Category Archives: Intervention
A multidisciplinary self-management intervention among patients with multimorbidity: Impact of socioeconomic factors
Improving patient-centred care for multimorbidity
Redesigning primary care for the people who use it: unveiling the results of the 3D trial for patients with multimorbidity in general practice
Is it possible to improve drug prescription in primary care patients with multimorbidity and polypharmacy by implementing the Ariadne principles in clinical practice?
The CARE Plus study
OPTIMAL, a promising intervention to improve outcomes for people with multimorbidity
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By Jess Garvey, Deirdre Connolly and Susan Smith
We investigated the effectiveness of an occupational therapy led self-management support programme, OPTIMAL, designed to address the challenges of living with multiple chronic conditions or multimorbidity in a primary care setting. We conducted a pragmatic feasibility randomised controlled trial including fifty participants with multimorbidity recruited from family practice and primary care settings in Dublin in Ireland. OPTIMAL is a six-week community-based programme, led by occupational therapy facilitators and focuses on problems associated with managing multimorbidity. The primary outcome was frequency of activity participation. Secondary outcomes included self-perception of, satisfaction with and ability to perform daily activities, independence in activities of daily living, anxiety and depression, self-efficacy, health-related quality of life, self-management support, healthcare utilisation and individualised goal attainment. Outcomes were collected within two weeks of intervention completion.
At immediate post intervention follow-up we found significant improvements in frequency of activity participation, measured using the Frenchay Activities Index, for the intervention group compared to the control group (Adjusted Mean Difference at follow up 4.22. 95% Confidence Interval 1.59-6.85). There were also significant improvements in perceptions of activity performance and satisfaction, self-efficacy, independence in daily activities and quality of life. Additionally, the intervention group demonstrated significantly higher levels of goal achievement, following the intervention. No significant differences were found between the two groups in anxiety, depression, self-management scores or healthcare utilisation.
OPTIMAL significantly improved frequency of activity participation, self-efficacy and quality of life for patients with multimorbidity. Further work is required to test the sustainability of these effects over time but this study indicates that it is a promising intervention that can be delivered in primary care and community settings.
Full details of this article can be found at http://www.biomedcentral.com/1471-2296/16/59/abstract
We would welcome contact and collaboration with other researchers looking to test the feasibility and effectiveness of the OPTIMAL programme in other healthcare settings.
Take a stand on complexity and gain a better understanding of the roles of professionals in care coordination!
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By Anne Doessing
We recently published a scoping study addressing two issues: what are the conditions of care coordination for patients with multimorbidity; and which factors promote or inhibit care coordination in provider organizations and among healthcare professionals [1].
The central theme emerging was complexity: The specific medical conditions of patients with multimorbidity are highly complex as is the organization of care delivery.
What are the implications for care coordination then? One approach is to reduce complexity and the other is to embrace complexity. Either way, future research in care coordination interventions in multimorbidity must take a more explicit stand on complexity.
In the included studies there was a significant lack of clarity regarding the role of different professionals in care coordination. It is unclear what role the various health professions play in care coordination, what coordination tasks different professions perform and whether some professions are more suited for care coordination than others. Also, it is unclear how different organizations and sectors affect the coordination carried out by different professions.
The research on care coordination interventions for patients with multimorbidity seems to focus on organizing healthcare without paying much attention to the role of professions in frontline care coordination. However, this ought to be a prerequisite for the development of care coordination interventions.
Therefore there is a need for more research to uncover the role of different professions in care coordination. This must comprehend both their actions and the health professionals’ own understanding of their role in care coordination.
Perhaps some of the failures of existing care coordination interventions can be explained by the fact that the specific delegation of coordination is at odds with the health professionals’ own understanding of their professional domain?
The complete article can be accessed at: http://www.jcomorbidity.com/index.php/test/article/view/39
1: Doessing A, Burau V. Care coordination of multimorbidity: a scoping study. J Comorbidity 2015;5:15-28
PACE in MM Website Launched
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By Martin Fortin and Moira Stewart
The research team PACE in MM “Patient-Centred Innovations for Persons with Multimorbidity” is happy to report its website (www. paceinmm.recherche.usherbrooke.ca) is now online in both French and English. The site outlines the PACE in MM research goals, objectives and research plan.
Visitors to the site are able to view the governance, type and structure of Committees within the team as well as review the research team members. A glossary of key terms related to the topic areas of PACE in MM is presented.
This resource will also allow visitors to keep updated on current news and events. A special section for output and activities will be updated regularly outlining presentations, publications, and meetings. A link to other helpful resources has also been developed.
If you have any suggestions or feedback for the website please send your comments to Research Coordinators, Tarek and Louisa.
Improving care for patients with multimorbidity
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By Chris Salisbury
Although there is a fairly clear sense of direction about how care needs to change for patients with multimorbidity, there have been few rigorous studies of new approaches.
Researchers from the Universities of Bristol, Glasgow, Manchester, Dundee, in partnership with the NHS and the Royal College of General Practitioners, have obtained funding for the ‘3D’ study to improve whole person care. This is an ambitious multi-centre cluster randomised trial of a new approach to improve the management of patients with multimorbidity in general practice, led by Professor Chris Salisbury. Funding of £1.78 million study has been obtained from the National Institute of Health Research (NIHR) through its Health Services and Delivery Research (HS&DR) Programme.
Following a pilot and optimisation study in 4 general practices, 32 practices will be recruited to the main trial and randomised to receive the new intervention or continue usual care. The intervention is designed to address the problems of illness burden (poor quality of life, depression) treatment burden (multiple unco-ordinated appointments, polypharmacy, poor primary/secondary care co-ordination) and lack of patient-centred care (low continuity, disregard of patients’ priorities) experienced by patients with multimorbidity.
Patients with multimorbidity will be identified and offered longer appointments with the same GP and nurse whenever possible, to maximise continuity of care. Instead of separate reviews of each of their long term conditions, patients will be invited for a comprehensive ‘3D’ health review every 6 months designed to cover all of their health issues. This will focus on identifying their main concerns and priorities to improve their quality of life, as well as seeking to improve disease control (Dimensions of health). The patients’ Drug regime will be reviewed and simplified, seeking to improve medication adherence. The clinician will check for and treat Depression. In order to improve integration of care, the practice will have a linked ‘general physician’ at the local hospital.
The aim is to recruit 1382 multimorbid patients into the trial and follow them up for 12 months. The primary outcome is the patient’s quality of life, with secondary outcomes including measures of disease control, the burden of illness and treatment, and measures of patient centred care. A parallel process evaluation using mixed methods will explore how the intervention is implemented and achieves its effects and how it could be improved. Through an economic evaluation we will compare the costs and benefits of the intervention from different perspectives and determine whether it is cost-effective. Further information is available from the study website at http://www.bristol.ac.uk/3d-study.
The integration of physician-patient-nurse collaboration for patients with multimorbidity seen in a Family Medicine Group setting: A pilot study
By Tarek Bouhali
A Family medicine group (FMG) is a group of family physicians who work in close cooperation with nurses to offer health care services to registered individuals. On average, a FMG serves 15,000 people, and involves 10 doctors and two nurses [1]. This new form of group practice based on patient-centered approaches leads to interprofessional collaboration.
Interprofessional collaboration usually involves two disciplines or professionals, who interact continuously in a joint effort to solve or explore common issues. This approach involves active patient participation, gives priority to his/her goals and values, and establishes mechanisms for continuous communication among health care providers. Working within such a structure requires a redefinition of the physician-nurse partnership. Evidence-based interprofessional collaboration should involve intra-disciplinary and interdisciplinary participation in clinical decision making, and encourages the contribution of all professionals [2]. A number of studies has highlighted the need to redefine inter-professional collaboration to include the patient as participant as his/her perspective has been missing so far [2-4].
In this regard, the present pilot study aims to:
1) clarify the expectations of physicians, patients, and nurses involved in a collaborative approach;
2) identify the elements of collaboration that are prioritized by the participating professionals;
3) document the experience of collaboration among physicians, nurses and patients;
4) assess the feasibility of using generic outcome measures;
5) collect preliminary data on the variability of results and their sensitivity to changes in patients with multimorbidity.
Patients included in this study are adults (40 to 65 years) with at least two chronic diseases from two FMGs in the Saguenay-Lac-St-Jean region (Quebec, Canada). Two family physicians and two nurses from each FMG will form four physician-nurse teams. Ten patients will be recruited among each of the participating physician’s practice, for a total of 40 patients.
Physicians and nurses will take part in a training session on physician-patient-nurse collaboration. They will then participate in individual interviews to express their expectations (T0), and discuss strategies and tools used to make collaboration more relevant and responsive to patients with multiple chronic conditions at two other times (T1 and T2).
Two evaluations are planned for patients: before the first visit (T0), and 24 weeks later (T2). Before starting the collaborative process (T0), patients will be invited to participate in a focus group to clarify their expectations. Patients met at T0 will be asked to participate in a second focus group at T2 to discuss elements of satisfaction or dissatisfaction regarding physician-patient-nurse collaboration. At T0 and T2, they will be asked to complete a self-administered questionnaire on quality of life, self-efficacy, functional level, process of care and the achievement of personal goals.
Interprofessional collaboration in patient care has the potential to lead to positive impacts on the process of patient empowerment and self-efficacy. It can also contribute to an improvement in patients’ quality of life and a decrease in their level of psychological distress. Their perception of health care quality should improve as well. This pilot study will allow us to define the form that may take the intervention and methodological elements of a subsequent larger demonstration project.
1. Commissaire à la santé et au bien-être. Rapport d’appréciation de la performance du système de santé et de services sociaux 2009: État de situation portant sur le système de santé et de services sociaux sur sa première ligne de soins. Québec; 2009.
2. Juanita Barrett, Vernon Curran, Lindsay Glynn. Canadian Health Services Research Foundation (CHSRF) Synthesis: Interprofessional Collaboration and Quality Primary Healthcare, December 2007. http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/SynthesisReport_E_rev4_FINAL.pdf)
3. Beaulieu M-D, Denis JL, D’ Amour D, et al. L’implantation des Groupes de médecine de famille : un défi de la réorganisation de la pratique et de la collaboration interprofessionnelle. Montréal: Canadian Health Services Research Foundation (CHSRF); 2006. (http://www.chsrf.ca/migrated/pdf/pastprograms/beaulieu_final.pdf )
4. Ivy Oandasan, G.Ross Baker, et al. Teamwork in Healthcare: Promoting effective teamwork in healthcare in Canada. Canadian Health Services Research Foundation (CHSRF). Ottawa: FCRSS; 2006. (http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/teamwork-synthesis-report_e.pdf )