Processes of care desired by elderly patients with multimorbidities

Prevalence and predictors of polypharmacy and comorbidities among patients with chronic obstructive pulmonary disease: a cross-sectional retrospective study in a tertiary hospital in Saudi Arabia

OBJECTIVE

This study aimed to determine the prevalence of polypharmacy, comorbidities and to investigate factors associated with polypharmacy among adult patients with Chronic Obstructive Pulmonary Disease (COPD).

METHODS

This was a retrospective single-centre cross-sectional study. Patients with a confirmed diagnosis of COPD according to the GOLD guidelines between 28 February 2020 and 1 March 2023 were included in this study. Patients were excluded if a pre-emptive diagnosis of COPD was made clinically without spirometry evidence of fixed airflow limitation. Population characteristics were presented as frequency for categorical variable. Logistic regression analysis was used to identify predictors of polypharmacy.

RESULTS

The study sample included a total of 705 patients with COPD. Most of the study sample were males (60%). The mean age of the study population was 65 years old. The majority of the study population had comorbid diseases (68%), hypertension and diabetes were the most common co-existent diseases. Around 55% of the study sample had polypharmacy. Females were significantly less likely to be on polypharmacy compared to males (OR = 0.68, 95% CI = [0.50-0.92], P-value = 0.012)). On the other hand, older patients aged 65.4 or more (OR = 2.31, 95% CI = [1.71-3.14], P-value ≤ 0.001), those with high BMI (≥ 29.2) (OR = 1.42, 95% CI = [1.05-1.92], P-value = 0.024), current smokers (OR = 1.9, 95% CI = [1.39-2.62], P-value ≤ 0.001), those who are receiving home care (OR = 5.29, 95% CI = [2.46-11.37], P-value ≤ 0.001), those who have comorbidities (OR = 19.74, 95% CI = [12.70-30.68], P-value ≤ 0.001) were significantly more likely to be on polypharmacy (p ≤ 0.05).

CONCLUSIONS

Polypharmacy is common among patients with COPD. Patients with high BMI, previous ICU hospitalization and older age are more likely to have polypharmacy. Future analytical studies are warranted to investigate outcomes in patients with COPD and polypharmacy.

Care models for individuals with chronic multimorbidity: lessons for low- and middle-income countries

BACKGROUND

Patients with multiple long-term conditions requires understanding the existing care models to address their complex and multifaceted health needs. However, current literature lacks a comprehensive overview of the essential components, impacts, challenges, and facilitators of these care models, prompting this scoping review.

METHODS

A scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for Scoping Reviews guideline. Our search encompassed articles from PubMed, Web of Science, EMBASE, SCOPUS, and Google Scholar. The World Health Organization's health system framework was utilized to synthesis the findings. This framework comprises six building blocks (service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance) and eight key characteristics of good service delivery models (access, coverage, quality, safety, improved health, responsiveness, social and financial risk protection, and improved efficiency). Findings were synthesized qualitatively to identify components, impacts, barriers, and facilitators of care models.

RESULTS

A care model represents various collective interventions in the healthcare delivery aimed at achieving desired outcomes. The names of these care models are derived from core activities or major responsibilities, involved healthcare teams, diseases conditions, eligible clients, purposes, and care settings. Notable care models include the Integrated, Collaborative, Integrated-Collaborative, Guided, Nurse-led, Geriatric, and Chronic care models, as well as All-inclusive Care Model for the Elderly, IMPACT clinic, and Geriatric Patient-Aligned Care Teams (GeriPACT). Other care models (include Care Management Plus, Value Stream Mapping, Preventive Home Visits, Transition Care, Self-Management, and Care Coordination) have supplemented the main ones. Care models improved quality of care (such as access, patient-centeredness, timeliness, safety, efficiency), cost of care, and quality of life for patients that were facilitated by presence of shared mission, system and function integration, availability of resources, and supportive tools.

CONCLUSIONS

Care models were implemented for the purpose of enhancing quality of care, health outcomes, cost efficiency, and patient satisfaction by considering careful recruitment of eligible clients, appropriate selection of service delivery settings, and robust organizational arrangements involving leadership roles, healthcare teams, financial support, and health information systems. The distinct team compositions and their roles in service provision processes differentiate care models.

Siloed mentality, health system suboptimization and the healthcare symphony: a Canadian perspective

Measuring and optimizing a health system is challenging when patient care is split between many independent organizations. For example, patients receive care from their primary care provider, outpatient specialist clinics, hospitals, private providers and, in some instances, family members. These silos are maintained through different funding sources (or lack of funding) which incentivize siloed service delivery. A shift towards prioritizing patient outcomes and keeping the patient at the centre of care is emerging. However, competing philosophies on patient needs, how health is defined and how health is produced and funded is creating and engraining silos in the delivery of health services. Healthcare and health outcomes are produced through a series of activities conducted by diverse teams of health professionals working in concert. Health professionals are continually learning from each patient interaction; however, silos are barriers to information exchange, collaborative evidence generation and health system improvement. This paper presents a systems view of healthcare and provides a systems lens to approach current challenges in health systems. The first part of the paper provides a background on the current state and challenges to healthcare in Canada. The second part presents potential reasons for continued health system underperformance. The paper concludes with a system perspective for addressing these challenges.

Enhanced Comprehensive Care Programme: a retrospective study of patient empanelment by generalist-led multidisciplinary teams to reduce acute care utilisation

INTRODUCTION

Singapore faces an increasingly aged population with complex multimorbidity and psychosocial impairment. This change in demographic is challenging for existing healthcare systems. Breaks in care coordination and continuity result in poor health outcomes, increased acute care utilisation and higher healthcare costs. We proposed a patient empanelment approach adapted for the Singapore context based on the University of Chicago Comprehensive Care Physician model.

METHODS

This retrospective quasi-experimental, matched-controlled observational study sought to assess the effectiveness of the Enhanced Comprehensive Care Programme (ECCP) in reducing acute care utilisation at National University Hospital, Singapore. The primary outcomes were the number of hospitalisations and emergency department (ED) visits 6 months pre- and post-enrolment in ECCP. We used propensity score matching to balance prior healthcare utilisation between the intervention and control groups.

RESULTS

Fifty-seven participants were recruited in the programme between October 2019 and April 2020. There was a reduction in the mean number of hospitalisations after intervention compared to before intervention (0.58 ± 1.03 vs. 1.90 ± 1.07, P < 0.001). There was also a reduction in the mean number of ED visits (0.77 ± 1.05 vs. 1.96 ± 1.14, P < 0.001). In the propensity-matched cohort, the mean number of hospitalisations was reduced in the intervention group (from 1.92 ± 1.07 to 0.58 ± 1.03, P < 0.001) compared to the control group (from 1.85 ± 0.99 to 1.06 ± 1.17, P = 0.04).

CONCLUSION

This observational study shows the potential benefits of ECCP healthcare redesign to reduce acute care utilisation.

The experiences of patients not conveyed after evaluation by emergency medical services in Southwest Finland - A qualitative survey study

BACKGROUND

The amount of non-critical Emergency Medical Services missions has been increasing. After examination and treatment, paramedics can decide, based on guidelines, not to convey the patient to a healthcare facility. This study aimed to investigate patients' experiences in non-conveyance situations in Southwest Finland. Our research questions were: 1) Which patient concerns were not addressed? 2) What key actions improved patient comfort? and 3) What possible enhancements could make the patient experience more positive?

METHODS

This was a qualitative survey study. In March 2023, all the patients who met the inclusion criteria (N = 1017) received a survey via mail. The data from three open-ended questions were analyzed using inductive content analysis.

RESULTS

The response rate was 22.2 % (n = 226). The unaddressed patient concerns were related to inadequate immediate care and guidance and non-clinical factors causing concern. Key actions for improved patient comfort were related to immediate treatment and guidance, as well as non-clinical factors that impact the patient experience. More thorough treatment processes and more attentive encounters would have enhanced the patient experience.

CONCLUSIONS

Predominantly, patients reported having received excellent services. Utilizing paramedics' soft skills and keeping the patient as the central focus is key to improving the non-conveyance process and experience.

The Effect of Coordinating the Outpatient Treatment across Medical Specialities for Patients With Multimorbidity

Introduction

Patients with multimorbidity attend multiple outpatient clinics. We assessed the effects on hospital use of scheduling several outpatient appointments to same-day visits in a multidisciplinary outpatient pathway (MOP).

Methods

This study used a quasi-experimental design. Eligible patients had multimorbidity, were aged ≥18 years and attended ≥2 outpatient clinics in five different specialties. Patients were identified through forthcoming appointments from August 2018 to March 2020 and divided into intervention group (alignment of appointments) and comparison group (no alignment). We used patient questionnaires and paired analyses to study care integration and treatment burden. Using negative binomial regression, we estimated healthcare utilisation as incidence rates ratios (IRRs) at one year before and one year after baseline for both groups and compared IRR ratios (IRRRs).

Results

Intervention patients had a 19% reduction in hospital visits (IRRR: 0.81, 95% CI: 0.70-0.96) and a 17% reduction in blood samples (IRRR: 0.83, 0.73-0.96) compared to comparison patients. No effects were found for care integration, treatment burden, outpatient contacts, terminated outpatient trajectories, hospital admissions, days of admission or GP contacts.

Conclusion

The MOP seemed to reduce the number of hospital visits and blood samples. These results should be further investigated in studies exploring the coordination of outpatient care for multimorbidity.

Research question

Can an intervention of coordinating outpatient appointments to same-day visits combined with a multidisciplinary conference influence the utilisation of healthcare services and the patient-assessed integration of healthcare services and treatment burden among patients with multimorbidity?

A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS)

Background

Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).

Patients and Methods

Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.

Results

Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.

Conclusion

ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.

Trial Registration

The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.

Enhancing patient-centred care in Taiwan's dental education system: Exploring the feasibility of doctor-patient communication education and training

Background/purpose

Improved communication can optimize treatment outcomes and patient satisfaction. Findings emphasize the need for tailored communication strategies based on patient characteristics. Implementing communication courses can enhance patient-centered care and reduce conflicts. Therefore, this study examined the feasibility of integrating doctor-patient communication education in Taiwan's dental education system.

Materials and methods

Using interviews and questionnaires, we conducted descriptive statistics and generalized linear mixed-effects model analysis on the importance of doctor-patient communication from the dentist and patient perspectives.

Results

More than 600 patient surveys and four interviewed dentists with 20+ years of experience stressed doctor-patient communication in dentistry. Patients' age and income were positively related to the emphasis on physician-patient communication but negatively associated with dental assistants' communication. Dentists valued communication education but differed in its execution and importance.

Conclusion

It is recommended to initiate dentist-patient communication education during university studies and continue its practice to adapt to the changing societal dynamics. Individuals with higher socioeconomic status and older age show a greater appreciation for dentist-patient communication, potentially driven by self-promotion, thereby highlighting the diverse nature of doctor-patient relationships. Based on our findings, we suggest to implement the doctor-patient communication courses in Taiwan.

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study

BACKGROUND

Patients with multimorbidity are frequent users of healthcare, but fragmented care may lead to suboptimal treatment. Yet, this has never been examined across healthcare sectors on a national scale. We aimed to quantify care fragmentation using various measures and to analyze the associations with patient outcomes.

METHODS

We conducted a register-based nationwide cohort study with 4.7 million Danish adult citizens. All healthcare contacts to primary care and hospitals during 2018 were recorded. Clinical fragmentation indicators included number of healthcare contacts, involved providers, provider transitions, and hospital trajectories. Formal fragmentation indices assessed care concentration, dispersion, and contact sequence. The patient outcomes were potentially inappropriate medication and all-cause mortality adjusted for demographics, socioeconomic factors, and morbidity level.

RESULTS

The number of involved healthcare providers, provider transitions, and hospital trajectories rose with increasing morbidity levels. Patients with 3 versus 6 conditions had a mean of 4.0 versus 6.9 involved providers and 6.6 versus 13.7 provider transitions. The proportion of contacts to the patient's own general practice remained stable across morbidity levels. High levels of care fragmentation were associated with higher rates of potentially inappropriate medication and increased mortality on all fragmentation measures after adjusting for demographic characteristics, socioeconomic factors, and morbidity. The strongest associations with potentially inappropriate medication and mortality were found for ≥ 20 contacts versus none (incidence rate ratio 2.83, 95% CI 2.77-2.90) and ≥ 20 hospital trajectories versus none (hazard ratio 10.8, 95% CI 9.48-12.4), respectively. Having less than 25% of contacts with your usual provider was associated with an incidence rate ratio of potentially inappropriate medication of 1.49 (95% CI 1.40-1.58) and a mortality hazard ratio of 2.59 (95% CI 2.36-2.84) compared with full continuity. For the associations between fragmentation measures and patient outcomes, there were no clear interactions with number of conditions.

CONCLUSIONS

Several clinical indicators of care fragmentation were associated with morbidity level. Care fragmentation was associated with higher rates of potentially inappropriate medication and increased mortality even when adjusting for the most important confounders. Frequent contact to the usual provider, fewer transitions, and better coordination were associated with better patient outcomes regardless of morbidity level.

Impact of primary care usual provider type and provider interdependence on outcomes for patients with diabetes: a cohort study

BACKGROUND

Interprofessional primary care (PC) teams are key to the provision of high-quality care. PC providers often 'share' patients (eg, a patient may see multiple providers in the same clinic), resulting in between-visit interdependence between providers. However, concern remains that PC provider interdependence will reduce quality of care, causing some organisations to hesitate in creating multiple provider teams. If PC provider teams are formalised, the PC usual provider of care (UPC) type (physician, nurse practitioner (NP) or physician assistant/associate (PA)) should be determined for patients with varying levels of medical complexity.

OBJECTIVE

To evaluate the impact of PC provider interdependence, UPC type and patient complexity on diabetes-specific outcomes for adult patients with diabetes.

DESIGN

Cohort study using electronic health record data from 26 PC practices in central North Carolina, USA.

PARTICIPANTS

Adult patients with diabetes (N=10 498) who received PC in 2016 and 2017.

OUTCOME

Testing for diabetes control, testing for lipid levels, mean glycated haemoglobin (HbA1c) values and mean low-density lipoprotein (LDL) values in 2017.

RESULTS

Receipt of guideline recommended testing was high (72% for HbA1c and 66% for LDL testing), HbA1c values were 7.5% and LDL values were 88.5 mg/dL. When controlling for a range of patient and panel level variables, increases in PC provider interdependence were not significantly associated with diabetes-specific outcomes. Similarly, there were no significant differences in the diabetes outcomes for patients with NP/PA UPCs when compared with physicians. The number and type of a patient's chronic conditions did impact the receipt of testing, but not average values for HbA1c and LDL.

CONCLUSIONS

A range of UPC types on PC multiple provider teams can deliver guideline-recommended diabetes care. However, the number and type of a patient's chronic conditions alone impacted the receipt of testing, but not average values for HbA1c and LDL.

Clinic for Multimorbidity: An Innovative Approach to Integrate General Practice and Specialized Health Care Services

Introduction

Caring for patients with multimorbidity in general practice is increasing in amount and complexity. To integrate care for patients with multimorbidity and to support general practitioners (GPs), the Clinic for Multimorbidity (CM) was established in 2012 at Silkeborg Regional Hospital, Denmark. This case study aims to describe the CM and the patients seen in it.

Results

CM is an outpatient clinic that offers a comprehensive one-day assessment of the patient's complete health status and medication. GPs can refer patients with complex multimorbidity (≥2 chronic conditions). It involves collaboration across medical specialties and healthcare professions. The assessment is completed with a multidisciplinary conference and recommendation.In all, 141 patients were referred to the CM between May 2012 and November 2017. The median age was 70 years, 80% had more than five diagnoses, and in median patients had a usage of 11 drugs (IQI, 7-15). Physical and mental health was reported low (SF-12 score: 26 and 42). In median four specialties were involved and 4 examinations (IQI, 3-5) conducted.

Conclusion

The CM offers innovative care by bridging and exceeding conventional boundaries of disciplines, professions, organizations, and primary and specialized care. The patients represented a very complex group, requiring many examinations and involvement of several specialists.

Patient perspectives on primary care for multimorbidity: An integrative review

INTRODUCTION

Improving healthcare for people with multiple chronic or ongoing conditions is receiving increased attention, particularly due to the growing number of people experiencing multimorbidity (MM) and concerns about the sustainability of the healthcare system. Primary care has been promoted as an important resource for supporting people with MM to live well with their conditions and to prevent unnecessary use of health care services. However, traditional primary care has been criticized for not centring the needs and preferences of people with MM themselves. Our aim was to conduct a review that centred on the perspective of people with MM in multiple ways, including having patient partners co-lead the design, conduct and reporting of findings, and focusing on literature that reported the perspective of people with MM, irrespective of it being experimental or nonexperimental.

METHODS

We searched for published literature in CINAHL with Full Text (EBSCOhost) and MEDLINE All (Ovid). Findings from experimental and nonexperimental studies were integrated into collaboration with patient partners.

RESULTS

Twenty-nine articles were included in the review. Findings are described in five categories: (1) Care that is tailored to my unique situation; (2) meaningful inclusion in the team; (3) a healthcare team that is ready and able to address my complex needs; (4) supportive relationships and (5) access when and where I need it.

CONCLUSION

This review supports a reorientation of primary care systems to better reflect the experiences and perspectives of people with MM. This can be accomplished by involving patient partners in the design and evaluation of primary care services and incentivizing collaboration among health and social supports and services for people with MM.

PATIENT OR PUBLIC CONTRIBUTION

Patient partners were involved in the design and conduct of this review, and in the preparation of the manuscript. Their involvement is further elucidated in the manuscript text.

Patient and practitioner priorities and concerns about primary healthcare interactions for osteoarthritis: A meta-ethnography

OBJECTIVE

To explore primary care practitioners' (PCPs) and patients' priorities and concerns for healthcare interactions for osteoarthritis (OA) in primary care.

METHODS

We searched Embase, CINAHL, Medline, PsychInfo (1990 to present) for primary qualitative and mixed methods studies with findings concerning healthcare interactions for OA symptoms. Patient and PCP perceptions were analysed separately then inter-related using a 'line of argument' synthesis.

RESULTS

Twenty-six studies reporting qualitative data from 557 patients and 199 PCPs were synthesised. Our findings suggest that therapeutic interactions for OA can be based on discordant priorities and concerns; some patients perceive that PCPs hold negative attitudes about OA and feel their concerns about impact are not appreciated; some PCPs feel patients have misconceptions about prognosis, and hold pessimistic views about outcomes; and both tend to de-prioritise OA within consultations.

CONCLUSION

Greater working in partnership could build mutual trust, facilitate tailored provision of information, and foster a shared understanding of OA upon which to build realistic goals for management.

PRACTICE IMPLICATIONS

Developing a better shared understanding of OA has the potential to improve the quality of healthcare interactions for both patients and PCPs. The significant impact of OA on everyday life means it should be given higher priority in primary care consultations.

Satisfaction among non-conveyed patients and significant others when discharged at the scene by the ambulance service: an exploratory cross-sectional survey

Background

The ambulance service is facing an increased number of calls and ambulance assignments. Between 12 and 42% of all assignments result in non-conveyance to the Accident and Emergency Department. However, there is limited knowledge regarding satisfaction among patients and significant others when patients are assessed as non-urgent and discharged at the scene. Therefore, the aim of the study was to explore and compare satisfaction with the ambulance service among patients and significant others when the patient was discharged at the scene.

Methods

The present study was designed as a cross-sectional exploratory survey with a consecutive sample employing the Consumer Emergency Care Satisfaction Scale questionnaire on patients and significant others.

Results

A total of 162 questionnaires were analysed, 87 patients and 75 significant others. Overall, satisfaction was high with no significant difference between patients and significant others, although 17-19% were dissatisfied with the discharge information.

Conclusions

Generally, patients and significant others are satisfied with the care provided by the Ambulance Service when discharged at the scene and thus not conveyed the Accident and Emergency Department. The participants were especially satisfied with Specialist Ambulance Nurses’ interpersonal skills, e.g., making time and providing thorough information. Guidelines for assignments involving non-conveyance, as well as information, instructions and what to expect when discharged at the scene can be improved.

A codesigned fit-for-purpose implementation framework for aged care

RATIONALE, AIMS AND OBJECTIVES

The field of implementation science is critical for embedding research evidence into healthcare practice, benefiting individuals, organizations, governments, and the broader community. Implementation science is messy and complex, underpinned by many theories and frameworks. Efficacious interventions for older people with multiple comorbidities exist, yet many lack effectiveness evaluation relevant to pragmatic implementation within aged care practice. This article outlines the conceptualization and development of an Implementation Framework for Aged Care (IFAC), fit-for-purpose for an aged care organization, Bolton Clarke, intent on embedding evidence into practice.

METHOD

A four-stage process was adopted to (1) explore context and relevant literature to conceptualize the IFAC; (2) identify key elements for a draft IFAC; (3) expand elements and refine the draft in consultation with experts and (4) apply the IFAC to three existing projects, identifying key learnings. A checklist to operationalize the IFAC was then developed.

RESULTS

The IFAC is grounded in codesign principles and encapsulated by the implementation context, from a social, cultural and political perspective. The IFAC addresses the questions of (1) why do we need to change?; (2) what do we know?; (3) who will benefit?; (4) who will make the change?; (5) what strategies will be used?; and (6) what difference are we making? Three pilot projects: early adoption of a Wellness and Reablement approach; a care worker and virtual physiotherapist-led program to prevent falls; and a therapeutic horticulture program for residential communities, highlight learnings of applying the IFAC in practice.

CONCLUSION

This fit-for-purpose IFAC was developed for a proactive and responsive aged care provider. The simplicity of the six-question IFAC is underpinned by substantial theoretical perspectives for its elements and their connections. This complexity is then consolidated into an 18-question checklist to operationalize the IFAC, necessary to advance the translation of evidence into clinical practice.

Assessing the experience of person-centred coordinated care of people with chronic conditions in the Netherlands: Validation of the Dutch P3CEQ

BACKGROUND

Countries are adapting their health and social care systems to better meet the needs of growing populations with (multiple) chronic conditions. To guide this process, assessment of the 'patient experience' is becoming increasingly important. For this purpose, the Person-Centred Coordinated Care Experience Questionnaire (P3CEQ) was developed in the United Kingdom, and translated into several languages.

AIM

This study aimed to assess the internal and construct validity of the Dutch P3CEQ to capture the experience of person-centred coordinated care of people with chronic conditions in the Netherlands.

PARTICIPANTS AND METHODS

Adults with chronic conditions (N = 1098) completed the Dutch P3CEQ, measures of health literacy and patient activation, and reported the use and perceived quality of care services. Data analysis included Principal Component and reliability analysis (internal validity), analysis of variance and Student's T-tests (construct validity).

RESULTS

The two-component structure found was pretty much the same as in the UK validation study. Sociodemographic correlates also resembled those found in the United Kingdom. Women, persons who were less educated, less health-literate or less activated experienced less person-centred coordinated care. P3CEQ scores correlated positively with general practitioner performance scores and quality ratings of the total care received.

CONCLUSION

The Dutch P3CEQ is a valid instrument to assess the experience of person-centred coordinated care among people with chronic conditions in the Netherlands. Awareness of inequity and more attention to communication skills in professional training are needed to ensure that care professionals better recognize the needs of women, lower educated or less health-literate persons, and improve their experiences of care.

PATIENT CONTRIBUTION

The P3CEQ has been developed in collaboration with a range of stakeholders. Eighteen persons with (multiple) chronic conditions participated as patient representatives and codesign experts in (four) codesign workshops. Other patient representatives participated in cognitive testing of the English-language instrument. The usability of the P3CEQ to capture the experience of person-centred coordinated care of older persons has been examined by interviewing 228 older European service users, including 13 living in the Netherlands, as part of the SUSTAIN project. More than a thousand persons with chronic conditions participated in the validation study of the Dutch P3CEQ.

An Atypical Case of Extreme Polypharmacy

A commonly reported definition of polypharmacy is the numerical definition of 5 or more medications daily, and definitions have ranged from 2 or more to 11 or more medications. In this case report, an extreme case of polypharmacy is presented, highlighted by the inordinate number of drugs used over time throughout the patient’s care. A 48-year-old African American female with multiple comorbidities experienced a serious adverse drug event (ADE) prompting reporting to MedWatch, the US Food and Drug Administration’s adverse drug event reporting system. The patient’s concomitant medications included 146 drug entities, across 82 therapeutic drug categories. It is apparent that the greatest influence on the occurrence of polypharmacy was the presence of multiple comorbidities, and treatment centered around addressing each morbidity with drug therapy. This case illustrates the insidious nature of polypharmacy and raises questions as to the appropriate progression and limits on the use of multiple medications.

Shared decision-making between older people with multimorbidity and GPs: focus group study

Background

Shared decision making (SDM), utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate SDM, yet few studies have explored this dynamic for older patients with multimorbidity in general practice.

Aim

To explore factors influencing SDM from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care.

Design and setting

Qualitative study. General practices (rural and urban) in Devon, England.

Method

Four focus groups: two with patients (aged ≥65 years with multimorbidity) and two with GPs. Data were coded inductively by applying thematic analysis.

Results

Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to SDM, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to SDM. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for SDM. Increasing consultation duration and improving continuity were viewed as facilitators.

Conclusion

Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to SDM and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of SDM training. The incorrect perception that most clinicians already effectively facilitate SDM should be addressed to improve the uptake of personalised care interventions.

Polypharmacy in Polish Older Adult Population-A Cross-Sectional Study: Results of the PolSenior Project

Polypharmacy is a challenging issue in geriatrics. The aim of the study was to characterize correlates of polypharmacy in the PolSenior project. The PolSenior project, was a comprehensive survey in a large and longitudinal representative sample of thePolish older population. The project was conducted by the International Institute of Molecular and Cell Biology in Warsaw between 2008 and 2011. All medications consumed during the week preceding the survey were evaluated for each participant (n = 4793, including 2314 females (48.3%)). Thereafter, the percentage of those with polypharmacy (at least 5 medications) and excessive polypharmacy (at least 10 medications) was calculated, and their correlates were determined. The average number of medications used by participants was 5.1 ± 3.6, and was higher in females than in males (5.5 ± 3.5 vs. 4.8 ± 3.5; p < 0.001). Polypharmacy characterized 2650 participants (55.3%) and excessive polypharmacy—532 of them (11.1%). The independent correlates associated withpolypharmacy were: age over 70 years, female sex, higher than primary education, living in an urban area, comorbidities, any hospitalization during past five years, and visiting general practicioners at least yearly. As for correlates with excessive polypharmacy, they were: age 80–84 years, female sex, living in an urban area, diagnosis of at least four chronic diseases, and at least two hospitalizations in the last five years. This study serves as a starting place to understand patient characteristics associated with polypharmacy, excessive polypharmacy, and identify targeted interventions.

Improving Health Care for Patients with Multimorbidity: A Mixed-Methods Study to Explore the Feasibility and Process of Aligning Scheduled Outpatient Appointments through Collaboration between Medical Specialties

Background

Many patients with multimorbidity have appointments and parallel trajectories in several outpatient clinics across medical specialties. This organisation may disintegrate care and challenges the navigation of the healthcare system.

Methods

This study explored the feasibility of an intervention targeting patients seen in several outpatient clinics for multiple diseases. The intervention aimed to coordinate outpatient appointments through enhanced collaboration across medical specialties. Feasibility and process were assessed through mixed methods by tracking the intervention through prospectively collected data and through semi-structured interviews with patients and healthcare professionals.

Results

A multidisciplinary outpatient pathway was established as an intervention. Appointments for different medical specialties were scheduled on the same day, information was rapidly transferred to the receiving outpatient clinic, and a multidisciplinary conference resulted in the circulation of a joint summary. In the first year, 20% of eligible patients were enrolled. Appointments were aligned in 15% of patients, and blood samples were reduced by 29%. Overall, intervention components were delivered as intended and seemed acceptable, although the patient selection needed refinement.

Conclusion

It seems feasible to set up an intervention for patients attending several hospital outpatient clinics. Future interventions should focus on selecting patients in greatest need for alignment of appointments.

Health care network model for older adults: a co-creation and participatory action research approach

Objective: To develop a collaborative, multidisciplinary care model for older adults that improves interdisciplinary teamwork and increases access to specialized services for frail patients, helping solve management problems in the Brazilian Unified Health System. In the state of Bahia, the health care network for older adults requires better interaction and integration with the Unified Health System and the Unified System of Social Assistance to improve patient flow in the network. Methods: We used a co-creation and participatory action research approach based on reflection, data collection, interaction, and feedback with participants and stakeholders. Data was collected from health professionals, representatives of health agencies, and older adults through collective and individual interviews, reflective diaries, and direct communication. Results: An action plan involving members of the older adult care network was developed to put the new model into practice. A pilot study with a multidisciplinary team allowed adjustments and implementation of the model at our institution. Conclusions: The new model improved both the internal management of the State Reference Center for Older Adult Health Care (Centro de Referência Estadual de Atenção à Saúde do Idoso - CREASI) and its interaction with primary care, optimizing patient flow and establishing rules for shared management between CREASI and primary care institutions. In view of this, restructuring the care model reorganized relations between the agencies, expanding CREASI’s role in the management and systematization of older adult health.

Patient, carer and healthcare professional experiences of complex care quality in multidisciplinary primary healthcare centres: qualitative study with face-to-face, in-depth interviews and focus groups in five French multidisciplinary primary healthcare centres

Objectives

To explore care experiences in multidisciplinary primary healthcare centres from the patients, carers and healthcare professionals perspectives.

Design

This qualitative study used face-to-face, in-depth interviews and focus groups. Patients with multimorbidity monitored by a General Practitioner (GP) and another professional from the health centre were recruited through purposive sampling and included with their carer. They were interviewed together while professionals were interviewed separately. Verbatims were coded with subsequent blind analysis, using an inductive approach, to find aspects and features. The constant comparative method highlighted data consistencies and variations.

Participants

Twenty-six patients, 23 family carers and 57 healthcare professionals.

Setting

Five multidisciplinary primary healthcare centres, in France, between March 2017 and December 2018.

Results

This unique study grouped perspectives into nine core quality of primary care aspects: having accessible, available, and varied care; feeling welcome and enjoying comfortable, well-equipped, and clean premises; having quality medicotechnical care (medical knowledge and technical skills); having a reliable GP; receiving appropriate care from healthcare professionals other than the GP; maintaining an efficient relationship with healthcare professionals; benefiting from organised and coordinated care; being an informed, supported and involved patient; having an informed, supported and involved carer. New areas of interest include the multidisciplinary nature of the centres, appreciation of other professionals within the centre, medicotechnical dimensions of care and the carer’s role in maintaining patient autonomy.

Conclusions

This is the first study to interview patients and carers alongside healthcare professionals. This enhanced knowledge improves understanding of these aspects and can guide implementation of evaluation tools that truly reflect patient and carer needs and enable an efficient experience in terms of quality. To address deficiencies in existing questionnaires, the new perspectives found will be added to former aspects to create a comprehensive quality of primary care evaluation tool.

Trial registration number

NCT02934711, Results.

Patient-centeredness in the multimorbid elderly: a focus group study

Background

 Patient-centeredness (PC) aims to adapt health care to the individual needs and preferences of patients. An existing integrative model of PC comprises several dimensions of PC which have not yet been investigated from the patients’ perspective. Older patients with multimorbidity represent a target group for patient-centered care, as their care needs are particularly complex and should be addressed individually. We aimed to assess the perspective that older patients with multimorbidity have of patient-centered care and to examine the transferability of the integrative model of PC to this specific population.

Method

We performed 4 guided focus group interviews with a total of 20 older individuals with multimorbidity. The focus group interviews were audio-recorded and transcribed verbatim. Patients’ statements were content-analyzed applying an a priori designed system of categories that included the dimensions of PC from the integrative model and the additional category ‘prognosis and life expectancy’, which had emerged from an initial literature search on aspects of PC specific to the multimorbid elderly.

Results

The new category ‘prognosis and life expectancy’ was confirmed and expanded to ‘individual care needs related to aging and chronic disesase’. All dimensions of our integrative PC model were confirmed for older patients with multimorbidity. Among these, we found that eight dimensions (individual care needs related to aging and chronic disease, biopsychosocial perspective, clinician-patient communication, essential characteristics of the clinician, clinician-patient-relationship, involvement of family and friends, coordination and continuity of care, access to care) were complemented by aspects specific to this target population.

Conclusions

The integrative PC model is applicable to the population of older patients with multimorbidity. For a population-specific adaptation, it might be complemented by the dimension ‘individual care needs in aging and chronic disease’, in conjunction with age-specific aspects within existing dimensions. Together with corresponding results from a Delphi survey, our adapted PC model will serve as the basis for a subsequent systematic review of instruments measuring PC in older patients with multimorbidity.

Trial registration

PROSPERO (https://www.crd.york.ac.uk/prospero; CRD42018084057; 2018/02/01), German Clinical Trials Register (www.drks.de; DRKS00013309; 2018/01/23).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02448-8.

The dialogue as decision support; lived experiences of extended collaboration when an ambulance is called

Purpose

This study aimed to describe extended collaboration in situations when an ambulance was called, as experienced by older patients, a significant other, and ambulance- and primary healthcare (PHC) centre personnel.

Methods

The study used a phenomenological reflective lifeworld research (RLR) approach. Participants included in three specific situations with extended collaboration were interviewed: three older patients, one significant other, three ambulance personnel and four personnel at the PHC centre. The transcribed interviews were analysed for meanings of the phenomenon.

Results

The extended collaboration means that decisions were supported through dialogue by bridging knowledge spaces between person, within-team and across-team levels. Through dialogue experience and knowledge were shared and certainty in decisions was increased. The extended collaboration was built on trust, responsibility taken, shared and entrusted, and the common goal of adapted care for the unique patient. A need for further improvement and transparency was elucidated.

Conclusions

The difficulty of making care decisions stresses the importance of available extended collaboration based on the dialogue between patients, significant others, and ambulance- and PHC centre personnel to increase certainty in decisions. Collaboration further requires respectful encounters, trust, responsibility and a common goal of adapting the care for the unique patient.

Trends, patterns and health consequences of multimorbidity among South Korea adults: Analysis of nationally representative survey data 2007-2016

Background

Multimorbidity is a global challenge. It is more common in the elderly and deprived populations. Health systems are not providing appropriate care for people with multimorbidity as they are focused on managing single diseases and are not oriented to effectively manage complexity of care-coordination for multimorbidity. This study aims to examine trends, disparities and consequences of multimorbidity over a 10-year period. It also aims to analyze different multimorbidity clusters and their association with quality of life.

Methods

This study analyzes Korea National Health and Nutrition Examination Survey – a cross-sectional survey repeated each year of 100 000 individuals aged one or more in 192 regions of South Korea – for the 10-year period 2007-2016. This is a population-based study based on nationally representative survey data for 10 years in Korea. Our study included 68 590 adults aged 19 or more who answered questions on presence of diseases. 39 chronic conditions were included. Disease clustering by frequency, composition and number of diseases from the top 10 most common chronic conditions were used to establish patterns of multimorbidity clusters. We performed regression analyses to analyze annual trend and the prevalence of multimorbidity across socioeconomic strata. Regressions were performed to measure association between multimorbidity and unmet need, health care service utilization, sickness days, perceived health status, and EQ-5D.

Results

Multimorbidity increased in the study period and was more prevalent in the elderly, females, and people with lower household income and education level. Multimorbidity was associated with increased unmet need, health care utilization and sickness days and reduced perceived health status and quality of life. Hypertension was the most common condition in individuals with multimorbidity. Reduced quality of life was associated with increasing number of chronic diseases and multimorbidity clusters which included stroke and arthritis.

Conclusions

The prevalence of multimorbidity varied across socioeconomic strata, with higher levels and health consequences observed in individuals in lower socio-economic income groups. Different multimorbidity clusters had differential effect on the quality of life. Health system designs incorporating integrated care strategies for complex conditions are required to effectively manage multimorbidity and different multimorbidity clusters.

Adults' experience of living with multimorbidity: a qualitative systematic review protocol

OBJECTIVE

The objective of the review is to synthesize the qualitative research literature on the experiences of adults living with multimorbidity.

INTRODUCTION

Persons living with two or more chronic health conditions, known as multimorbidity, is a global health problem in countries of all income levels. Multimorbidity presents an ever-increasing resource and financial burden for health care systems and similarly challenges those living with multiple health conditions because of the complexity of their health and treatment requirements. Overall, persons with multimorbid conditions experience a high risk of mortality and a lower quality of life. Understanding the adult experience of multimorbidity is important for creating and implementing health care that meets the needs of individuals living with the burden of multiple chronic health conditions.

INCLUSION CRITERIA

The systematic review will include published peer-reviewed and unpublished English-language studies from 2000 to 2020 that provide qualitative evidence of adults' (18+ years of age) experiences of living with multimorbidity.

METHODS

CINAHL with full text, Cochrane, MEDLINE, Embase, PsycINFO, Consumer Health Database, Scopus, and ScienceDirect journals and books will be searched. Reference lists of included studies will also be cross-checked with search outcomes to identify additional studies. Sources of gray literature will also be searched for unpublished studies. The critical appraisal of selected studies and the extraction of data will be independently undertaken by two reviewers using JBI methods. The findings will be pooled using meta-aggregation to produce comprehensive synthesized findings. A ConQual Summary of Findings will also be presented.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020152038.

The Development of a Situation-Specific Nurse-Led Culturally Tailored Self-Management Theory for Chinese Patients With Heart Failure

INTRODUCTION

Self-management is essential for treating heart failure (HF). Culture influences the ability to cope, negotiate, and adopt self-management behaviors. However, current HF self-management interventions for Chinese patients do not take culture into consideration. The aim of this article is to describe the development of a situation-specific nurse-led culturally tailored self-management theory for Chinese patients with HF.

METHODOLOGY

An integrative approach was used as theory development strategy for the situation-specific theory.

RESULTS

Based on theoretical and empirical evidence, and theorists' experiences from research and practice, a nurse-led culturally tailored self-management theory for Chinese patients with HF was developed.

DISCUSSION

Researchers addressing health phenomena often have difficulty defining, conceptualizing, and operationalizing culture. The situation-specific theory developed in this study has the potential to increase specificity (i.e., logical adequacy and usefulness) of existing theories while informing the application to nursing practice. Further critique and testing of the situation-specific theory is warranted.

Evaluating the content of a patient-reported outcome measure for people with multimorbidity: a Delphi consensus

PURPOSE

Evidence supporting multimorbidity-adapted interventions is scarce, mostly due to a lack of adapted outcome measures. Measurement constructs for a novel patient-reported outcome measure (PROM) were defined in previous studies using a literature review, a qualitative description from stakeholders, and an item pool identification process. The aim of this study was to attain consensus on the content of this novel PROM.

METHODS

A three-round electronic modified Delphi technique was conducted using an academic and clinical expert panel. Using a Likert scale, the panel rated the relevance, improvability, and self-ratability of each construct and item of the preliminary version of the PROM. The main outcome was consensus attainment, defined as strong (≥ 70%), moderate (50-69%) or low agreement (< 50%). Constructs and items with strong consensus were kept, moderate were sent to the next round and low agreement were rejected.

RESULTS

From the 61 experts contacted, 39 participated in the first round of the Delphi, with a 12.8% attrition at the second round (n = 34) and 38.2% at the third round (n = 21). The panel included mostly female academic experts from nursing and medicine backgrounds. The preliminary PROM included 19 constructs and 70 items; from these, 16 constructs and 50 items attained consensus. The consensus attainment process excluded three constructs and their items: awareness, weight control and social integration.

CONCLUSION

Consensus was reached for a patient-reported outcome measure adapted for people with multimorbidity including 50 relevant, improvable and self-ratable items categorized under 16 constructs. As more interventions tailored to multimorbidity are implemented, there is an increasing need for a valid measure of the effectiveness of these interventions.

Priorities and preferences for care of people with multiple chronic conditions

Background

To guide the development of high‐quality care for people with multiple chronic conditions, partners of the European Joint Action CHRODIS developed the Integrated Multimorbidity Care Model. To assess its suitability for improving care for people with multimorbidity in the Netherlands, the model was piloted in a primary care setting with both patients and care providers.

Aim

This paper reports on the patient perspective, and aims to explore the priorities, underlying values and preferences for care of people with multimorbidity.

Participants and methods

Twenty persons with multimorbidity (selected from general practice registries) participated in a focus group or telephone interview. Subsequently, a questionnaire was completed by 863 persons with multimorbidity registered with 14 general practices. Qualitative data were thematically analysed and quantitative data by means of descriptive statistics.

Results

Frequently prioritized elements of care were the use of shared electronic health records, regular comprehensive assessments, self‐management support and shared decision making, and care coordination. Preferences for how these elements should be specifically addressed differed according to individual values (eg weighing safety against privacy) and needs (eg ways of coping with multimorbidity).

Conclusion

The JA‐CHRODIS Integrated Multimorbidity Care Model reflects the priorities and preferences for care of people with multimorbidity in the Netherlands, which supports its relevance to guide the development of person‐centred integrated care for people with multiple chronic conditions in the Netherlands.

Patient contribution

European patient experts contributed to the development and applicability assessment of the JA‐CHRODIS Integrated Multimorbidity Care Model; Dutch patients participated in focus groups, interviews and a survey.

Quality of Life among Community-Dwelling Middle-Aged and Older Adults: Function Matters More than Multimorbidity

OBJECTIVES

Quality of life stands for the comprehensive assessment for health conditions and the central concerns in the seniors' care. The inter-relationship between health-related quality of life (HRQoL) and multimorbidity among community-dwelling healthy older adults remains uncertain.

METHODS

Data of 1839 participants from the I-Lan Longitudinal Aging Study were excerpted for analysis. Functional status and HRQoL were measured by the Functional Autonomy Measurement System and the Chinese version of 12-item Short-Form Health Survey version 2. Poor HRQoL was defined as lowest quintile of physical and mental components summaries (PCS and MCS). Multivariable linear and logistic regression analysis were applied to explore associations between variables of interest.

RESULTS

Adjusted for potential confounders, multivariable linear regression showed that multimorbidity and functional impairment were negatively associated with PCS (β coefficients -1.8 vs. -8.4) and MCS (β coefficients -1.9 vs. -4.8). Logistic regression affirmed similar associations that the odds of being poor HRQoL were 1.6 (95% CI 1.1-2.2) for multimorbidity, and 5.4 (95% CI 2.8-10.3) for functional impairment in PCS; 1.9 (95% CI 1.4-2.6) for multimorbidity and 6.0 (95%CI 3.2-11.5) for functional impairment in MCS. Adjusted for depressive symptoms and cognitive performance, functional impairment was significantly associated with poor physical component (OR:4.68, 95% CI: 0.35-19.34, p<0.001) and mental component in HRQoL (OR:2.4, 95% CI: 1.1-5.5, p=0.032), but the associations were insignificant in multimorbidity.

CONCLUSIONS

Findings from the study strengthened the importance of functional performance on HRQoL among community-living middle-aged and older adults, which is essential in community health promotion activities and health service programs.

Making care more patient centered; experiences of healthcare professionals and patients with multimorbidity in the primary care setting

BACKGROUND

The present study describes how primary care can be improved for patients with multimorbidity, based on the evaluation of a patient-centered care (PCC) improvement program designed to foster the eight PCC dimensions (patient preferences, information and education, access to care, physical comfort, coordination of care, continuity and transition, emotional support, and family and friends). This study characterizes the interventions implemented in practice as part of the PCC improvement program and describes the experiences of healthcare professionals and patients with the resulting PCC delivery.

METHODS

This study employed a mixed-methods design. Semi-structured interviews were conducted with nine general practitioners and nurse practitioners from seven primary care practices in Noord-Brabant, the Netherlands, that participated in the program (which included interventions and workshops). The qualitative interview data were examined using thematic analysis. A longitudinal survey was conducted with 138 patients with multimorbidity from these practices to assess perceived improvements in PCC and its underlying dimensions. Paired sample t tests were performed to compare survey responses obtained at a 1-year interval corresponding to program implementation.

RESULTS

The PCC improvement program is described, and themes necessary for PCC improvement according to healthcare professionals were generated [e.g. Aligning information to patients' needs and backgrounds, adapting a coaching role]. PCC experiences of patients with multimorbidity improved significantly during the year in which the PCC interventions were implemented (t = 2.66, p = 0.005).

CONCLUSION

This study revealed how primary PCC can be improved for patients with multimorbidity. It emphasizes the importance of investing in PCC improvement programs to tailor care delivery to heterogenous patients with multimorbidity with diverse care needs. This study generates new perspectives on care delivery and highlights opportunities for its improvement according to the eight dimensions of PCC for patients with multimorbidity in a primary care setting.

Association between continuity of care and subsequent diagnosis of multimorbidity in Ontario, Canada from 2001-2015: A retrospective cohort study

BACKGROUND

Continuity of care is a well-recognized principle of the primary care discipline owing to its medical, interpersonal, and cost-saving benefits. Relationship continuity or the ongoing therapeutic relationship between a patient and their physician is a particularly desirable goal, but its role in preventing the accumulation of chronic conditions diagnoses in individuals is unknown. The objective of this study was to investigate the effect of continuity of care with physicians on the rate of incident multimorbidity diagnoses in patients with existing conditions.

METHODS

This was a population-based, retrospective cohort study from 2001 to 2015 that focused on patients aged 18 to 105 years with at least one chronic condition (n = 166,665). Our primary exposure was relationship continuity of care with general practitioners and specialists measured using the Bice-Boxerman Continuity of Care Index (COCI). COCI was specified as a time-dependent exposure prior to the observation period. Our outcomes of interest were the time to diagnosis of a second, third, and fourth chronic condition estimated using cause-specific hazard regressions accounting for death as a competing risk.

FINDINGS

We observed that patients with a single chronic condition and high continuity of care (>0.50) were diagnosed with a second chronic condition or multimorbidity at an 8% lower rate compared to individuals with low continuity (cause-specific hazard ratio (HR) 0.92 (95% Confidence Interval 0.90-0.93; p<0.0001) after adjusting for age, sex, income, place of residence, primary care enrolment, and the annual number of physician visits. Continuity remained protective as the degree of multimorbidity increased. Among patients with two conditions, the risk of diagnosis of a third chronic condition was also 8% lower for individuals with high continuity (HR 0.92; CI 0.90-0.94; p<0.0001). Patients with three conditions and high continuity had a 9% lower risk of diagnosis with a fourth condition (HR 0.91; CI 0.89-0.93; p<0.0001).

CONCLUSIONS

Continuity of care is a potentially modifiable health system factor that reduces the rate at which diagnoses of chronic conditions are made over time in patients with multimorbidity. Additional research is needed to explain the underlying mechanisms through which continuity is related to a protective effect and the clinical sequalae.

Preservation of Person-Centered Care Through Videoconferencing for Patient Follow-up During the COVID-19 Pandemic: Case Study of a Multidisciplinary Care Team

Background

The Patient-Centered Team (PACT) focuses on the transitional phase between hospital and primary care for older patients in Northern Norway with complex and long-term needs. PACT emphasizes a person-centered care approach whereby the sharing of power and the patient’s response to “What matters to you?” drive care decisions. However, during the COVID-19 pandemic, videoconferencing was the only option for assessing, planning, coordinating, and performing treatment and care.

Objective

The aim of this study is to report the experience of the PACT multidisciplinary health care team in shifting rapidly from face-to-face care to using videoconferencing for clinical and collaborative services during the initial phase of the COVID-19 pandemic. This study explores how PACT managed to maintain person-centered care under these conditions.

Methods

This case study takes a qualitative approach based on four semistructured focus group interviews carried out in May and June 2020 with 19 PACT members and leaders.

Results

The case study illustrates that videoconferencing is a good solution for many persons with complex and long-term needs and generates new opportunities for interaction between patients and health care personnel. Persons with complex and long-term needs are a heterogeneous group, and for many patients with reduced cognitive capacity or hearing and vision impairment, the use of videoconferencing was challenging and required support from relatives or health care personnel. The study shows that using videoconferencing offered an opportunity to use health care personnel more efficiently, reduce travelling time for patients, and improve the information exchange between health care levels. This suggests that the integration of videoconferencing contributed to the preservation of the person-centered focus on care during the COVID-19 pandemic. There was an overall agreement in PACT that face-to-face care needed to be at the core of the person-centered care approach; the main use of videoconferencing was to support follow-up and coordination.

Conclusions

The COVID-19 pandemic and the rapid adoption of digital care have generated a unique opportunity to continue developing a health service to both preserve and improve the person-centered care approach for persons with complex and long-term needs. This creates demand for overall agreements, including guidelines and procedures for how and when to use videoconferencing to supplement face-to-face treatment and care. Implementing videoconferencing in clinical practice generates a need for systematic training and familiarization with the equipment and technology as well as for an extensive support organization. Videoconferencing can then contribute to better preparing health care services for future scenarios.

Patient Activation and its Predictors in Hospitalized Older Adults in Singapore

BACKGROUND

Patient activation is critical in hospitalized older adults preparing for discharge as it enhances their ability to self-care at home. Little is known about how person-centred care and demographic predictors could influence activation in Asian patients.

AIMS

To explore patient activation and its predictors in hospitalized older adults in Singapore.

METHODS

Multi-centre cross-sectional survey of hospitalized older adults. Multivariable analysis conducted with age, gender, education, socioeconomic status, functional dependency and perception of person-centred care as potential predictors to patient activation.

RESULTS

300 older adults were surveyed, 65% were at the top two levels of activation. Perception of person-centred nursing care was the strongest predictor with the largest effect on patient activation, (β=0.22, b=3.48, 95% CI:1.70-5.26, p<0.001). Other predictors were age, education, income and independence in care.

CONCLUSION

Our study highlights the importance of person-centred nursing care in raising patient activation in hospitalized older adults, enhancing their capacity to self-care.

The complexity of caregiving for community-living older adults with multiple chronic conditions: A qualitative study

Background:

Older adults with multiple chronic conditions (MCC) rely heavily on caregivers for assistance with care. However, we know little about their psychosocial experiences and their needs for support in managing MCC. The purpose of this study was to explore the experiences of caregivers of older adults living in the community with MCC.

Methods:

This qualitative study was a secondary analysis of previously collected data from caregivers in Ontario and Alberta, Canada. Participants included caregivers of older adults (65 years and older) with three or more chronic conditions. Data were collected through in-depth, semi-structured interviews. Interview transcripts were coded and analyzed using Thorne’s interpretive description approach.

Results:

Most of the 47 caregiver participants were female (76.6%), aged 65 years of age or older (61.7%), married (87.2%) and were spouses to the care recipient (68.1%). Caregivers’ experiences of caring for community-living older adults with MCC were complex and included: (a) dealing with the demands of caregiving; (b) prioritizing chronic conditions; (c) living with my own health limitations; (d) feeling socially isolated and constrained; (e) remaining committed to caring; and (f) reaping the rewards of caregiving.

Conclusions:

Healthcare providers can play key roles in supporting caregivers of older adults with MCC by providing education and support on managing MCC, actively engaging them in goal setting and care planning, and linking them to appropriate community health and social support services. Communities can create environments that support caregivers in areas such as social participation, social inclusion, and community support and health services.

Supporting frail older people with depression and anxiety: a qualitative study

OBJECTIVES

Depression and anxiety are common in later life, particularly when people are frail. This leads to reduced quality of life, faster decline in physical health and increased health/social care use. Available treatments are commonly not tailored to people with frailty. We explored frail older peoples' experiences of depression and/or anxiety and how services could be adapted to their needs.

METHODS

Semi-structured interviews with 28 older people in the UK purposively sampled for practice location and severity of frailty and anxiety/depression. We asked about symptoms, interactions with physical health, help-seeking, treatments and what might help in future. We audio-recorded and transcribed interviews, using thematic analysis to inductively derive themes.

RESULTS

Frail older people had low expectations of their wellbeing at this point in life due to multiple physical health issues and so anxiety and mild depressive symptoms were normalised. There was a particular reluctance and uncertainty regarding help-seeking for anxiety. Treatments were considered appropriate where they aligned with coping skills developed over their lifetime, and facilitated independence and problem-solving skills. Most older people felt their knowledge of mental health was limited and relied upon information about and endorsement of therapies from an expert. This was usually their GP, but access was often problematic. Online methods of accessing information and therapies were not popular.

CONCLUSION

Mental health support for frail older people needs to address late-life anxieties as well as depression, account for physical health issues, align with older people's need for independence and facilitate coping skills.

Patients' aged ≥65 years dispositions during ambulance assignments, including factors associated with non-conveyance to hospital: a longitudinal and comparative study

OBJECTIVES

Patients ≥65 years old represent 30%-50% of all ambulance assignments (AAs), and the knowledge of which care level they are disposed to is limited and diverging. The aim of this study was therefore to describe and compare characteristics of patients' aged ≥65 years dispositions during AA, including determining changes over time and factors associated with non-conveyance to hospitals.

DESIGN

A longitudinal and comparative database study.

SETTING

Ambulance service in a Swedish region.

PARTICIPANTS

32 085 AAs with patients ≥65 years old during the years 2014, 2016 and 2018.

EXCLUSION CRITERIA

AAs with interhospital patient transfers and lack of patients' dispositions data.

OUTCOME MEASURES

Dependent factors: conveyance and non-conveyance to hospitals. Independent factors: age, sex, symptom, triage level, scene, time, day and season.

RESULTS

The majority (n=29 060; 90.6%) of patients' dispositions during AA were conveyance to hospitals. In total, the most common symptoms were circulatory (n=4953; 15.5%) and respiratory (n=4529; 14.1%). A significant increase, p<0.01, of non-conveyance to hospitals was shown during 2014 and 2018, from 801 (7.8%) to 1295 (11.4%). Increasing age was associated with decreasing odds of non-conveyance, 85-89 years (OR=0.85, 95 % CI=0.72 to 0.99) and 90 years or older (OR=0.80, 95 % CI=0.68 to 0.93). Several factors were associated with non-conveyance, for example, symptoms of diabetes (OR=8.57, 95 % CI=5.99 to 12.26) and mental disorders (OR=5.71, 95 % CI=3.85 to 8.48) in comparison with infections.

CONCLUSIONS

The study demonstrates several patient characteristics, and factors associated with non-conveyance to hospitals, such as age, symptom, triage level, scene, time, day and season. The increasing non-conveyance trend highlights the importance of further studies on optimal care levels for patients ≥65 years old.

A Novel Approach to Developing a Discordance Index for Older Adults With Chronic Kidney Disease

BACKGROUND

Older adults with chronic kidney disease (CKD)-discordant conditions (comorbid conditions with treatment recommendations that potentially complicate CKD management) have higher risk of hospitalization and death. Our goal is to develop a CKD-Discordance Index using electronic health records to improve recognition of discordance.

METHODS

This retrospective cohort study included Kaiser Permanente Southern California patients aged ≥65 years and older with incident CKD (N = 30,932). To guide inclusion of conditions in the Index and weight each condition, we first developed a prediction model for 1-year hospitalization risk using Cox regression. Points were assigned proportional to regression coefficients derived from the model. Next, the CKD-Discordance Index was calculated as an individual's total points divided by the maximum possible discordance points. The association between CKD-Discordance Index and hospitalizations, emergency department visits, and mortality was accessed using multivariable-adjusted Cox regression model.

RESULTS

Overall, mean (SD) age was 77.9 (7.6) years, 55% of participants were female, 59.3% were white, and 32% (n = 9,869) had ≥1 hospitalization during 1 year of follow-up. The CKD-Discordance Index included the following variables: heart failure, gastroesophageal reflux disease/peptic ulcer disease, osteoarthritis, dementia, depression, cancer, chronic obstructive pulmonary disease/asthma, and having four or more prescribers. Compared to those with a CKD-Discordance Index of 0, adjusted hazard ratios (95% confidence interval) for hospitalization were 1.39 (1.27-1.51) and 1.81 (1.64-2.01) for those with a CKD-Discordance Index of 0.001-0.24 and ≥0.25, respectively (ptrend < .001). A graded pattern of risk was seen for emergency department visits and all-cause mortality.

CONCLUSION

A data-driven approach identified CKD-discordant indicators for a CKD-Discordance Index. Higher CKD-Discordance Index was associated with health care utilization and mortality.

[Health care for patients with multimorbidity. The perception of professionals]

Objetivo

Explorar las percepciones de los profesionales sanitarios sobre las características de la atención sanitaria a pacientes con multimorbilidad.

Diseño

Estudio cualitativo de trayectoria fenomenológica realizado entre enero y septiembre de 2015 mediante 3 entrevistas grupales (grupos de discusión) y 15 individuales.

Emplazamiento

Servicio Aragonés de Salud.

Participantes

Profesionales médicos y de enfermería del Servicio Aragonés de Salud pertenecientes a distintos servicios: Medicina Interna, Atención Primaria, Urgencias y Gestión. También se incluyó un farmacéutico.

Métodos

Se realizó un muestreo intencional no probabilístico que permitiese configurar las unidades muestrales buscando criterios de representatividad del discurso, permitiendo conocer e interpretar el fenómeno estudiado en profundidad, en sus diferentes visiones. Se entrevistó a profesionales sanitarios con perfiles diferentes que conociesen en profundidad la atención a pacientes con multimorbilidad. Las entrevistas fueron grabadas, transcritas literalmente e interpretadas, mediante el análisis social del discurso.

Resultados

Se identifica una cultura profesional orientada a la atención de enfermedades individuales, falta de coordinación entre especialidades, pacientes sometidos a numerosas prescripciones, Guías de Práctica Clínica y formación especialmente centradas en enfermedades individuales.

Conclusiones

Tanto la cultura profesional como la organización del sistema sanitario se encuentran orientadas a la atención de enfermedades individuales, lo que redunda en dificultades para ofrecer una atención más integral a los pacientes con multimorbilidad.

Self-management program versus usual care for community-dwelling older adults with multimorbidity: A pragmatic randomized controlled trial in Ontario, Canada

Background:

Multimorbidity, the co-existence of 2+ (or 3+) chronic diseases in an individual, is an increasingly common global phenomenon leading to reduced quality of life and functional status, and higher healthcare service use and mortality. There is an urgent need to develop and test new models of care that incorporate the components of multimorbidity interventions recommended by international organizations, including care coordination, interdisciplinary teams, and care plans developed with patients that are tailored to their needs and preferences.

Purpose:

To determine the effectiveness of a 6-month, community-based, multimorbidity intervention compared to usual home care services for community-dwelling older adults (age 65+ years) with multimorbidity (3+ chronic conditions) that were newly referred to and receiving home care services.

Methods:

A pragmatic, parallel, two-arm randomized controlled trial evaluated the intervention, which included in-home visits by an interdisciplinary team, personal support worker visits, and monthly case conferences. The study took place in two sites in central Ontario, Canada. Eligible and consenting participants were randomly allocated to the intervention and control group using a 1:1 ratio. The participants, statistician/analyst, and research assistants collecting assessment data were blinded. The primary outcome was the Physical Component Summary (PCS) score of the 12-Item Short-Form health survey (SF-12). Secondary outcomes included the SF-12 Mental Component Summary (MCS) score, Center for Epidemiological Studies of Depression (CESD-10), Generalized Anxiety Disorder (GAD-7), Self-Efficacy for Managing Chronic Disease, and service use and costs. Analysis of covariance (ANCOVA) tested group differences using multiple imputation to address missing data, and non-parametric methods explored service use and cost differences.

Results:

59 older adults were randomized into the intervention (n = 30) and control (n = 29) groups. At baseline, groups were similar for the primary outcome and number of chronic conditions (mean of 8.6), but the intervention group had lower mental health status. The intervention was cost neutral and no significant group differences were observed for the primary outcome of PCS from SF-12 (mean difference: −4.94; 95% CI: −12.53 to 2.66; p = 0.20) or secondary outcomes.

Conclusion:

We evaluated a 6-month, self-management intervention for older adults with multimorbidity. While the intervention was cost neutral in comparison to usual care, it was not found to improve the PCS from SF-12 or secondary health outcomes. Recruitment and retention challenges were significant obstacles limiting our ability to assess intervention effectiveness. Yet, the intervention was grounded in internationally-endorsed recommendations and implemented in a practice setting (home care) viewed as a key upstream resource fostering independence in older adults. These features collectively support the identification of ways to recruit/retain older adults and test alternative implementation strategies for interventions that are based on sound principles of multimorbidity management.

Experiences of Complex Patients With Telemonitoring in a Nurse-Led Model of Care: Multimethod Feasibility Study

BACKGROUND

Telemonitoring (TM) interventions have been designed to support care delivery and engage patients in their care at home, but little research exists on TM of complex chronic conditions (CCCs). Given the growing prevalence of complex patients, an evaluation of multi-condition TM is needed to expand TM interventions and tailor opportunities to manage complex chronic care needs.

OBJECTIVE

This study aims to evaluate the feasibility and patients' perceived usefulness of a multi-condition TM platform in a nurse-led model of care.

METHODS

A pragmatic, multimethod feasibility study was conducted with patients with heart failure (HF), hypertension (HTN), and/or diabetes. Patients were asked to take physiological readings at home via a smartphone-based TM app for 6 months. The recommended frequency of taking readings was dependent on the condition, and adherence data were obtained through the TM system database. Patient questionnaires were administered, and patient interviews were conducted at the end of the study. An inductive analysis was performed, and codes were then mapped to the normalization process theory and Implementation Outcomes constructs by Proctor.

RESULTS

In total, 26 participants were recruited, 17 of whom used the TM app for 6 months. Qualitative interviews were conducted with 14 patients, and 8 patients were interviewed with their informal caregiver present. Patient adherence was high, with patients with HF taking readings on average 76.6% (141/184) of the days they were asked to use the system and patients with diabetes taking readings on average 72% (19/26) of the days. The HTN adherence rate was 55% (29/52) of the days they were asked to use the system. The qualitative findings of the patient experience can be grouped into 4 main themes and 13 subthemes. The main themes were (1) making sense of the purpose of TM, (2) engaging and investing in TM, (3) implementing and adopting TM, and (4) perceived usefulness and the perceived benefits of TM in CCCs.

CONCLUSIONS

Multi-condition TM in nurse-led care was found to be feasible and was perceived as useful. Patients accepted and adopted the technology by demonstrating a moderate to high level of adherence across conditions. These results demonstrate how TM can address the needs of patients with CCCs through virtual TM assessments in a nurse-led care model by supporting patient self-care and keeping patients connected to their clinical team.

A complex intervention for multimorbidity in primary care: A feasibility study

Aim

To assess the feasibility of a patient-centered complex intervention for multimorbidity (CIM) based on general practice in collaboration with community health-care centers and outpatient clinics.

Methods

Inclusion criteria were age ≥18 years, diagnoses of two or more of three chronic conditions (diabetes, chronic obstructive pulmonary disease (COPD), and chronic heart conditions), and a hospital contact during the previous year. The CIM included extended consultations and nurse care manager support in general practice and intensified cross-sectorial collaboration. Elements included a structured care plan based on patients' care goals, coordination of services, and, if appropriate, shifting outpatient clinic visits to general practice, medication review, referral to rehabilitation, and home care. The acceptability dimension of feasibility was assessed with validated questionnaires, observations, and focus groups.

Results

Forty-eight patients were included (mean age 72.2 (standard deviation (SD) 9.5, range 52-89); 23 (48%) were men. Thirty-seven patients had two diseases; most commonly COPD and cardiovascular disease (46%), followed by diabetes and cardiovascular disease (23%), and COPD and diabetes (15%). Eleven (23%) patients had all three conditions. Focus group interviews with patients with multimorbidity identified three main themes: (1) lack of care coordination existed across health-care sectors before the CIM, (2) extended consultations provided better care coordination, and (3) patients want to be involved in planning their treatment and care. In focus groups, health-care professionals discussed two main themes: (1) patient-centered care and (2) culture and organizational change. Completion rates for questionnaires were 98% (47/48).

Conclusions

Patients and health-care professionals found the CIM acceptable.

Older persons' experience with health care at two primary level clinics in Cape Town, South Africa: a qualitative assessment

Background

Efficient methods of assessing older persons’ healthcare needs are required in busy public sector primary healthcare clinics in South Africa. These clinics are the main points of entry into the healthcare system. This study was part of a larger study to test the local applicability and adaptability of the World Health Organization's (WHO) Age Friendly Primary Care Toolkit for assessing and managing chronic diseases and common geriatric syndromes.

Aim

To assess how older persons experience healthcare delivery at two primary healthcare clinics, and identify perceived gaps in health care to older people.

Design & setting

A qualitative study at two primary healthcare sites in the suburbs of Cape Town, South Africa.

Method

Focus group discussions (two at each facility) using an interview guide.

Results

Analysed data were categorised into five themes: ‘despite the challenges, there is overall good care’; ‘communication gaps and the frustration of feeling unheard’; ‘the health service is experienced as being unreliable, stretched, and is difficult to access’; ‘there is a perception of pervasive structural ageism in the clinics’; and ‘there is a perception that the quality of care received is related to the profession of the healthcare provider’.

Conclusion

Challenges of access and care for older clients at primary care clinics are linked to their age-specific holistic needs, which are not fully met by the current age-friendly arrangements. Measures should be taken at the clinics to complement the perceived good clinical care received, by improving access to care, making care appropriate to the need, reducing waiting times, and creating opportunities for older persons to feel respected and heard.

An integrated model of multimorbidity and symptom science

BACKGROUND

Prevalence and complexity of persons with multiple chronic conditions (MCC), also known as multimorbidity, are shifting clinical practice from a single disease focus to one considering MCC and symptoms. Although symptoms are intricately bound to concepts inherent in MCC science, symptoms are largely ignored in multimorbidity research and literature.

PURPOSE

Introduce an Integrated Model of Multimorbidity and Symptom Science.

METHODS

Critical integrative review and synthesis process.

FINDINGS

The model comprises three primary domains: 1. Contributing/ Risk Factors; 2. Symptom/Disease/Treatment Interactions; and 3. Patient Outcomes.

DISCUSSION

The model highlights the multilevel nature of contributing factors and the recursive interactions among multiple etiologies, conditions, symptoms, therapies, and outcomes.

Views of patients with multi-morbidity on what is important for patient-centered care in the primary care setting

BACKGROUND

Patient-centered care (PCC) has been proposed as the way forward in improving primary care for patients with multi-morbidity. However, it is not clear what PCC exactly looks like in practice for patients with multi-morbidity. A better understanding of multi-morbid patients' views on what PCC should look like and which elements are most important may help to improve care delivery for this vulnerable population. The present study thus aimed to identify views of patients with multi-morbidity on the relative importance of PCC aspects in a Dutch primary care setting.

METHODS

Interviews were conducted with 16 patients with multi-morbidity using Q-methodology, which combines quantitative and qualitative analyses. The participants ranked 28 statements about the eight dimensions of PCC (patients' preferences, information and education, access to care, emotional support, family and friends, continuity and transition, physical comfort, and coordination of care) by relative importance. By-person factor analysis using centroid factor extraction and varimax rotation were used to reveal factors that represent viewpoints. Qualitative interview data were used to interpret the viewpoints.

RESULTS

The analyses revealed three factors representing three distinct viewpoints of patients with multi-morbidity on what is important for patient-centered care in the primary care setting. Patients with viewpoint 1 are prepared proactive patients who seem to be well-off and want to be in charge of their own care. To do so, they seek medical information and prefer to be supported by a strongly coordinated multidisciplinary team of healthcare professionals. Patients with viewpoint 2 are everyday patients who visit GPs and require well-coordinated, respectful, and supportive care. Patients with viewpoint 3 are vulnerable patients who are less resourceful in terms of communication skills and finances, and thus require accessible care and professionals taking the lead while treating them with dignity and respect.

CONCLUSION

The findings of this study suggest that not all patients with multi-morbidity require the same type of care delivery, and that not all aspects of PCC delivery are equally important to all patients.

Multimorbidity and cardiovascular disease: a perspective on low- and middle-income countries

New and changing patterns of multimorbidity (MM), i.e., multiple concurrent acute or chronic diseases in a person, are emerging in low- and middle-income countries (LMICs). The interplay of underlying population-specific factors and lifestyle habits combined with the colliding epidemics of communicable and non-communicable diseases presents new disease combinations, complexities and risks that are not common in high-income countries (HICs). The complexities and risks include those arising from potentially harmful drug-drug and drug-disease interactions (DDIs), the management of which may be considered as MM in the true sense. A major concern in LMICs is the increasing burden of leading cardiovascular diseases, prevalence of associated risk factors and co-occurrence with other morbidities. New models of MM management and integrated care can respond to the needs of specific multimorbid populations, with some LMICs making substantial progress (e.g., integration of tuberculosis and HIV services in South Africa). But there is a dearth of relevant data on the changing patterns and underlying factors and determinants of MM, the associated complexities and risks of DDIs in MM management, and the barriers to integrated care in LMICs. This requires careful attention.

Racial and Ethnic Disparities in Serious Psychological Distress Among Those With Alzheimer's Disease and Related Dementias

BACKGROUND

Alzheimer's disease and related dementias (ADRD) is a growing public health challenge. Prior research suggests that non-Hispanic whites (whites), non-Hispanic African Americans (African Americans), and Hispanics have differing risks for ADRD.

OBJECTIVE

To examine the existence of serious psychological distress (SPD) among whites, African Americans, and Hispanics; to calculate the predicted probability of ADRD in whites, African Americans, and Hispanics, and to decompose the differences among ADRD populations, quantifying the burden of higher SPD among African Americans and Hispanics, compared to whites.

DATA AND METHOD

The authors use nationally representative data from the Medical Expenditure Panel Survey (2007-2015) to estimate the association between ADRD and race, ethnicity, and SPD. Using Blinder-Oaxaca decomposition analysis, the authors estimate to what extent higher SPD among Hispanics and African Americans was associated with higher ADRD rates compared to whites.

RESULTS

After controlling for individuals' demographic and socioeconomic characteristics and co-existing medical conditions, the presence of SPD was still significantly associated with a higher likelihood of having ADRD. The model predicted significantly higher likelihood of having ADRD among African Americans (7.1%) and Hispanics (5.7%) compared to whites (4.5%). Higher rates of having SPD among African Americans explained 15% of white-black difference and 40% of the white-Hispanic difference in ADRD rates, respectively.

DISCUSSION AND CONCLUSION

Our findings suggest a significant relationship between SPD and ADRD and that the burden of SPD was greater among African Americans and Hispanics with ADRD. Efficient screening using self-reported SPD, compared to simply using diagnoses codes of mental illness, may be more helpful to reduce racial and ethnic disparities in ADRD.

The experience of care coordination for people living with multimorbidity at risk of hospitalisation: an interpretative phenomenological analysis

Objective: There is growing interest in improving the care of people living with multimorbidity who require care coordination to help manage their health and reduce risk of hospitalisation. There has been limited past research exploring experiences of care for people living with multimorbidity. This qualitative study sought to explore the care experience of people enrolled in a care coordination intervention.Design: We interviewed 23 people living with multimorbidity enrolled in a care coordination intervention to examine their perceptions of the care experience. We used interpretative phenomenological analysis to identify themes from participants' perspectives of involvement in their care, using information to make decisions, and the meanings they made of their care experiences.Results: We identified three master themes of the participants' experience of care: Needing expert guidance, Circle of care, and I want to be spoken to like a person. We discuss these findings in the context of the recent literature on person-centred care.Conclusion: Understanding participants' experience of care reinforces the need for person-centred approaches. These findings suggest care coordination offered to people living with multimorbidity can be implemented through practical support and information alongside establishing a relationship of trust.