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Background As the population is aging, the number of persons living with multiple chronic conditions (MCC) is expected to increase. This review seeks to answer two research questions from the perspectives of older adults with MCC, their caregivers and their health care providers (HCPs): 1) What are the health and social care needs of community-dwelling older adults with MCC and their caregivers? and 2) How do social and structural determinants of health impact these health and social care needs? Methods We conducted a scoping review guided by a refinement of the Arksey & O’Malley framework. Articles were included if participants were 55 years or older and have at least two chronic conditions. We searched 7 electronic databases. The data were summarized using thematic analysis. Results Thirty-six studies were included in this review: 28 studies included participants with MCC; 12 studies included HCPs; 5 studies included caregivers. The quality of the studies ranged from moderate to good. Five main areas of needs were identified: need for information; coordination of services and supports; preventive, maintenance and restorative strategies; training for older adults, caregivers and HCPs to help manage the older adults’ complex conditions; and the need for person-centred approaches. Structural and social determinants of health such as socioeconomic status, education and access influenced the needs of older adults with MCC. Conclusion The review highlights that most of the needs of older adults with MCC focus on lack of access to information and coordination of care. The main structural and social determinants that influenced older adults’ needs were their level of education/health literacy and their socioeconomic status.

Background Approximately one-third of all adults worldwide are diagnosed with multiple chronic conditions (MCCs). The literature has identified several challenges facing providers and patients coping with managing MCCs in the community, yet few studies have considered their viewpoints in combination. A qualitative study involving healthcare providers and users was thus conducted to examine facilitators and barriers of managing patients with MCCs in the community in Singapore. Methods This study involves 26 semi-structured interviews with 10 physicians, 2 caregivers and 14 patients seeking treatment in the polyclinics that provide subsidised primary care services. Topic guides were developed with reference to the literature review, Chronic Care Model (CCM) and framework for patient-centred access to healthcare. Results Despite the perceived affordability and availability of the support system, some patients still encountered financial difficulties in managing care. These include inadequacy of the nation-wide medical savings scheme to cover outpatient treatment and medications. Half of healthcare users did not know where to seek help. While patients could access comprehensive services in polyclinics, those who did not visit the clinics might not receive timely care. Furthermore, patients reported long consultation waiting time. Physicians were able to propose and drive quality improvement projects to improve care quality. However, there were challenges to delivering safe and quality care with limited consultation duration due to the need to manage high patient load and waiting time, inadequate communication with specialists to coordinate care, and resource constraints in managing complex patients. Although providers could equip patients with self-management and lifestyle-related guidelines, patients’ actions are influenced by multiple factors, including work requirements, beliefs and environment. Conclusions There were barriers on care access, delivery and self-management. It is crucial to adopt a whole-of-society approach involving individuals, community, institutions and policymakers to improve and support MCC management. This study has also highlighted the importance of considering the different viewpoints of healthcare providers and users in policy formulation and community care planning.

Objectives. To determine whether a community health worker (CHW) intervention improved outcomes in a low-income population with multiple chronic conditions. Methods. We conducted a single-blind, randomized clinical trial in Philadelphia, Pennsylvania (2013–2014). Participants (n = 302) were high-poverty neighborhood residents, uninsured or publicly insured, and diagnosed with 2 or more chronic diseases (diabetes, obesity, tobacco dependence, hypertension). All patients set a disease-management goal. Patients randomly assigned to CHWs also received 6 months of support tailored to their goals and preferences. Results. Support from CHWs (vs goal-setting alone) led to improvements in several chronic diseases (changes in glycosylated hemoglobin: −0.4 vs 0.0; body mass index: −0.3 vs −0.1; cigarettes per day: −5.5 vs −1.3; systolic blood pressure: −1.8 vs −11.2; overall P = .08), self-rated mental health (12-item Short Form survey; 2.3 vs −0.2; P = .008), and quality of care (Consumer Assessment of Healthcare Providers and Systems; 62.9% vs 38%; P < .001), while reducing hospitalization at 1 year by 28% (P = .11). There were no differences in patient activation or self-rated physical health. Conclusions. A standardized CHW intervention improved chronic disease control, mental health, quality of care, and hospitalizations and could be a useful population health management tool for health care systems. Trial Registration. clinicaltrials.gov identifier: NCT01900470.

Multimorbidity or multiple long-term conditions (MLTCs), the coexistence of two or more chronic conditions within an individual, presents a growing concern for healthcare systems and individuals' well-being. However, we know little about the experiences of those living with MLTCs in low- and middle-income countries (LMICs) such as India. We explore how people living with MLTCs describe their illness, their engagements with healthcare services, and challenges they face within primary care settings in Kerala, India. We designed a qualitative descriptive study and conducted in-depth, semi-structured interviews with 31 people (16 males and 15 females) from family health centres (FHCs) in Kerala. Interview data were recorded, transcribed, and thematic analysis using the Framework Method was undertaken. Two main themes and three sub-themes each were identified; (1) Illness impacts on life (a)physical issues (b) psychological difficulties (c) challenges of self-management and (2) Care-coordination maze (a)fragmentation and poor continuity of care (b) medication management; an uphill battle and (c) primary care falling short. All participants reported physical and psychological challenges associated with their MLTCs. Younger participants reported difficulties in their professional lives, while older participants found household activities challenging. Emotional struggles encompassed feelings of hopelessness and fear rooted in concerns about chronic illness and physical limitations. Older participants, adhering to Kerala's familial support norms, often found themselves emotionally distressed by the notion of burdening their children. Challenges in self-management, such as dietary restrictions, medication adherence, and physical activity engagement, were common. The study highlighted difficulties in coordinating care, primarily related to traveling to multiple healthcare facilities, and patients' perceptions of FHCs as fit for diabetes and hypertension management rather than their multiple conditions. Additionally, participants struggled to manage the task of remembering and consistently taking multiple medications, which was compounded by confusion and memory-related issues. This study offers an in-depth view of the experiences of individuals living with MLTCs from Kerala, India. It emphasizes the need for tailored and patient-centred approaches that enhance continuity and coordination of care to manage complex MLTCs in India and similar LMICs.

Background The prevalence of multiple chronic conditions (MCC) among older persons is increasing worldwide and is associated with poor health status and high rates of healthcare utilization and costs. Current health and social services are not addressing the complex needs of this group or their family caregivers. A better understanding of the experience of MCC from multiple perspectives is needed to improve the approach to care for this vulnerable group. However, the experience of MCC has not been explored with a broad sample of community-living older adults, family caregivers and healthcare providers. The purpose of this study was to explore the experience of managing MCC in the community from the perspectives of older adults with MCC, family caregivers and healthcare providers working in a variety of settings. Methods Using Thorne’s interpretive description approach, semi-structured interviews ( n  = 130) were conducted in two Canadian provinces with 41 community-living older adults (aged 65 years and older) with three or more chronic conditions, 47 family caregivers (aged 18 years and older), and 42 healthcare providers working in various community settings. Healthcare providers represented various disciplines and settings. Interview transcripts were analyzed using Thorne’s interpretive description approach. Results Participants described the experience of managing MCC as: (a) overwhelming, draining and complicated, (b) organizing pills and appointments, (c) being split into pieces, (d) doing what the doctor says, (e) relying on family and friends, and (f) having difficulty getting outside help. These themes resonated with the emotional impact of MCC for all three groups of participants and the heavy reliance on family caregivers to support care in the home. Conclusions The experience of managing MCC in the community was one of high complexity, where there was a large gap between the needs of older adults and caregivers and the ability of health and social care systems to meet those needs. Healthcare for MCC was experienced as piecemeal and fragmented with little focus on the person and family as a whole. These findings provide a foundation for the design of care processes to more optimally address the needs-service gap that is integral to the experience of managing MCC.

Background The aim of this study was to describe barriers and facilitators for shared decision making (SDM) as experienced by older patients with multiple chronic conditions (MCCs), informal caregivers and health professionals. Methods A structured literature search was conducted with 5 databases. Two reviewers independently assessed studies for eligibility and performed a quality assessment. The results from the included studies were summarized using a predefined taxonomy. Results Our search yielded 3838 articles. Twenty-eight studies, listing 149 perceived barriers and 67 perceived facilitators for SDM, were included. Due to poor health and cognitive and/or physical impairments, older patients with MCCs participate less in SDM. Poor interpersonal skills of health professionals are perceived as hampering SDM, as do organizational barriers, such as pressure for time and high turnover of patients. However, among older patients with MCCs, SDM could be facilitated when patients share information about personal values, priorities and preferences, as well as information about quality of life and functional status. Informal caregivers may facilitate SDM by assisting patients with decision support, although informal caregivers can also complicate the SDM process, for example, when they have different views on treatment or the patient’s capability to be involved. Coordination of care when multiple health professionals are involved is perceived as important. Conclusions Although poor health is perceived as a barrier to participate in SDM, the personal experience of living with MCCs is considered valuable input in SDM. An explicit invitation to participate in SDM is important to older adults. Health professionals need a supporting organizational context and good communication skills to devise an individualized approach for patient care.

Medically complex patients are a heterogeneous group that contribute to a substantial proportion of health care costs. Coordinated efforts to improve care and reduce costs for this patient population have had limited success to date. To define distinct patient clinical profiles among the most medically complex patients through clinical interpretation of analytically derived patient clusters. This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles. Complex patient profiles, 1-year health care utilization, and mortality outcomes by profile. The analysis included 104 869 individuals representing 3.3% of the adult population (mean [SD] age, 70.7 [14.5] years; 52.4% women; 39% non-White race/ethnicity). Latent class analysis resulted in a 7-class solution. Stakeholders defined the following complex patient profiles (prevalence): high acuity (9.4%), older patients with cardiovascular complications (15.9%), frail elderly (12.5%), pain management (12.3%), psychiatric illness (12.0%), cancer treatment (7.6%), and less engaged (27%). Patients in these groups had significantly different 1-year mortality rates (ranging from 3.0% for psychiatric illness profile to 23.4% for frail elderly profile; risk ratio, 7.9 [95% CI, 7.1-8.8], P < .001). Repeating the analysis using k-means clustering resulted in qualitatively similar groupings. Each clinical profile suggested a distinct collaborative care strategy to optimize management. The findings suggest that highly medically complex patient populations may be categorized into distinct patient profiles that are amenable to varying strategies for resource allocation and coordinated care interventions.

Background Interventions to improve patient-centered care for persons with multimorbidity are in constant growth. To date, the emphasis has been on two separate kinds of interventions, those based on a patient-centered care approach with persons with chronic disease and the other ones created specifically for persons with multimorbidity. Their effectiveness in primary healthcare is well documented. Currently, none of these interventions have synthesized a patient-centered care approach for care for multimorbidity. The objective of this project is to determine the particular elements of patient-centered interventions and interventions for persons with multimorbidity that are associated with positive health-related outcomes for patients. Method A scoping review was conducted as the method supports the rapid mapping of the key concepts underpinning a research area and the main sources and types of evidence available. A five-stage approach was adopted: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing and reporting results. We searched for interventions for persons with multimorbidity or patient-centered care in primary care. Relevant studies were identified in four systematic reviews (Smith et al. (2012;2016), De Bruin et al. (2012), and Dwamena et al. (2012)). Inductive analysis was performed. Results Four systematic reviews and 98 original studies were reviewed and analysed. Elements of interventions can be grouped into three main types and clustered into seven categories of interventions: 1) Supporting decision process and evidence-based practice; 2) Providing patient-centered approaches; 3) Supporting patient self-management; 4) Providing case/care management; 5) Enhancing interdisciplinary team approach; 6) Developing training for healthcare providers; and 7) Integrating information technology. Providing patient-oriented approaches, self-management support interventions and developing training for healthcare providers were the most frequent categories of interventions with the potential to result in positive impact for patients with chronic diseases. Conclusion This scoping review provides evidence for the adaption of patient-centered interventions for patients with multimorbidity. Findings from this scoping review will inform the development of a toolkit to assist chronic disease prevention and management programs in reorienting patient care.

Introduction Caregivers make an essential contribution to the self‐care of patients with multiple chronic conditions (MCCs), but no studies have described caregiver contribution (CC) and caregiver self‐efficacy in contributing to patient self‐care in low‐/middle‐income countries (LMICs). This study aimed to describe the CC to patient self‐care and caregiver self‐efficacy of patients affected by MCCs living in a low‐middle‐income country such as Albania. Design A Multicenter cross‐sectional study design was used. Methods A sample of 376 Albanian caregivers was enrolled if identified by the patient with MCCs as the primary unpaid informal caregiver in outpatient settings in Albania. The Caregiver Contribution to Self‐Care of Chronic Illness Inventory (CC‐SCCII) and the Caregiver Self‐Efficacy in Contributing to Patient Self‐Care Scale (CSE‐CSC) were used to measure the CC to patient self‐care maintenance, monitoring, and management and the caregiver's confidence in their ability to contribute to patient self‐care, respectively. Results Participants' mean age was 48.10 (15.14) years. Most of the caregivers were women (67.9%), adult children (53.2%) or spouses (46.8%) of the patient. Regarding the CC to self‐care maintenance, inadequate behaviors were observed in caregiver recommendations for physical activity (41%) and stress management (33%). In the CC to patient self‐care monitoring, inadequate behaviors in recognition of symptoms were reported (20%) by caregivers. In the CC to patient self‐care management, inadequate behaviors were found in caregiver ability to recognize reflecting on the effectiveness of the remedy used to manage signs and symptoms of the patient's illness (60%) and in alerting the healthcare provider (25%). Caregiver self‐efficacy was lower in the ability to persist in finding a remedy for symptoms of the person for whom they care (27%) and to evaluate the effectiveness of a remedy they used (27%). Conclusion We found, on average, adequate CC to patient self‐care maintenance, monitoring, management behaviors, and caregiver self‐efficacy in contributing to patient self‐care of MCCs, but specific CC behaviors were found to be insufficient. Clinical Relevance This study described CC and caregiver self‐efficacy in contributing to patient self‐care in a low‐middle‐income country. This knowledge will enable healthcare professionals to identify inadequate caregiver contributions to self‐care and strengthen them through targeted educational interventions, thus optimizing the scarce resources available in these contexts.