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Monthly Archives: August 2011

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 )

A request to the International Research Community on Multimorbidity

By Helene Rosenbrandt

In Denmark the health sector is split in three: regions (responsible for hospitals), general practitioners and communities. I am planning process and content in a series of meetings in a political committee regarding multimorbidity. The political committee is interested in performing a study trip to other countries (if possible in Europe) who are working with handling challenges regarding multimorbidity in a yet more specialised health service. Our interest is in projects/activities that “can be seen” for example including interventions for patients (more than research on databases etc). I contact you with hope that you have ideas regarding interesting projects and solutions on this topic?

 We work with two different meanings of the area:
–      Multimorbidity where the perspective is the “whole” patient – all diseases are seen as equal.
–      Comorbidity where one disease is the primary and other diseases are seen as comorbidity to the primary disease – the perspective is a specialist one where a specialist in one primary disease tries to take other diseases (comorbidity) into consideration.

 Our focus is multimorbidity.

Some of the problems we see are:
–      That the hospital sector gets more and more specialized and if one follows the clinical guidelines for the individual diagnoses it leads to overwhelming treatment plans for the patient with 2, 3 or more simultaneous diseases – including polypharmacy.
–      In the actual process of diagnosing the patient a more general or cooperating view on the patient may lead to quicker diagnosis and start of relevant treatment.
–      The general practitioner have a role in this broad look on the patient but does not possess the specialist competences needed with more severe diseases.
–      One or more chronic diseases often lead to even more diseases – partly through negative feedback on lifestyle factors (arthritis may lead to inactivity which may then increase the risk of getting diabetes etc..).

We are interested in a broad range of projects and activities which deal with multimorbidity:
–      Handling multimorbidity in a specialised hospital sector.
–      The general practitioners role as an anchor/coordinator.
–      Cooperation between primary and secondary health sector.
–      Polypharmacy issues.
–      Patients own role in handling multimorbidity (self efficacy, social inequalities in health).

Best wishes,

Helene Rosenbrandt
(Administrator in the Regional part of the Danish Health sector)