity: A
Handbook for Lawyers (2005) and British Medical Association
and Law Society, Assessment of Mental Capacity: A Practical
Guide for Doctors and Lawyers, 3rd ed. (2010).
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Delineating Professional Competencies
Competency-based professional
education
– Outcome/skills oriented, not focused on
process inputs or recitation of information
– Premise: Teaching can improve performance
– Assessing decisional capacity is a core
competency that attorneys and physicians
should be able to demonstrate
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Delineating specific competencies
– Build on General Competencies of
Accreditation Council for Graduate
Medical Education (ACGME)
Interpersonal and Communication Skills
– “…work effectively as a member or leader of a
health care team or other professional group.”
Professionalism
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– Build on Interprofessional Education
Collaborative (IPEC) (organizations of health
education institutions), Core Competencies for
Interprofessional Collaboration Practice
(2011). Did not address working with
attorneys.
Core competencies:
– Values/ethics
– Roles/responsibilities
– Communication
– Teams and teamwork
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Roles of Public Policy
 Encouraging and Facilitating the Development
and Implementation of Core Competencies
– Government grants (e.g., NIA, HRSA, AoA) to
support educational innovations, at least
demonstrations, leveraged with private
foundation support
– Medicare payment to physicians for
interprofessional capacity assessments under
Part B, factor cost of this service into payment
rate offered by CMS to Medicare Advantage
plans
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 Integrate expectation of interprofessional
capacity assessments into legal standard of care
for physicians through Clinical Practice
Guidelines (whose development and
dissemination is supported through grants from
the Agency for Healthcare Research and Quality
[AHRC]). Integrate expectation of
interprofessional capacity assessments into legal
standard of care for attorneys through changes
in ABA Model Rules of Professional
Responsibility.
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– Government or private grants (e.g., HRSA) to
support and encourage certain medical
specialty boards to incorporate demonstration
of relevant core competencies into specialty
certification examinations.
– Government or private grants to support and
encourage organizational and state Bar legal
specialty designation boards to incorporate
demonstration of relevant core competencies
into specialty certification processes.
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 Removing or Mitigating Barriers to
Implementation of the Core Competencies
– Clarify/modify Health Insurance Portability and
Accountability Act (HIPAA) to facilitate information
exchange and interprofessional communication
involving medical information
– Clarify/modify ABA Model Rules of Professional
Responsibility to facilitate information exchange and
interprofessional communication involving information
known by the attorney
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Discussion?
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