Living with multimorbidity: medical and lay healthcare approaches

An interpretative phenomenological analysis of the lived experience of people with multimorbidity in low- and middle-income countries

People living with multimorbidity (PLWMM) have multiple needs and require long-term personalised care, which necessitates an integrated people-centred approach to healthcare. However, people-centred care may risk being a buzzword in global health and cannot be achieved unless we consider and prioritise the lived experience of the people themselves. This study captures the lived experiences of PLWMM in low- and middle-income countries (LMICs) by exploring their perspectives, experiences, and aspirations.We analysed 50 semi-structured interview responses from 10 LMICs across three regions-South Asia, Latin America, and Western Africa-using an interpretative phenomenological analysis approach.The bodily, social, and system experiences of illness by respondents were multidirectional and interactive, and largely captured the complexity of living with multimorbidity. Despite expensive treatments, many experienced little improvements in their conditions and felt that healthcare was not tailored to their needs. Disease management involved multiple and fragmented healthcare providers with lack of guidance, resulting in repetitive procedures, loss of time, confusion, and frustration. Financial burden was exacerbated by lost productivity and extreme finance coping strategies, creating a vicious cycle. Against the backdrop of uncertainty and disruption due to illness, many demonstrated an ability to cope with their conditions and navigate the healthcare system. Respondents' priorities were reflective of their desire to return to a pre-illness way of life-resuming work, caring for family, and maintaining a sense of independence and normalcy despite illness. Respondents had a wide range of needs that required financial, health education, integrated care, and mental health support.In discussion with respondents on outcomes, it appeared that many have complementary views about what is important and relevant, which may differ from the outcomes established by clinicians and researchers. This knowledge needs to complement and be incorporated into existing research and treatment models to ensure healthcare remains focused on the human and our evolving needs.

Automanejo en personas con multimorbilidad: aportes desde la salutogénesis y el modelo de activos en salud

Diferentes modelos de cuidado en contexto de cronicidad y multimorbilidad incorporan a la comunidad, sistema de salud, práctica clínica, políticas sanitarias, prevención y promoción de salud. Entre estos se señala el rol facilitador del equipo de salud en el automanejo, siendo las personas protagonistas de su proceso. El abordaje de la multimorbilidad se realiza mayormente desde un enfoque centrado en el riesgo y la enfermedad, limitando la exploración de los recursos de las personas y su entorno. Incorporar un enfoque de salud positiva puede aportar a una mayor integralidad. El propósito de este artículo es proponer un abordaje desde el modelo sinérgico de salud, integrando la salutogénesis y el modelo de activos, para facilitar el automanejo promoviendo la capacidad de agencia de las personas. Se presentan potenciales áreas de aplicación de estos modelos en el contexto de multimorbilidad, fomentando condiciones de salud y bienestar en las personas y sus familias.

Patient experiences of integrated care within the United Kingdom: A systematic review

Introduction

Integrated care and patient experience are central to the coordination and delivery of high quality health and social care in the UK, but their joint application is poorly understood. This systematic review aimed to gain an understanding of patient experience within current integrated care services in the UK, and specifically, whether they reflect person-centred coordinated care (PCCC).

Methods

Following PRISMA, electronic databases (ProQuest, EBSCO and Cochrane Library) were searched from 2012 to 2019 for primary, peer-reviewed literature. Papers were included where patients’ or carers’ experiences of integrated care were reported. Papers were excluded where they focused on acute integrated care interventions, measured experience via satisfaction scores only, or findings lacked sufficient depth to answer the research question. Quality was assessed using Mixed Methods Appraisal Tool, and findings synthesised using a framework approach, incorporating the Rainbow Model of Integrated Care and Measuring Integrated Care Patient Framework.

Results

Sixteen studies were included. Person-centred and shared responsibility experiences were most often discussed. Experiences were not always described as positive and some patients experienced a lack of PCCC. Clinical, professional/organisational and functional integration processes were associated with experiencing domains of PCCC.

Discussion

People with complex needs experience a lack of coordination across teams and wider community resources, and limited associations were made between integration processes and patient experience. Further research which gives context to individual experience, provides greater detail of integration processes and utilises validated patient experience measures of PCCC is required to understand the association between integration processes and domains of PCCC.

Timing of onset and self-management of multiple chronic conditions: A qualitative examination taking a lifespan perspective

OBJECTIVES

Over two-thirds of older individuals live with multiple chronic conditions, yet chronic diseases are often studied in silos. Taking a lifespan approach to understanding the development of multiple chronic conditions in the older population helps to further elucidate opportunities for targeted interventions that address the complexities of multiple chronic conditions.

METHODS

Semi-structured interviews were conducted with 38 older adults (age 64+) diagnosed with at least two chronic health conditions. Content analysis was used to build understanding of how older adults discuss the timing of diagnoses and subsequent self-management of multiple chronic conditions.

RESULTS

Findings highlight the complex process by which illnesses unfold in the context of individuals' lives and the subsequent engagement and/or disengagement in self-management behaviors. Two primary themes were evident regarding timing of illnesses: illnesses were experienced within the context of social life events and/or health events, and illnesses were not predominantly seen as connected to one another by patients. Self-management behaviors were described in response to onset of each illness.

DISCUSSION

Findings provide insight into how older adults understand their experience of multiple chronic conditions and change in self-management behaviors over time. In order for practitioners to ignite behavioral changes, a person's history and life experiences must be considered.

Digital methods to enhance the usefulness of patient experience data in services for long-term conditions: the DEPEND mixed-methods study

Background

Collecting NHS patient experience data is critical to ensure the delivery of high-quality services. Data are obtained from multiple sources, including service-specific surveys and widely used generic surveys. There are concerns about the timeliness of feedback, that some groups of patients and carers do not give feedback and that free-text feedback may be useful but is difficult to analyse.

Objective

To understand how to improve the collection and usefulness of patient experience data in services for people with long-term conditions using digital data capture and improved analysis of comments.

Design

The DEPEND study is a mixed-methods study with four parts: qualitative research to explore the perspectives of patients, carers and staff; use of computer science text-analytics methods to analyse comments; co-design of new tools to improve data collection and usefulness; and implementation and process evaluation to assess use of the tools and any impacts.

Setting

Services for people with severe mental illness and musculoskeletal conditions at four sites as exemplars to reflect both mental health and physical long-terms conditions: an acute trust (site A), a mental health trust (site B) and two general practices (sites C1 and C2).

Participants

A total of 100 staff members with diverse roles in patient experience management, clinical practice and information technology; 59 patients and 21 carers participated in the qualitative research components.

Interventions

The tools comprised a digital survey completed using a tablet device (kiosk) or a pen and paper/online version; guidance and information for patients, carers and staff; text-mining programs; reporting templates; and a process for eliciting and recording verbal feedback in community mental health services.

Results

We found a lack of understanding and experience of the process of giving feedback. People wanted more meaningful and informal feedback to suit local contexts. Text mining enabled systematic analysis, although challenges remained, and qualitative analysis provided additional insights. All sites managed to collect feedback digitally; however, there was a perceived need for additional resources, and engagement varied. Observation indicated that patients were apprehensive about using kiosks but often would participate with support. The process for collecting and recording verbal feedback in mental health services made sense to participants, but was not successfully adopted, with staff workload and technical problems often highlighted as barriers. Staff thought that new methods were insightful, but observation did not reveal changes in services during the testing period.

Conclusions

The use of digital methods can produce some improvements in the collection and usefulness of feedback. Context and flexibility are important, and digital methods need to be complemented with alternative methods. Text mining can provide useful analysis for reporting on large data sets within large organisations, but qualitative analysis may be more useful for small data sets and in small organisations.

Limitations

New practices need time and support to be adopted and this study had limited resources and a limited testing time.

Future work

Further research is needed to improve text-analysis methods for routine use in services and to evaluate the impact of methods (digital and non-digital) on service improvement in varied contexts and among diverse patients and carers.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 28. See the NIHR Journals Library website for further project information.

Positioning the six-month review in the recovery process post-stroke: The ideology of personal responsibility

Stroke is the UK's fourth highest cause of death and an estimated 300,000 people in England are living with related disability. This paper explores the six-month review (6MR), a policy initiative that aimed to ameliorate unmet need. A multiple case study approach underpinned by critical realism was used to elicit the views of patients, carers, providers and commissioners across three sites using interviews, observations and documentation. Forty-six patients (age range 28-91 years), 30 carers and 28 professionals were interviewed between December 2015 and October 2016. Twenty-nine reviews were observed. Data was analysed thematically across sites. 6MRs carried out by stroke nurse specialists (SNSs) were found to be more medically orientated than those completed by a Stroke Association (SA) co-ordinator who focused on social issues. Reviewers regarded reviews primarily as an opportunity to address unmet need and signpost to further services. Patients responded in three different ways: proactive and engaged, reflected an active orientation to recovery and self-management; proactive and self-managing on their own terms, encompassed patients who were striving for independence but took their own approach sometimes at odds with that of clinicians; and passive orientation, whereby patients did not engage in rehabilitation or self-management. Patients identified different priorities to those of reviewers, particularly those with other long-term conditions and this appeared to contribute to the dissatisfaction that some expressed. In conclusion, there was little evidence that the 6MR played a key role in recovery. Locally defined outcomes for the 6MR reflecting national policy were not substantiated by the findings. Our findings suggest that the 6MR should review therapy goals and facilitate patient-led goals. Reviewers should be allowed the freedom to individualise the process rather than adhering to a rigid framework dictated by national policy and local protocols.

Delivering person-centred holistic care for older people

Purpose

This paper is an evaluated case study of the Wellbeing Coordinator (WBC) service in Cheshire, UK. WBCs are non-clinical members of the GP surgery or hospital team who offer advice and support to help people with long-term conditions and unmet social needs remain independent at home. The paper aims to discuss this issue.

Design/methodology/approach

A mixed method design assessed the outcomes of care for recipients and carers using interviews, diaries and validated wellbeing measures. Service utilization data, interviews and observations of WBC consultations enabled investigation of changes in processes of care. Data were analysed using simple descriptive statistics, established instrument scoring systems and accepted social science conventions.

Findings

The WBC complements medical approaches to supporting people with complex health and social care problems, with support for carers often a key service component. Users reported improvements in their wellbeing, access to social networks, and maintenance of social identity and valued activities. Health and social care professionals recognized the value of the service.

Practical implications

The WBC concept relieves the burden on health and social care professionals as the social elements of ill-health are addressed. A shift in thinking from ill-health to wellbeing means older people feel more able to regain control over their own lives, being less dependent on consulting professionals.

Originality/value

The WBC is a new service focussing on the individual in their health, social and economic context. Process and outcomes evaluations are rare in this field.