Entete 3

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 )


  • 1
    Martin Fortin
    August 30, 2011 - 9:30 am | Permalink

    The mentioned pilot study was made possible by a $50,000 grant from the Medical Research Centre, Université de Sherbrooke,

    The research team is composed of:

    Martin Fortin MD MSc CMFC(F), Department of Family Medicine, Université de Sherbrooke, CIHR Applied Research Chair – Health Services and Policy Research on Chronic Diseases in Primary Care, based at the CSSS de Chicoutimi;

    Catherine Hudon MD MSc PhD(c) CMFC, Department of Family Medicine, University of Sherbrooke, Director of the Family Medicine Unit of the CSSS de Chicoutimi;

    Jeannie Haggerty PhD, Department of Family Medicine, McGill University, McGill Research Chair in Family and Community Medicine Research, based at St. Mary’s Hospital Center;

    Christine Loignon, PhD, M.Sc, Department of Family Medicine, Université de Sherbrooke, and the Hôpital Charles LeMoyne Research Centre;

    Maud-Christine Chouinard Inf PhD, Department of Health Sciences, Université du Quebec à Chicoutimi (UQAC);

    Marie France Dubois PhD, Department of Community Health Sciences, Université de Sherbrooke.

  • 2
    September 15, 2011 - 1:59 pm | Permalink

    This is very interesting work, and we can all learn a lot from it.

    The team that I support at Johns Hopkins (in Baltimore, Maryland, USA) developed a similar model of comprehensive primary care, called Guided Care, where a registered nurse located in the primary care practice partners with 3-4 physicians to provide patient-centered, cost-effective care to 50-60 high-risk patients with multiple chronic conditions. Following a comprehensive in-home assessment and care planning process (aligned with patients’ preferences, priorities, and intentions), the Guided Care nurse promotes patient self-management, monitors conditions monthly, coordinates efforts of all health care providers, smoothes transitions between sites of care, educates and supports family caregivers, and facilitates access to community resources.

    Results of a 32-month, multi-site, cluster randomized controlled trial showed that, compared to usual care, Guided Care significantly improved the quality of chronic care (Boyd CM et al. J Gen Intern Med 2010) and improved physicians’ satisfaction with chronic care (Marsteller JA et al. Ann Fam Med 2010). The results also indicate that Guided Care may reduce the use and cost of expensive health services, especially in well-managed systems (Boult C et al. Arch Intern Med 2011). The 32-month data is currently being analyzed.

    If there are opportunities to learn from each other, we welcome a collaboration. My email is tnovak@jhsph.edu.

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