The complex patient: A concept clarification

Beyond Diagnosis and Comorbidities-A Scoping Review of the Best Tools to Measure Complexity for Populations with Mental Illness

Beyond the challenges of diagnosis, complexity measurement in clients with mental illness is an important but under-recognized area. Accurate and appropriate psychiatric diagnoses are essential, and further complexity measurements could contribute to improving patient understanding, referral, and service matching and coordination, outcome evaluation, and system-level care planning. Myriad conceptualizations, frameworks, and definitions of patient complexity exist, which are operationalized by a variety of complexity measuring tools. A limited number of these tools are developed for people with mental illness, and they differ in the extent to which they capture clinical, psychosocial, economic, and environmental domains. Guided by the PRISMA Extension for Scoping Reviews, this review evaluates the tools best suited for different mental health settings. The search found 5345 articles published until November 2023 and screened 14 qualified papers and corresponding tools. For each of these, detailed data on their use of psychiatric diagnostic categories, definition of complexity, primary aim and purpose, context of use and settings for their validation, best target populations, historical references, extent of biopsychosocial information inclusion, database and input technology required, and performance assessments were extracted, analyzed, and presented for comparisons. Two tools-the INTERMED, a clinician-scored and multiple healthcare data-sourced tool, and the VCAT, a computer-based instrument that utilizes healthcare databases to generate a comprehensive picture of complexity-are exemplary among the tools reviewed. Information on these limited but suitable tools related to their unique characteristics and utilities, and specialized recommendations for their use in mental health settings could contribute to improved patient care.

Tinkering with symptoms, causes and solutions: Tracing the enactments of multiple chronic illnesses in specialised outpatient check-ups

People living with multiple chronic illnesses and an increasing need for acute care is a global health challenge, which questions the conventional ways of managing illness. A central issue is how medical practices can become more patient-centred and aligned with the everyday life of patients. Communicative strategies for eliciting the patient's goals and preferences are often proposed. In this article, we draw on ethnographic data from fieldwork conducted during 2019-2020 in health-care settings and among people living with multiple chronic illness(es) and repeated acute admissions in Denmark. Inspired by science and technology studies of chronic illness and care, we trace the enactments of illness and illness work in a patient trajectory marked by persistent symptoms and medical complexity. We analyse three medical encounters, and we show how 'tinkering' with clinical signs and utterances in each encounter constantly enacts new versions, shaping how the patient could and should live with his illness. We argue that specialised outpatient check-ups for these patients must provide space for continuous tinkering with the concrete effects of illness in everyday life.

Particularity, Engagement, Actionable Inferences, Reflexivity, and Legitimation tool for rigor in mixed methods implementation research

BACKGROUND

Implementation science helps generate approaches to expedite the uptake of evidence in practice. Mixed methods are commonly used in implementation research because they allow researchers to integrate distinct qualitative and quantitative methods and data sets to unravel the implementation process and context and design contextual tools for optimizing the implementation. To date, there has been limited discussion on how to ensure rigor in mixed methods implementation research.

PURPOSE

To present Particularity, Engagement, Actionable Inferences, Reflexivity, and Legitimation (PEARL) as a practical tool for understanding various components of rigor in mixed methods implementation research.

DATA SOURCES

This methodological discussion is based on a nurse-led mixed methods implementation study. The PEARL tool was developed based on an interpretive, critical reflection, and purposive reading of selected literature sources drawn from the researchers' knowledge, experiences of designing and conducting mixed methods implementation research, and published methodological papers about mixed methods, implementation science, and research rigor.

CONCLUSION

An exemplar exploratory sequential mixed methods study in nursing is provided to illustrate the application of the PEARL tool. The proposed tool can be a useful and innovative tool for researchers and students intending to use mixed methods in implementation research. The tool offers a straightforward approach to learning the key rigor components of mixed methods implementation research for application in designing and conducting implementation research using mixed methods.

CLINICAL RELEVANCE

Rigorous implementation research is critical for effective uptake of innovations and evidence-based knowledge into practice and policymaking. The proposed tool can be used as the means to establish rigor in mixed methods implementation research in nursing and health sciences.

How family physicians in Singapore recognise complexity during consultations: a qualitative study

BACKGROUND

The prevalence of persons with complex needs in Singapore is rising. Poor understanding of what constitutes complexity impedes the identification of care gaps and development of interventions to improve care for these individuals. We aim to identify the characteristics contributing to complexity in primary care, from the Family Physicians' (FP) perspectives.

METHODS

Focus group discussions (FGDs) were conducted from January to September 2021 with experienced FPs across 14 study sites, employing a qualitative descriptive approach based on a complexity framework. Data were coded independently and categorised using thematic analysis by two independent investigators.

RESULTS

Five FGDs were conducted with 18 FPs aged 32 to 57 years old working in different primary care settings, with a mean of 13.5 years of primary care experience. Participants emphasised the need for a unified definition of complexity. Complexity is characterised by the presence of issues spanning across two or more domains (medical, psychological, social or behavioural) that adversely impact medical care and outcomes. Persons with complex needs contrast with persons with medically difficult issues. Medical domain issues include the number of active medical problems, poor chronic disease control, treatment interactions, ill-defined symptoms, management of end-of-life conditions and functional impairment. Psychological domain issues include the presence of mental health conditions or cognitive impairment. Social domain issues include the lack of social support, competing social responsibilities and financial issues, while behavioural domain issues include a lack of trust in healthcare workers, fixed health beliefs and poor health literacy.

CONCLUSION

Recognising the medical, psychological, social and behavioural factors that contribute to complexity aids in discerning the diverse needs of individuals with complex needs. This underscores the need for additional support in these pertinent areas.

Nursing interventions to promote dyspnea self-management of complex chronic patients: An integrated review

Objectives

Chronic dyspnea, a distressing symptom in patients with complex chronic conditions, is linked to higher risks of mortality. This study aimed to identify nursing interventions that could improve self-management for complex chronic patients, thereby enhancing control over chronic dyspnea. The findings intend to guide nursing care strategies that promote self-management among this population.

Methods

We searched the databases Medline, Scopus, Web of Science, CINAHL, Cochrane Database of Systematic Reviews (CDSR), and Joanna Briggs Institute (JBI) databases were searched in December 2023. We included adult patients with complex chronic conditions with chronic dyspnoea. The team screened articles collaboratively, using Rayyan software. A qualitative appraisal was performed according to JBI Critical Appraisal Checklist tools. The review protocol is registered under the number CRD42023456021.

Results

Our review included 18 studies that explored a variety of interventions for chronic dyspnea. We identified pharmacological interventions (such as oxygen therapy and inhalation treatments) and non-pharmacological approaches (including educational programs, breathing exercises, fluid intake management, body awareness techniques, peer support, emotional intelligence training, and the use of web applications). Those interventions empower patients, improve their ability to fulfill life roles, mitigate emotional distress, and improve overall quality of life. Nursing care can be crucial in enabling individuals to achieve independence and autonomy in self-care.

Conclusions

Promoting self-management for chronic dyspnea in complex chronic patients requires a holistic approach, encompassing multidisciplinary interventions, individualized self-care education, peer engagement, and technological support. Current research on self-management inadequately addresses interventions targeting patient behaviour change. It highlights the need to delve deeper into the self-management process. Further research is needed to expand the evidence base and refine these interventions.

Finding meaning in complex care nursing in a hospital setting

This study explores the experiences of nurses that provide 'complex', generalist healthcare in hospital settings. Complex care is described as care for patients experiencing acute issues additional to multimorbidity, ageing or psychosocial complexity. Nurses are the largest professional group of frontline healthcare workers and patients experiencing chronic conditions are overrepresented in acute care settings. Research exploring nurses' experiences of hospital-based complex care is limited, however. This study aims to add to what is known currently. Four 'complex care' nurses undertook in-depth semistructured interviews and their narratives were analysed using the conceptual framework of complex adaptive phenomenology. Two overarching themes constituting the 'essence' of complex care nursing were identified: Contextual factors and attribute/value-based elements. Creating meaningful patient outcomes and feeling part of a team were experienced as fulfilling, whereas time constraints, institutional settings and systemic barriers to comprehensive caregiving diminished the experience of providing complex care. Overall, work meaning presented as a dynamic phenomenon, shaped by personal and professional values, local settings and systemic factors. It is recommended that more expansive research be undertaken to explore the experience of complex care for nurses. Such knowledge can contribute to initiatives that draw a skilled, effective and engaged hospital-based complex care nursing workforce.

Identifying people requiring special care dentistry: A scoping review

AIMS

This scoping review aimed to document tools designed to identify persons requiring special care dentistry (SCD) and to provide a better understanding of the factors that justify adaptation in the provision of care.

METHODS

A scoping review methodology was applied. An electronic search was performed in April 2021 using Pubmed and Embase. Additional tools were sought using hand searches and informal professional networking.

RESULTS

Ten tools were identified that either predict the complexity of dental management or that retrospectively judge the complexity of care, of which two are as yet unpublished. Some had been developed for a specific population (e.g., patients with Alzheimer's disease, with learning disability, elderly persons) whilst others were applicable for any population (case mix tools). Factors considered included the patient's medical history, ability to cooperate, physical and cognitive autonomy, communication skills, anxiety, need for sedation, oral risk factors, ability to consent and the administrative burden for the dentist.

CONCLUSION

Identifying persons requiring SCD is possible by looking at various factors that influence the provision of dental care. There may be need for adaptation of tools to local circumstances and to the intended usage of the tool at a health services, systems or policy level.

Alleviating suffering of individuals with multimorbidity and complex needs: A descriptive qualitative study

BACKGROUND

Individuals living with multimorbidity and/or mental health issues, low education, socioeconomic status, and polypharmacy are often called complex patients. The complexity of their health and social care needs can make them prone to disease burden and suffering. Therefore, they frequently access health care services to seek guidance for managing their illness and suffering.

AIMS

The aim of this research was to describe the approaches used by nurses to alleviate the suffering of individuals with multimorbidity and complex needs in acute care settings.

RESEARCH DESIGN

A qualitative descriptive approach.

PARTICIPANTS AND RESEARCH CONTEXT

Semi-structured interviews were conducted with 19 nurses working in general, medical-surgical, specialized, and intensive care settings across five hospitals in Pakistan. Reflexive thematic analysis was used for analysis.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the Ethical Committee of Al-Nafees Medical College Islamabad, Pakistan.

FINDINGS

Four themes were generated: Deeper Exploration of Patients' Health-Illness Situation and Complexity, Prioritizing Patient Psychosocial and Emotional Needs, Instilling Hope and Encouragement in Patients, and Creating a Comforting Environment to Foster Sharing of felt needs.

DISCUSSION

Nurses emphasized the need of deeper inquiry into patients illness situation and complexity to discern the impact of determinants on their well-being and develop care plans that are tailored to address psychosocial, emotional, and physical suffering of this patient population.

CONCLUSIONS

Alleviation of patient suffering is integral to compassionate nursing care. Nurses use a multifaceted approach entailing sensitive understanding, recognizing sociocultural and structural determinants impact on patient situation, and individual and interdisciplinary altruistic actions to alleviate patient suffering.

Content validity testing of the INTERMED Self-Assessment in a sample of adults with rheumatoid arthritis and rheumatology healthcare providers

BACKGROUND

Care complexity can occur when patients experience health challenges simultaneously with social barriers including food and/or housing insecurity, lack of transportation or other factors that impact care and patient outcomes. People with rheumatoid arthritis (RA) may experience care complexity due to the chronicity of their condition and other biopsychosocial factors. There are few standardised instruments that measure care complexity and none that measure care complexity specifically in people with RA.

OBJECTIVES

We assessed the content validity of the INTERMEDS Self-Assessment (IMSA) instrument that measures care complexity with a sample of adults with RA and rheumatology healthcare providers (HCPs). Cognitive debriefing interviews utilising a reparative framework were conducted.

METHODS

Patient participants were recruited through two existing studies where participants agreed to be contacted about future studies. Study information was also shared through email blasts, posters and brochures at rheumatology clinic sites and trusted arthritis websites. Various rheumatology HCPs were recruited through email blasts, and divisional emails and announcements. Interviews were conducted with nine patients living with RA and five rheumatology HCPs.

RESULTS

Three main reparative themes were identified: (1) Lack of item clarity and standardisation including problems with item phrasing, inconsistency of the items and/or answer sets and noninclusive language; (2) item barrelling, where items asked about more than one issue, but only allowed a single answer choice; and (3) timeframes presented in the item or answer choices were either too long or too short, and did not fit the lived experiences of patients. Items predicting future healthcare needs were difficult to answer due to the episodic and fluctuating nature of RA.

CONCLUSIONS

Despite international use of the IMSA to measure care complexity, patients with RA and rheumatology HCPs in our setting perceived that it did not have content validity for use in RA and that revision for use in this population under a reparative framework was unfeasible. Future instrument development requires an iterative cognitive debriefing and repair process with the population of interest in the early stages to ensure content validity and comprehension.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public contributions included both patient partners on the study team and people with RA who participated in the study. Patient partners were involved in study design, analysis and interpretation of the findings and manuscript preparation. Data analysis was structured according to emergent themes of the data that were grounded in patient perspectives and experiences.

Clinical Utility Assessment of a Nursing Checklist Identifying Complex Care Needs Due to Inequities Among Ambulatory Patients With Cancer: Protocol for a Mixed Methods Study

BACKGROUND

Disparities in cancer incidence, complex care needs, and poor health outcomes are largely driven by structural inequities stemming from social determinants of health. To date, no evidence-based clinical tool has been developed to identify newly diagnosed patients at risk of poorer outcomes. Specialist cancer nurses are well-positioned to ameliorate inequity of opportunity for optimal care, treatment, and outcomes through timely screening, assessment, and intervention. We designed a nursing complexity checklist (the "Checklist") to support these activities, with the ultimate goal of improving equitable experiences and outcomes of care. This study aims to generate evidence regarding the clinical utility of the Checklist.

OBJECTIVE

The primary objectives of this study are to provide qualitative evidence regarding key aspects of the Checklist's clinical utility (appropriateness, acceptability, and practicability), informed by Smart's multidimensional model of clinical utility. Secondary objectives explore the predictive value of the Checklist and concordance between specific checklist items and patient-reported outcome measures.

METHODS

This prospective mixed methods case series study will recruit up to 60 newly diagnosed patients with cancer and 10 specialist nurses from a specialist cancer center. Nurses will complete the Checklist with patient participants. Within 2 weeks of Checklist completion, patients will complete 5 patient-reported outcome measures with established psychometric properties that correspond to specific checklist items and an individual semistructured interview to explore Checklist clinical utility. Interviews with nurses will occur 12 and 24 weeks after they first complete a checklist, exploring perceptions of the Checklist's clinical utility including barriers and facilitators to implementation. Data describing planned and unplanned patient service use will be collected from patient follow-up interviews at 12 weeks and the electronic medical record at 24 weeks after Checklist completion. Descriptive statistics will summarize operational, checklist, and electronic medical record data. The predictive value of the Checklist and the relationship between specific checklist items and relevant patient-reported outcome measures will be examined using descriptive statistics, contingency tables, measures of association, and plots as appropriate. Qualitative data will be analyzed using a content analysis approach.

RESULTS

This study was approved by the institution's ethics committee. The enrollment period commenced in May 2022 and ended in November 2022. In total, 37 patients with cancer and 7 specialist cancer nurses were recruited at this time. Data collection is scheduled for completion at the end of May 2023.

CONCLUSIONS

This study will evaluate key clinical utility dimensions of a nursing complexity checklist. It will also provide preliminary evidence on its predictive value and information to support its seamless implementation into everyday practice including, but not limited to, possible revisions to the Checklist, instructions, and training for relevant personnel. Future implementation of this Checklist may improve equity of opportunity of access to care for patients with cancer.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48432.

Exploring the Impact of ECHO Ontario Integrated Mental and Physical Health on Participants' Approach and Attitude Toward the Care of Patients With Complex Needs

OBJECTIVE

To examine how project Extension for Community Healthcare Outcomes-Integrated Mental and Physical Health (ECHO-IMPH) influences the attitudes and approaches of primary care providers and other participants towards patients.

METHODS

An exploratory qualitative approach was undertaken using semistructured interviews conducted between August 2020 and March 2021. One hundred and sixty-four individuals from two cycles of ECHO-IMPH were invited to participate, and 22 (n = 22) agreed to participate. Data were analyzed using the Braun and Clarke method for thematic analysis.

RESULTS

Three major themes were identified: 1) enhanced knowledge and skills; 2) changes in attitude and approach; 3) space for reflection and exploration. When participants were asked about areas for improvement, suggestions were focused on the structure of the sessions. Participants identified that ECHO-IMPH helped them to view patients more holistically, which led to greater patient-centered care in their practice. Additionally, skills gained in ECHO-IMPH gave participants the concrete tools needed to have more empathetic interactions with patients with complex needs.

CONCLUSIONS

ECHO-IMPH created a safe space for participants to reflect on their practice with patients with complex needs. Participants applied newly acquired knowledge and skills to provide more empathetic and patient-centered care for patients with complex needs. Based on the shift in perspectives described by participants, transformative learning theory was proposed as a model for how ECHO-IMPH created change in participants' practice.

Impact, scope of practice and competencies of Advanced Practice Nurses within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings: a scoping review protocol

INTRODUCTION

The increase of young and middle-aged adult patients with multimorbid and/or complex chronic conditions has created new challenges for healthcare systems and services. Advanced Practice Nurses (APNs) play an essential role in treating these patients because of their expertise and advanced nursing skills. Little is known about competencies, scope of practice and impact of APNs within APN-led care models for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings. The objective of this scoping review is to describe the impact, scope of practice and competencies of APNs within APN-led care models for young and middle-aged adult patients in hospital settings.

METHODS AND ANALYSIS

This scoping review will be conducted using the methodological framework proffered by Arksey and O'Malley, incorporating the methodological enhancement of Levac et al. It will comply with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) for Scoping Reviews' guidelines of Tricco et al. Systematic research will be conducted in the databases MEDLINE (PubMed), CINAHL (EBSCO), EMBASE (Ovid), CENTRAL and PsycINFO (Ovid) using all recognised keywords, index terms and search strings. Grey literature will be scanned. Bibliography of all selected studies will be hand searched. Studies will be selected based on defined inclusion and exclusion criteria, screened by title and abstracts. Data from full-text articles meeting the inclusion criteria will be extracted independently by two authors. Disagreements in evaluation will be discussed and resolved by consensus. Results will be reported in the form of descriptive tables. Narrative summery is used to present the results of the review in the context of the study's objectives and questions.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. The review will be handed in as part of a doctoral thesis and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER OSF

4PM38.

Nurses' Challenges to Developing Interpersonal Relationships During Integrated Care for Complex Patients

BACKGROUND

Individuals with multimorbidity and complexity have multifaceted care needs requiring integrated and collaborative care from nurses, families, and health care teams. Nurses, as the frontline care professionals, should develop therapeutic relationships with patients and their families and professional relationships with health care team members to ensure the delivery of effective integrated care. Failure to develop effective interpersonal and professional relationships can negatively affect patient care.

OBJECTIVE

The purpose of this study was to explore nurses' challenges with developing interpersonal and professional relationships during integrated care for individuals with multimorbidity and complexity.

METHODS

A descriptive qualitative design was used. We interviewed a purposive sample of 19 nurses with experience of caring for individuals with multimorbidity and complexity across two hospitals in Pakistan. Semi-structured interviews were used for data collection, and data were analyzed using reflexive thematic analysis.

RESULTS

Two challenges were identified affecting the relationships between patients' families and nurses, and two challenges influencing the professional relationships within the team. Families withheld information, controlled care access of their relatives, posed unrealistic demands, and abused nurses, affecting nurse-family relationships. Power struggles to demonstrate authority in decision-making were common within health care teams, affecting nurses' professional capacity to provide effective care.

CONCLUSIONS

Health care team, patient, and family collaboration is instrumental in improved care for individuals with multimorbidity and complexity. Nurse leaders and health care organizations should take initiatives to address nurses' interpersonal confrontations to support them in the provision of quality care.

Special needs dentistry in multidisciplinary head and neck cancer management - characterizing scope and complexity of patient care

AIMS

To describe the involvement and need for specialists in special needs dentistry (SND) in the multidisciplinary management of patients and to characterize the complexity of patients with special health care needs.

METHODS

Referrals for SND review from the Fiona Stanley Hospital head and neck cancer (HNC) multidisciplinary team between January 1 and December 31, 2019 were screened. Data recorded included demographic information, medical history, dental status, and dental treatment provided prior to HNC management.

RESULTS

In total 127 patients were referred to the SND clinic in 2019 of which 89.0% were males and 74.8% were aged 50-79. The mean waiting time for SND review was 19.6 days. On average patients had a decayed, missing, filled tooth (DMFT) score of 20.3. During the study period 407 extractions and 30 restorations were completed. Seventeen patients (13.4%) had all their teeth removed prior to HNC management. The majority of patients (79.6%) were categorized as either moderate or severe complexity. Increasing complexity was seen in older age groups.

CONCLUSIONS

Significant oral disease is seen in patients with HNC often requiring extensive dental treatment. Complexity is seen in patients requiring multidisciplinary care however characteristics that constitute complexity are varied given the spectrum encompassing 'special needs'.

Key characteristics of patient complexity and patient complexity conceptual models/measurement tools: a scoping review protocol

INTRODUCTION

The social determinants of health have been gaining recognition, confirming that multidimensional biopsychosocial assessment is essential to improving the health of individuals. This trend has led to the development of conceptual models and measurement tools assessing 'patient complexity', understood as a complex interplay of biopsychosocial factors, to improve the efficiency and effectiveness of care; however, the variety of meanings encompassed by the term has led to confusion in the interpretation of patient complexity such that there is no consensus regarding the definition or conceptualisation of patient complexity. The primary objective of this scoping review is to identify and map what is known about the key characteristics of patient complexity through multiple database searches.

METHODS AND ANALYSIS

This study will follow an established framework for conducting scoping reviews. The data will be extracted through searches of MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, The Cochrane Library and Google Scholar. Included articles will have: investigated participants aged 19 years or older, with any health condition; described patient complexity, a model for patient complexity, or a measurement tool for patient complexity; and been published in English from 1 January 1970 to April 2022. Article selection and data extraction will be conducted independently by two reviewers and if necessary for consensus, a third reviewer. A descriptive summary will be prepared to explain how the results apply to the scoping review questions. The findings will be a detailed mapping of the health dimensions that emerge from the classification of the extracted data. Subsequently, a definition of patient complexity will be developed.

ETHICS AND DISSEMINATION

This review does not require ethical approval, as we will use publicly available data. The study findings will be disseminated through a relevant conference presentation and a peer-reviewed journal. This protocol is registered on the Open Science Framework (www.osf.io/hpa3c).

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.

Complex adaptive phenomenology: A conceptual framework for healthcare research

RATIONALE

Healthcare research exploring the lived experiences of health care professionals from different disciplines, such as nursing, medicine, and allied health, has repeatedly highlighted many methodological challenges, especially in understanding the individual human experience within complex systems. In response, complexity theory and phenomenological approaches emerged and evolved in ways that potentially offered researchers frameworks to inform an understanding of the individual human experience. However, while these two theoretical approaches inform a method of inquiry, there is a gap in understanding the phenomenon of 'being' and how this is embodied within complex systems such as the healthcare system.

THE AIMS AND OBJECTIVES

The aim of this paper is to present an integrated theoretical framework, namely complex adaptive phenomenology (CAP). CAP aims to address this inquiry gap by offering a structured conceptual framework wherein complexity theory and phenomenology are complementary but multi-dimensional. The key objective of CAP was to synthesize and integrate two methods of inquiry that examine the relational aspects of 'being', that is the gestalt of perception, action, and context, The authors argue that CAP is well-suited to complex research contexts such as healthcare. The framework focuses on the reciprocal, co-constructive relationships extant between perception, meaning, context, and action that shape experiences of 'being' within complex systems. Complexity theory's connectionist orientation explains the relationships that are formative of the experience of being, while phenomenology explores the manifestations of these formative relationships by attending to the notion of 'being' itself.

CONCLUSION

The authors propose that an integrated framework, of phenomenology and complexity theory, can provide a platform for deeper understandings of the experiences of health professionals and contribute to healthcare scholarship.

Nurses' perceived barriers to the delivery of person-centred care to complex patients: A qualitative study using theoretical domains framework

AIMS AND OBJECTIVES

To determine nurses' perceived barriers to the delivery of person-centred care to complex patients with multiple chronic conditions in acute care settings.

BACKGROUND

Complex patients have multiple physical and mental health problems, and their life is also greatly affected by sociocultural and economic determinants of health. These patients require person-centred care, but nurses often find it challenging to provide effective care to these patients due to their complex health needs.

DESIGN

A descriptive qualitative design was used. The COREQ guidelines were followed for reporting.

METHODS

Semi-structured interviews were conducted with a purposive sample of 19 nurses in two hospitals. Data were analysed using deductive thematic analysis guided by the Theoretical Domains Framework, which entails 14 domains about factors affecting behaviours.

RESULTS

The key barriers were identified under environmental context and resources, social influences, emotions, knowledge and skills domains. Deep-rooted social issues delay patients' health-seeking and nurses' abilities to understand patients' needs and discern appropriate care. Interpersonal hostility influenced nurse-patient-families interactions, and doctor-nurses conflicts affected collaborative efforts towards optimal care.

CONCLUSIONS

Nurses' perceived barriers to care were intertwined with the deep-rooted social and cultural beliefs about nurses' image, patients' expectations and families' preference for home remedies over specialised nursing care. These barriers to person-centred care demonstrate an intricate interplay of personal, social and organisational issues and power struggles. Multifaceted implementation strategies targeting environmental context and resources, social influences, emotions, knowledge and skills domains may be beneficial to enable nurses to provide better person-centred care to complex patients.

RELEVANCE TO CLINICAL PRACTICE

Designing implementation facilitation teams, organising person-centred care grand rounds, and allocation of stress management resources to address hostility, social-cultural influences, and organisational barriers is essential. Nurses could focus on their self-awareness and collaborative skills to address emotional and interprofessional conflicts.

Interprofessional Collaboration in Complex Patient Care Transition: A Qualitative Multi-Perspective Analysis

Healthcare professionals often feel challenged by complex patients and the associated care needs during care transition. Interprofessional collaboration (IPC) is considered an effective approach in such situations. However, a fragmented healthcare system can limit IPC. This study explored experiences of Swiss healthcare professionals regarding complex patient care transition and the potential of IPC. Professionals from nursing, medicine, psychology, physiotherapy, dietetics and nutrition, social service, occupational therapy, and speech therapy were included. A qualitative between-method triangulation design was applied, with two focus group discussions and ten individual interviews. The combination of different data-collection methods allowed us to explore complex patient care transition and to systematically add perspectives of healthcare professionals from different care settings. Three main themes were identified: (1) Participants described their vision of an ideal complex patient care transition, i.e., the status they would like to see implemented; (2) participants reported challenges in complex patient care transition as experienced today; and (3) participants suggested ways to improve complex patient care transition by IPC. This study highlighted that healthcare professionals regarded IPC as an effective intervention to improve complex patient care transition. It emerged that sustainable implementation of IPC across care organizations is currently limited in Switzerland. In the absence of strong and direct promotion of IPC by the healthcare system, professionals in clinical practice can further promote IPC by finding hands-on solutions to overcome organizational boundaries.

The concentration of complexity: case mix in New Zealand general practice and the sustainability of primary care

Introduction New Zealand general practice and primary care is currently facing significant challenges and opportunities following the impact of the coronavirus disease 2019 (COVID-19) pandemic and the introduction of health sector reform. For future sustainability, it is important to understand the workload associated with differing levels of patient case mix seen in general practice. Aim To assess levels of morbidity and concomitant levels of socio-economic deprivation among primary care practices within a large primary health organisation (PHO) and associated Māori provider network. Methods Routinely collected practice data from a PHO of 57 practices and a Māori provider (PHO) of five medical practices in the same geographical area were used to compare a number of population health indicators between practices that had a high proportion of high needs patients (HPHN) and practices with a low proportion of high needs patients (Non-HPHN). Results When practices in these PHOs are grouped in terms of ethnicity distribution and deprivation scores between the HPHN and Non-HPHN groups, there is significantly increased clustering of both long-term conditions and health outcome risk factors in the HPHN practices. Discussion In this study, population adverse health determinants and established co-morbidities are concentrated into the defined health provider grouping of HPHN practices. This 'concentration of complexity' raises questions about models of care and adequate resourcing for quality primary care in these settings. The findings also highlight the need to develop equitable and appropriate resourcing for all patients in primary care.

Effects of implementing a clinical pathway on antibiotic prophylaxis for patients who underwent an elective surgery

A reduction in the unnecessary use of antibiotic prophylaxis can prevent antibiotic resistance and adverse drug events. We aimed to evaluate the effects of implementing clinical pathways (CPs) on adherence to a systematic and appropriate duration of antibiotic prophylaxis. We identified 61 eligible CPs and a total of 44,062 patients who underwent elective surgeries associated with CPs. The Poisson mixed model with an interrupted time-series analysis frame was applied to the patient-level data. This enabled a comparison of the adherence rate before and after CP implementation. Furthermore, we examined the effect of application or completion of CP on the adherence rate after implementation. Adherence to the antibiotic prophylaxis guideline substantially increased (incident rate ratio [IRR] 8.05; 95 confidence interval [CI] 2.64-24.55), compared with that before implementation. Following the implementation into the electronic entry system, we observed an improved adherence not only in CP completion but also in attempted CP execution (IRR of the executed but not completed cases 1.54; 95% CI 1.17-2.04; IRR of the executed and competed cases, 1.94; 95% CI 1.4-2.69). The implementation of CP into the electronic prescribing system was associated with a significant increase in the appropriate use of antibiotic prophylaxis among patients who underwent elective surgeries. The results suggest that a computer-assisted CP system for electronic health records could improve antibiotic adherence without significant expense.

From Individuals to Systems and Contributions to Creations: Novel Framework for Mapping the Efforts of Individuals by Convening The Center of Health and Health Care

Background

People with lived health care experiences (often referred to as “patients”) are increasingly contributing to health care and are most effective when they are involved as partners who can contribute complementary knowledge alongside other stakeholders in health care.

Objective

Convening The Center aimed to bring together “people known as patients”—the center of health care—to address priorities as they defined them.

Methods

According to the original project design, an in-person gathering was to be conducted; however, as a result of the COVID-19 pandemic, the in-person gathering was transformed into a series of digital gatherings, including an in-depth interview phase, small-group gatherings, and a collective convening of 25 participants (22 women and 3 men from the United States, India, Costa Rica, Sweden, and Pakistan). Each participant was interviewed on Zoom (Zoom Video Communications Inc), and the interview data were thematically analyzed to design a subsequent small group and then full cohort Zoom sessions. Visual note-taking was used to reinforce a shared understanding of each individual- and group-level conversation.

Results

The interviews and gatherings for Convening The Center offered unique perspectives on patient activities in research, health innovation, and problem-solving. This project further developed a novel, two-spectrum framework for assessing different experiences that patients may have or seek to gain, based on what patients actually do, and different levels of patients’ involvement, ranging from individual to community to systemic involvement.

Conclusions

The descriptors of patients in academic literature typically focus on what health care providers think patients “are” rather than on what patients “do.” The primary result of this project is a framework for mapping what patients “do” and “where” they do their work along two spectra: from creating their own projects to contributing to work initiated by others and from working at levels ranging from individual to community to systems. A better understanding of these spectra may enable researchers to more effectively engage and leverage patient expertise in health care research and innovation.

Influence of health-system change on treatment burden: a systematic review

BACKGROUND

Treatment burden is a patient-centred concept describing the effort required of people to look after their health and the impact this has on their functioning and wellbeing. High treatment burden is more likely for people with multiple long-term conditions (LTCs). Validated treatment burden measures exist, but have not been widely used in practice or as research outcomes.

AIM

To establish whether changes in organisation and delivery of health systems and services improve aspects contributing to treatment burden for people with multiple LTCs.

DESIGN AND SETTING

Systematic review of randomised controlled trials (RCTs) investigating the impact of system-level interventions on at least one outcome relevant to previously defined treatment burden domains among adults with ≥2 LTCs.

METHOD

The Embase, Ovid MEDLINE, and Web of Science electronic databases were searched for terms related to multimorbidity, system-level change, and treatment burden published between January 2010 and July 2021. Treatment burden domains were derived from validated measures and qualitative literature. Synthesis without meta-analysis (SWiM) methodology was used to synthesise results and study quality was assessed using the Cochrane risk-of-bias (version 2) tool.

RESULTS

The searches identified 1881 articles, 18 of which met the review inclusion criteria. Outcomes were grouped into seven domains. There was some evidence for the effect of system-level interventions on some domains, but the studies exhibited substantial heterogeneity, limiting the synthesis of results. Some concern over bias gave low confidence in study results.

CONCLUSION

System-level interventions may affect some treatment burden domains. However, adoption of a standardised outcome set, incorporating validated treatment burden measures, and the development of standard definitions for care processes in future research would aid study comparability.

Behavioural indicators of compassionate nursing care of individuals with complex needs: A naturalistic inquiry

AIMS AND OBJECTIVES

To explore behavioural indicators of compassionate nursing care from the perspectives of individuals with multimorbidities and complex needs.

BACKGROUND

Complex patients are individuals with multimorbidity and/or mental health concerns, andoften with medication and drug-related problems requiring ongoing person-centered care, mental health interventions, and family and community resources. They are frequent consumers of health-care services and it is documented that these patients experience discrimination and substandard care. Compassionate care can improve patient care experiences and health outcomes. However, missing is the guidance on how to provide compassionate care for this population from the perspectives of complex patients.

DESIGN

A qualitative descriptive approach was conducted in eastern Canada from December 2020-April 2021. The COREQ guidelines were followed for reporting.

METHODS

Data from in-person and virtual semi-structured interviews with 23 individuals having experiences as complex patients were analysed using reflexive thematic analysis. Among them 19 were homeless and lived in a shelter.

FINDINGS

Six indicators of compassionate nursing care were generated: sensitivity, awareness, a non-judgmental approach, a positive demeanour, empathic understanding, and altruism.

CONCLUSIONS

Individuals perceived that nurses who acknowledge personal biases are better at providing compassionate care by manifesting compassion through their genuine and selfless interest in the complicated health problems and underlying socio-cultural determinants of each patient. Kindness, positivity, and a respectful nursing approach elicit openness and the sharing of heartfelt concerns.

RELEVANCE TO CLINICAL PRACTICE

Comprehensive health assessment, dedicated efforts to know the patient as a human being, and listening to the patient's preferences can improve health outcomes among individuals with complex needs. Healthcare administrators can effect the change by supporting nurses to address complex health and social care needs with compassion.

PATIENT OR PUBLIC CONTRIBUTION

Patients and healthcare professionals helped in data collection at the community care centre.

Understanding complexity in psychological services: A modified Delphi study

RATIONALE, AIMS AND OBJECTIVES

The concept of patient or case complexity is relevant-and widely used-at all levels and stages of mental health service provision, but there have been few methodologically robust attempts to define this term. This study aimed to establish a consensus on factors contributing to patient complexity in adult psychological services using Delphi methodology.

METHOD

Applied psychologists in a single urban/suburban UK National Health Service setting took part in a three-round modified Delphi study. Twenty-eight respondents in Round 1 gave qualitative data on factors they considered when assessing complexity, which was subject to thematic analysis. Twenty-five respondents in Round 2 rated how central/peripheral each theme was to their judgement using Likert scales. In a third round, 20 respondents addressed discrepancies and possible utilities of the emerging framework.

RESULTS

Thirteen factors contributing to patient/case complexity (active severe/enduring mental health, current coping/functioning, engagement, forensic history, iatrogenic factors, interpersonal functioning, neurocognitive functioning, physical health, problematic substance use, risk, severity/chronicity of presenting problems, systemic and socioeconomic factors and trauma) were identified with a high degree of consensus. All were rated as central to complexity.

CONCLUSIONS

We conclude that applied psychologists do have a shared understanding of complexity and make recommendations for further research validating, developing and applying this empirically derived framework.

Exploring the Nursing Care Process for Patients with COVID-19: A Grounded Theory Study

Introduction:

A specific model and process of nursing care for patients with COVID-19 has yet to be developed. However, nurses are navigating how to care for patients and themselves in a novel and stressful work environment. A care process is needed that promotes effective nursing for patients’ health and well-being.

Objective:

This study aimed to explore the current nursing care process for patients with COVID-19.

Methods:

The present qualitative study used a grounded theory approach. Participants included 23 nurses working in a hospital COVID-19 ward who were selected through purposive sampling. Semi-structured interviews were conducted with nurses, and data were simultaneously analyzed using MAXQDA software to code the data. Grounded theory with a storyline approach was used to categorize codes to elucidate themes from interviews and check for data saturation. This consists of several steps, including open coding, developing concepts in terms of their properties and dimensions, analyzing data for context, bringing the process into the analysis, and integrating categories.

Results:

Data analysis revealed seven main categories to describe nurses’ conceptions of the care process for COVID-19 patients: ‘patients’ complicated condition’, ‘severe nursing staff shortage’, ‘nursing professionalism’, ‘treatment team collaboration’, ‘work and environmental pressure’, ‘efficacy of care’ and ‘care deficit’. The category of ‘nursing professionalism’ was determined to be the core concept that nurses used to describe their care process.

Conclusion:

Though nurses think highly of their efficacy of care for patients with COVID-19, they face many challenges in their care process that lessen the care they are able to provide for patients and themselves. These include the complex health status of patients, shortage of staff, environmental stresses such as becoming infected, and lack of resources in the hospital. The results of the present study can be used for planning in various fields of nursing, including management, education and clinical training.

Construction of a conceptual model of comprehensive care for Indonesian children with human immunodeficiency virus

PURPOSE

To construct a conceptual model of comprehensive care for Indonesian children with Human Immunodeficiency Virus.

DESIGN AND METHODS

A qualitative constructivist grounded theory design. Purposive sampling was used to interview 12 children with Human Immunodeficiency Virus and 8 family members with the age of the children ranged from 9 to 18 years, and 23 health professionals, including general practitioners, paediatric specialists, nurses, midwife, and nutritionist from public health centres and provincial hospitals in East Java, Indonesia. Data was analysed using constant comparative coding methods, theoretical sensitivity, memo writing, and diagramming to facilitate the development of the substantive theory.

RESULTS

Exploring the perspectives of the participants has revealed the need to enhance the delivery of comprehensive care across the continuum, because HIV care and services for children was sub-optimal. Understanding children's needs and preferences forms the foundation of the development of a framework for the comprehensive care of children with HIV consisting of child-centred care and social support, delivered by integration and coordination of care through a healthcare service.

CONCLUSIONS

The conceptual model provides new knowledge and has the capacity to bring together optimal care across the continuum addressing the challenges of fragmentation of care for children and their families.

PRACTICE IMPLICATIONS

The model informs that children with HIV not only need pharmacotherapy, but also other care interventions depending on their individual needs, preferences, and age. Implementing the model may help to resolve such problems, to improve collaborative practice and enhance children's participation, thereby promoting children's health outcomes.

The radical and requisite openness of viable systems: Implications for healthcare strategy and practice

This paper addresses an ontological question about the nature of health and challenges some underpinning assumptions in western healthcare. In its analysis, health in its various statuses, is framed as a naturally occurring complex adaptive system made up of dynamically interacting subsystems that include the physiological, psychological, and social realms. Furthermore, openness in complex systems such as health, is necessary for the exchange of energy, information, and resources. Yet, within healthcare much effort is invested in constraining systems' behaviours, whether they be systems of knowledge, health, healthcare, and more. This paper draws on the complexity sciences and Levinasian philosophy to explicate the essential role of system openness in individual, population, and systemic viability. It highlights holism to be "not whole-ism", and system openness to be, not just a reality, but a critical feature of viability. Hence requisite openness is advocated as essential to efficacious and ethical healthcare practice and strategy, and vital for health.

An evaluation of five regional health information technology-based programmes to improve health and social care coordination: A quasi-experimental controlled before/after mixed design

Objectives

Health information technology (HIT) can help coordinate health and social actors involved in patients’ pathways. We assess five regional HIT-based programmes (‘ Territoires de Soins Numériques’ or TSN) introduced in France, covering the period 2012–2018.

Methods

This was a quasi-experimental controlled before/after mixed design. We used data from the French National Health Insurance database, qualitative and quantitative surveys, and information extracted from project documents and databases. We assessed the impact of TSN using four main impact indicators: emergency room visits, unplanned hospitalizations, avoidable hospitalizations and rehospitalization within 30 days. We also collected qualitative and secondary quantitative data covering perceived needs, knowledge, use, satisfaction, adoption and understanding of projects, pathway experience, impact on professional practices and appropriateness of hospitalizations.

Results

TSN implemented a heterogeneous mix of HIT. Implementation was slower than expected and was not well documented. Users perceived the HIT as having a positive but weak overall effect. There were no significant differences in trends for the main impact indicators, nor on the appropriateness of hospitalizations, but favourable trends on secondary polypharmacy indicators.

Conclusions

If similar innovations take place in future, they should be based on a logical framework that defines causal, measurable links between services provided and expected impacts.

Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis

Introduction:

Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use.

Methods:

A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada).

Results:

Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers’ access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use.

Conclusion and discussion:

This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.

Case management programs for people with complex needs: Towards better engagement of community pharmacies and community-based organisations

Introduction

The objectives of this study were 1) to describe how case management programs engaged community pharmacies and community-based organisations in a perspective of integrated care for people with complex needs, and 2) to identify enablers, barriers and potential strategies for this engagement.

Methods

Using a descriptive qualitative design, individual interviews and focus groups with patients, healthcare providers and managers were analysed according to a mixed thematic analysis based on a deductive (Rainbow Model of Integrated Care) and an inductive approach.

Results and discussion

Participants highlighted the individualized service plan as a significant tool to foster a shared person-focused vision of care, information exchanges and concerted efforts. Openness to collaboration was also considered as an enabler for community stakeholders’ engagement. The lack of recognition of community-based organisations by certain providers and the time required to participate in individualized service plans were outlined as barriers to professional integration. Limited opportunities for community stakeholders to be involved in decision-making within case management programs were reported as another constraint to their engagement. Cultural differences between organisations regarding the focus of the intervention (psychosocial vs healthcare needs) and differences in bureaucratic structures and funding mechanisms may negatively affect community stakeholders’ engagement. Formal consultation mechanisms and improvement of communication channels between healthcare providers and community stakeholders were suggested as ways to overcome these barriers.

Conclusion

Efforts to improve care integration in case management programs should be directed toward the recognition of community stakeholders as co-producers of care and co-builders of social policies across the entire care continuum for people with complex needs.

Nurses' perceptions and beliefs related to the care of adults living with multimorbidity: A systematic qualitative review

AIMS AND OBJECTIVES

To identify and synthesise the available qualitative evidence on nurses' perceptions and beliefs related to the care of adults living with multimorbidity.

BACKGROUND

The rising prevalence of adults living with multimorbidity has increased demand for health care and challenges nursing care. No review has been conducted to date of the studies of nurses' perceptions and beliefs related to the provision of care to guide policy makers, practitioners and further research to identify and deliver quality care for persons living with multimorbidity.

DESIGN

Systematic review of qualitative studies conducted in line with the PRISMA checklist.

METHODOLOGY

Eight electronic publication databases and sources of grey literature were searched to identify original qualitative studies of the experience of nurses caring for adults with multiple chronic conditions with no restrictions on the date of publication or study context. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Data were extracted using the Joanna Briggs Institute standardised data extraction tool for qualitative research. Data synthesis was undertaken through meta-aggregation.

RESULTS

Eleven qualitative studies were included in the review. All studies met eight or more of the 10 assessment criteria of the JBI Critical Appraisal Checklist for Qualitative Research. Four synthesised findings were generated from the aggregated findings: (i) the challenge of providing nursing care; (ii) the need to deliver holistic and person-centred nursing care; (iii) the importance of developing a therapeutic nurse-patient relationship, and (iv) delivering nursing care as part of an interprofessional care team.

CONCLUSIONS

The complexity of multimorbidity and the predominant single-disease model of chronic care present challenges for the delivery of nursing care to adults living with multimorbidity.

RELEVANCE TO CLINICAL PRACTICE

The nursing care of persons with multimorbidity needs to incorporate holistic assessment and person-centred care principles as part of a collaborative and interprofessional team approach.

PROSPERO REGISTRATION

CRD42020186773.

How do healthcare providers construe patient complexity? A qualitative study of multimorbidity in HIV outpatient clinical practice

INTRODUCTION

Patient complexity is an increasingly used concept in clinical practice, policy debates and medical research. Yet the literature lacks a clear definition of its meaning and drivers from the health provider's perspective. This shortcoming is problematic for clinical practice and medical education in the light of a rising number of multimorbid patients and the need for future healthcare providers that are adequately trained in treating complex patients.

OBJECTIVES

To develop an empirically grounded framework of healthcare providers' perceptions of patient complexity and to characterise the relationship between case complexity, care complexity and provider experience as complexity-contributing factors.

DESIGN

Qualitative study based on semistructured in-depth interviews with healthcare practitioners.

SETTING

A Swiss hospital-based HIV outpatient clinic.

PARTICIPANTS

A total of 31 healthcare providers participated. Participants volunteered to take part and comprised 17 nurses, 8 junior physicians (interns) and 6 senior physicians (residents, fellows and attendings).

RESULTS

Perceived patient complexity arises from the combination of case complexity drivers, the provider's perceived controllability, and a set of complexity moderators at the levels of the patient, the care provider and the broader care context. We develop a conceptual framework that outlines key relationships among these complexity-contributing factors and present 10 key questions to help guide medical professionals in making complexity more explicit and more manageable in daily practice.

CONCLUSIONS

The framework presented in this study helps to advance a shared understanding of patient complexity. Our findings inform curriculum design and the teaching of essential skills to medical students in areas characterised by high patient complexity such as general internal medicine and geriatrics. From a policy perspective, our findings have important implications for the design of more effective healthcare interventions for complex patients.

Describing agreement in the main condition coding field using Canadian ICD-11 inpatient data

INTRODUCTION

Countries use varying coding standards, which impact international coded data comparability. The 'main condition' (MC) field is coded within the Discharge Abstract Database as "reason for admission" or "largest resource use".

OBJECTIVE

We offer a preliminary analysis on the frequency of and contributing factors to MC definition agreements within an inpatient Canadian dataset.

METHODS

Six professional coders performed a chart review between August 2016 and June 2017 on 3,000 randomly selected inpatient charts from three acute care hospitals in Calgary, Alberta. Coders classified the MC as "reason for admission", "largest resource use" or "both". Patients were admitted between 1st January and 30th June 2015 and met the inclusion criteria if they were ≥18 years, had an Alberta personal health care number, and had an inpatient visit for any service outside of obstetrics. Agreement between the two MC definitions was stratified by length of stay (LOS), emergency department admission, hospital of origin, discharge location, age, sex, procedures, and comorbidities. Chi-square analysis and frequency of inconsistencies were reported.

RESULTS

Only 34 (1.51%) of the 2,250 patient charts had disagreeing MC definitions. Age, emergency visit on admit, LOS, hospital, and discharge location were associated with MC agreement. Chronic conditions were seen more often in MC definition agreements, and acute conditions seen within those disagreeing.

CONCLUSION

There was a small proportion of cases in which the condition bringing the patient to hospital was not also the condition occupying the largest resources. Within disagreements, further research using a larger sample size is needed to explore the presence of MC in a secondary/tertiary condition, the association between patient complexity and disagreeing MC definitions, and the nature of the conditions seen in the inconsistent MC definitions.

Complex patients' effect on family physicians: high cognitive load and negative emotional impact

BACKGROUND AND OBJECTIVES

Complex patients present an increasing challenge to the health care system and family physicians play an important role in their care. As part of a larger project exploring family physicians' perceptions of complex patients, we sought to understand how complex patients affect family physicians and if these effects might be related to physician burnout.

METHODS

We conducted a qualitative study involving interviews with family physicians from various practice settings. We invited the physicians to choose three of their patients between the ages of 18 and 64 whom they considered to have complex medical problems and to have access to their medical records during a telephone interview using a semi-structured interview guide. Interviews were audio-recorded, professionally transcribed and coded. Using qualitative analytical software, research team members worked together to analyse the interview data and determine emerging themes.

RESULTS

Eleven family physicians participated in the interviews and described 29 unique complex patients, including challenges and effects on them personally. Analysis of the available 10 family physicians' interviews revealed two themes related to complexity's impact on physicians: (i) high cognitive load and (ii) negative emotional impact.

CONCLUSION

Although preliminary, this study offers a previously unconsidered understanding of drivers of physician burnout, including high cognitive load and negative emotional impact on family physicians created by caring for complex patients. Interventions to improve health care, including addressing physician wellness and burnout, should include the provision of resources to assist them with decreasing cognitive load and negative emotional impact when caring for complex patients.

Integrating patient complexity into health policy: a conceptual framework

Objective Clinicians across all health professions increasingly strive to add value to the care they deliver through the application of the central tenets of people-centred care (PCC), namely the 'right care', in the 'right place', at the 'right time' and 'tailored to the needs of communities'. This ideal is being hampered by a lack of a structured, evidence-based means to formulate policy and value the commissioning of services in an environment of increasing appreciation for the complex health needs of communities. This creates significant challenges for policy makers, commissioners and providers of health services. Communities face a complex intersection of challenges when engaging with healthcare. Increasingly, complexity is gaining prominence as a significant factor in the delivery of PCC. Based on the World Health Organization (WHO) components of health policy, this paper proposes a policy framework that enables policy makers, commissioners and providers of health care to integrate a model of complexity into policy, subsequent service planning and development of models of care. Methods The WHO components of health policy were used as the basis for the framework. Literature was drawn on to develop a policy framework that integrates complexity into health policy. Results Within the framework, complexity is juxtaposed between the WHO components of 'vision', 'priorities' and 'roles'. Conclusion This framework, supported by the literature, provides a means for policy makers and health planners to conduct analyses of and for policy. Further work is required to better model complexity in a manner that integrates consumer needs and provider capabilities. What is known about the topic? There is a growing body of evidence regarding patient complexity and its impact on the delivery of health services, but there is little consideration of patient complexity in policy, which is an important consideration for service provision. What does this paper add? This paper presents an argument for the inclusion of patient complexity in health policy and provides a framework for how that might occur. What are the implications for practitioners? The inclusion of patient complexity in policy could provide a means for policy makers to consider the factors that contribute to patient complexity in service provision decisions.

Strategies for case management in transitional care in emergency services: scoping review

OBJECTIVE

to map and synthesize the strategies implemented for case management in transitional care for patients with complex needs in emergency services.

METHOD

a scoping review conducted under the Joanna Briggs Institute guidance. Twenty-three studies were analyzed, with different methodological designs, on the strategies used in case management involving adult and elderly populations in emergency services.

RESULTS

the main strategies employed were patient risk stratification screening/identification, care management plan, coordination of care through multidisciplinary activities, support for the transition process, continuous patient monitoring, and follow-up.

FINAL CONSIDERATIONS

these strategies used structured approaches to care in emergency services to promote support for self-management and effective transitional care for people with complex needs, ensuring comprehensiveness, coordination, and continuity of care.

Clinical Case Complexity in Occupational Health: Contributing Factors and a Proposed Conceptual Framework Model

OBJECTIVES

Clinical case complexity is an inherent factor in occupational health (OH), yet it is poorly defined and understood. Our aim was to identify the multiple sources of complexity in OH and propose a conceptual complexity framework model for clinical OH practice.

METHODS

Through a scoping review, expert panel consensus, and content analysis of OH clinical case reports, we identified relevant complexity-contributing factors (CCFs) specifically tailored to the OH setting, which we defined and validated.

RESULTS

The proposed model consists of three primary domains (PDs); health factors, workplace factors and biopsychosocial factors. Twenty-seven CCFs are described and defined within these PDs.

CONCLUSIONS

This work lays the foundation for improved understanding, identification, and assessment of complexity in OH. This is imperative for ensuring high quality clinical practice standards, identifying training needs and appropriate triaging/resource allocation.

Clustering Complex Chronic Patients: A Cross-Sectional Community Study From the General Practitioner's Perspective

Objective:

Characterize subgroups of Complex Chronic Patients (CCPs) with cluster analysis from the general practitioner’s perspective.

Study design:

Cross-sectional population-based study.

Setting:

Three Primary Care urban centres for a reference population of 43,647 inhabitants over 14 years old in Sabadell, Catalonia, Spain.

Methods:

Complexity is defined by the independent clinical judgment of general practitioners with the aid of complexity domains (both clinical and social). We used a Two-Step Cluster method to identify relevant subgroups of CCPs.

Results:

Three relevant subgroups were identified. The first one was mainly managed by primary care professionals, and 63% of its CCPs belonged to the high-risk stratum of the Adjusted Morbidity Groups (GMA). The second subgroup included younger patients than the other two clusters, and showed the highest ratios of social deprivation and severe mental disease; 48% of its CCPs belonged to the high-risk stratum of the GMA. A third cluster included patients who belonged to the high-risk stratum of the GMA. Their age was similar to that of the patients in the first cluster, but they showed the highest values in the following areas: (i) risk of admission; (ii) proportion of advanced chronic disease and limited-life prognosis; (iii) functional loss and (iv) geriatric syndromes, along with special uncertainty in decision-making and clinical management.

Conclusions:

Characterization of CCPs shows clearly distinct profiles of needs, which provides an improved epidemiological picture by identifying clusters of patients who are likely to benefit from targeted interventions.

A scoping Review of tools used to assess patient Complexity in rheumatic disease

OBJECTIVE

Patients with rheumatic diseases often have multiple comorbidities which may impact well-being leading to high psychosocial complexity. This scoping review was undertaken to identify complexity measures/tools used in rheumatology that could help in planning and coordinating care.

METHODS

MEDLINE, EMBASE and CINAHL were searched from database inception to 14 December 2019 using keywords and Medical Subject Headings for "care coordination", "complexity" and selected rheumatic diseases and known complexity measures/tools. Articles describing the development or use of complexity measures/tools in patients with adult rheumatologic diagnoses were included regardless of study design. Included articles were evaluated for risk of bias where applicable.

RESULTS

The search yielded 407 articles, 37 underwent full-text review and 2 were identified during a hand search with 9 included articles. Only 2 complexity tools used in populations of adult patients with rheumatic disease were identified: the SLENQ and the INTERMED. The SLENQ is a 97-item patient needs questionnaire developed for patients with systemic lupus (n = 1 study describing tool development) and applied in 5 cross-sectional studies. Three studies (a practice article, trial and a cross-sectional study) applied the INTERMED, a clinical interview to ascertain complexity and support coordinated care, in patients with rheumatologic diagnoses.

CONCLUSIONS

There is limited information on the use of patient complexity measures/tools in rheumatology. Such tools could be applied to coordinate multidisciplinary care and improve patient experience and outcomes.

PATIENT CONTRIBUTION

This scoping review will be presented to patient research partners involved in co-designing a future study on patient complexity in rheumatic disease.

The Importance of Taking a Patient-Centered, Community-Based Approach to Preventing and Managing Frailty: A Public Health Perspective

Across the world, life expectancy is increasing. However, the years of life gained do not always correspond to healthy life years, potentially leading to an increase in frailty. Given the extent of population aging, the association between frailty and age and the impact of frailty on adverse outcomes for older people, frailty is increasingly being recognized to be a significant public health concern. Early identification of the condition is important to help older adults regain function and to prevent the negative outcomes associated with the syndrome. Despite the importance of diagnosing frailty, there is no definitive evidence or consensus of whether screening should be routinely implemented. A broad range of screening and assessment instruments have been developed taking a biopsychosocial approach, characterizing frailty as a dynamic state resulting from deficits in any of the physical, psychological and social domains, which contribute to health. All these aspects of frailty should be identified and addressed using an integrated and holistic approach to care. To achieve this goal, public health and primary health care (PHC) need to become the fulcrum through which care is offered, not only to older people and those that are frail, but to all individuals, favoring a life-course and patient-centered approach centered around integrated, community-based care. Public health personnel should be trained to address frailty not merely from a clinical perspective, but also in a societal context. Interventions should be delivered in the individuals' environment and within their social networks. Furthermore, public health professionals should contribute to education and training on frailty at a community level, fostering community-based interventions to support older adults and their caregivers to prevent and manage frailty. The purpose of this paper is to offer an overview of the concept of frailty for a public health audience in order to raise awareness of the multidimensional aspects of frailty and on how these should be addressed using an integrated and holistic approach to care.

What works in managing complex conditions in older people in primary and community care? A state-of-the-art review

The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.

Assessing Complexity Among Patients With Tuberculosis in California, 1993-2016

Background

Although the number of patients with active tuberculosis (TB) has decreased in the last 25 years, anecdotal reports suggest that the complexity of these patients has increased. However, this complexity and its components have never been quantified or defined. We therefore aimed to describe the complexity of patients with active TB in California during 1993–2016.

Methods

We analyzed data on patient comorbidities, clinical features, and demographics from the California Department of Public Health TB Registry. All adult patients who were alive at the time of TB diagnosis in California during 1993–2016 were included in the analyses. Factors deemed by an expert panel to increase complexity (ie, increased resources or expertise requirement for successful management) were analyzed and included the following: age >75 years, HIV infection, multidrug resistance (MDR), and extrapulmonary TB disease. Second, using additional information on other comorbidities available starting in 2010, we performed exploratory factor analysis on 25 variables in order to define the dimensions of complexity.

Results

Among the 67512 patients analyzed, the proportion of patients with extrapulmonary disease, age >75 years, or MDR-TB each increased over the study period (P < .001), while the proportion of patients with HIV decreased. Furthermore, the proportion of patients with at least 1 factor of those increased, rising from 38.8% to 45.3% (P < .001) from 1993 to 2016. Dimensions of complexity identified in the exploratory factor analysis included the following: race/immigration, social features, elderly/institutionalized, advanced TB, comorbidity, and drug resistance risk.

Conclusions

In this first description of complexity in the setting of TB, we found that the complexity of patients with active TB has risen over the last 25 years in California. These findings suggest that despite the overall decline in active TB cases, effective management of more complex patients may require additional attention and resource investment.

Long-Term Care for Tracheotomised Patients With or Without Invasive Ventilation. Lessons Learned from a Scoping Review of International Concepts

INTRODUCTION

Patients with long-term tracheostomies, with or without mechanical ventilation have complex and comprehensive healthcare needs. The number of patients is increasing internationally. Evidence suggests poor healthcare quality and outcomes, especially in Germany. Against this background, we searched for international concepts tailoring healthcare to these special needs, their key characteristics and results from their evaluations.

METHODS

A scoping review was performed in 2018 based on a systematic search of scientific databases and grey literature without restrictions to publication type. Key information was charted and thematically analysed based on the taxonomy of integrated care. Evaluations were analysed descriptively.

RESULTS

Seventy-nine publications related to 25 programmes from five countries were included. Healthcare concepts are usually regionally adapted and tertiary sector-based with a cross-sectoral approach. Care coordination responsibility is usually assigned to advanced nurse practitioners, embedded in multi-professional programme teams. Interventions consist of specialised needs-based clinical services combined with care coordination, homecare support and education. Evaluation of concepts is scarce, but existing results indicate beneficial effects on patient-related outcomes, care coordination, healthcare utilisation and costs.

CONCLUSIONS

The concepts available in the literature are often poorly described and rarely evaluated. Research is needed on their impact on healthcare quality and outcomes. However, several key characteristics were identified, which should be considered when developing and implementing integrated and needs-based approaches for the patient group in Germany and beyond.

Understanding Barriers to and Facilitators of Case Management in Primary Care: A Systematic Review and Thematic Synthesis

PURPOSE

Despite evidence on the benefits of case management for the care of patients with complex needs in primary care, implementing the program-necessary to achieve its benefits-has been challenging worldwide. Evidence on factors affecting implementation remains disparate. Accordingly, the objective of this systematic review was to identify barriers to and facilitators of case management, from the perspectives of health care professionals, in primary care settings around the world.

METHODS

We conducted a systematic review and thematic synthesis of qualitative findings. In collaboration with 2 librarians, we searched 3 electronic databases (MEDLINE, CINAHL, EMBASE) for studies related to factors affecting case management function in primary care. Two researchers screened titles, abstracts, and full texts for inclusion, then assessed included studies for quality. Results from included studies were synthesized by thematic synthesis, and a framework was developed.

RESULTS

Of 1,640 unique records identified, 22 studies, originating from 6 countries, met the inclusion criteria. We identified 9 barriers and facilitators: family context; policy and available resources; physician buy-in and understanding of the case manager role; relationship building; team communication practices; autonomy of case managers; training in technology; relationships with patients; and time pressure and workload. We describe these factors, then present a framework demonstrating the relationships among them.

CONCLUSIONS

Our study's findings show that multiple factors influence case management implementation. These findings have implications for researchers, clinicians, and policy makers who strive to implement or reform case management programs in local or larger primary care settings.

Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review

BACKGROUND

General practitioner (GP) shortages and increasing demand for care led to the introduction of nurse practitioners (NPs) to primary care. Many concepts for task sharing among health professionals feature complexity. The aim of this narrative review was to examine how complexity is used as a factor for task allocation between GPs and NPs.

METHODS

According to the PRISMA statement, PubMed and CINAHL were searched systematically, and eligibility criteria were applied to detect literature concerning GPs and NPs in primary care and complexity in the context of task allocation. Relevant information was extracted, and a narrative analysis was performed.

RESULTS

Thirty-seven studies from seven countries were included, comprising quantitative, qualitative, and mixed methods. Complexity was used to describe patients, their needs, and health professionals' tasks. The understanding of the use of complexity as a factor for task allocation between NPs and GPs was based on the patient population (specific vs. unspecific), the setting (specific vs. unspecific), the numbers of health professionals involved (two vs. more than two), and the NP role (distinct model of care vs. no model). Despite similarities in these areas, the tasks which NPs perform range from providing minor to complex care. However, there is a slight trend towards NPs treating socially complex patients and GPs focusing on medically complex cases.

CONCLUSION

Complexity as a concept is prominent in primary care but remains broad and inconsistent as a factor for task allocation between NPs and GPs. This review can be used as a point of reference when practitioners are seeking methods for task allocation in a collaborative primary care setting.