Multidisciplinary care: Experience of patients with complex needs
TL;DR: Perceptions of the diabetic patients' experience of multidisciplinary care, in particular their perceptions, perceived barriers and facilitators, showed that patients found it inconvenient to be referred to many health professionals because of multiple physical and psychosocial barriers.
Abstract: The rapidly increasing prevalence of diabetes with its high morbidity and mortality raises the need for an integratedmultidisciplinaryservicefromhealthcareprovidersacrosshealthsectors.Theaimofthisstudywastoexplorethe diabetic patients' experience of multidisciplinary care, in particular their perceptions, perceived barriers and facilitators. Thirteenpatientswithtype-2diabetesadmittedtotheemergencydepartmentofalocalhospitalinNSWwereinterviewedand completed a demographic questionnaire. Results showed that patients found it inconvenient to be referred to many health professionals because of multiple physical and psychosocial barriers. Separate sets of instructions from different health professionalswereoverwhelming,confusingandconflicting.Lackofadedicatedcoordinatorofcare,followupandsupport forself-managementfromhealthprofessionalswerefactorsthatcontributedtopatients'challengesinbeingactivelyinvolved in their care. The presence of multiple co-morbidities made it more difficult for patients to juggle priorities and 'commitments' to many health professionals. In addition, complex socioeconomic and cultural issues, such as financial difficulties, lack of transport and language barriers, intensified the challenge for these patients to navigate the health system independently.Fewpatientsfeltthathavingmanyhealthprofessionalsinvolvedintheircareimprovedtheirdiabetescontrol. Communicationamongthemultidisciplinarycareteamwasfragmentedandhadanegativeeffectonthecoordinationofcare. The patients' perspective is important to identify the problems they experience and to formulate strategies for improving multidisciplinary care for patients with diabetes.
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01 Jan 2014
TL;DR: Musculoskeletal conditions, including rheumatoid arthritis, osteoarthritis and osteoporosis, are prevalent in the Australian population, and they impose a substantial burden on the health care system and the community, reflected by their status as a national health priority area.
Abstract: Executive summary Policy context Musculoskeletal conditions, including rheumatoid arthritis, osteoarthritis and osteoporosis, are prevalent in the Australian population, and they impose a substantial burden on the health care system and the community, reflected by their status as a national health priority area. They are the main cause of impaired physical functioning globally. These conditions have high chronicity rates and often have a long term impact, leading to reduced mobility and dexterity, chronic pain, reduced capacity for employment, and negative impact on family and social life. Much of the care for these conditions is provided in primary health care (PHC) settings.
6 citations
TL;DR: In this article, the authors highlight the ongoing challenges facing primary care providers in the management of CKD in patients with T2D including the consideration of comorbidities, adoption of new treatment options, and implementation of individualized care.
Abstract: Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at high risk of CKD progression and cardiovascular (CV) disease. Prevalence of CKD in patients with T2D is currently around 40% and continues to grow. The increasing number of people with CKD and T2D will ultimately have a significant impact upon health resource use and costs of care for people with T2D. Management of CKD in patients with T2D aims to preserve kidney function to reduce the risk of end-stage kidney disease, CV events, and mortality. Evidence-based recommendations for the treatment of patients with CKD and T2D are provided by several international and national organizations and recommend several lifestyle and pharmacological approaches to help prevent or delay the progression of CKD in patients with T2D. Guidelines include regular screening of patients with T2D for CKD using spot urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (at least annually and at least twice a year if UACR >300 mg/g). Additionally, assessment of vascular complications, together with interventions designed to improve glycemic control and lipid levels, maintain healthy body weight, and optimize blood pressure should be performed. Medications shown to slow progression of CKD include renin-angiotensin system inhibitors, sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide 1 receptor agonists, and, more recently, selective, non-steroidal mineralocorticoid receptor antagonists. This review highlights the ongoing challenges facing primary care providers in the management of CKD in patients with T2D including the consideration of comorbidities, adoption of new treatment options, and implementation of individualized care. Achieving consensus for optimal treatment of this disease is critical in providing consistent and appropriate care for all patients. Strategies to improve outcomes should also include use of clear referral criteria, use of a multi-disciplinary approach, and patient education.
6 citations
TL;DR: This paper illustrates how this HIE-supported IHN vision may be achieved with an Australian case study demonstrating the integration of linked pseudonymised records with knowledge- and evidence-based guidelines using semantic web tools and informatics-based methods.
Abstract: General practice should become the hub of integrated health neighbourhoods (IHNs), which involves sharing of information to ensure that medical homes are also part of learning organisations that use electronic health record (EHR) data for care, decision making, teaching and learning, quality improvement and research. The IHN is defined as the primary and ambulatory care services in a locality that relates largely to a single hospital-based secondary care service provider and is the logical denominator and unit of comparison for the optimal use of EHR data and health information exchange (HIE) to facilitate integration and coordination of care. Its size may vary based on the geography and requirements of the population, for example between city, suburban and rural areas. The conceptual framework includes context; integration of data, information and knowledge; integration of clinical workflow and practice; and inter-professional integration to ensure coordinated shared care to deliver safe and effective services that are equitable, accessible and culturally respectful. We illustrate how this HIE-supported IHN vision may be achieved with an Australian case study demonstrating the integration of linked pseudonymised records with knowledge- and evidence-based guidelines using semantic web tools and informatics-based methods, researching causal links bewteen data quality and quality of care and the key issues to address. The data presented in this paper form part of the evaluation of the informatics infrastructure - HIE and data repository - for its reliability and utility in supporting the IHN. An IHN can only be created if the necessary health informatics infrastructure is put in place. Integrated care may struggle to be effective without HIE.
6 citations
09 Aug 2017
TL;DR: This work analyzed 4 years of data from 3 healthcare centers in Chile, corresponding to 2,838 patients, and showed that team prevalence is related to patient and healthcare center characteristics.
Abstract: Around 10% of the population suffers from diabetes, and this percentage is expected to rise. Healthcare guidelines propose a multidisciplinary, collaborative approach for treatment. However, there is little data to understand whether healthcare professionals are actually collaborating and how this collaboration takes place. We analyzed 4 years of data from 3 healthcare centers in Chile, corresponding to 2,838 patients. Patients were classified according to the composition of the healthcare team into four categories: highly multidisciplinary teams, specialized teams, physician-nurse centered teams, and non-collaborative treatment. Our results show that team prevalence is related to patient and healthcare center characteristics.
3 citations
26 Nov 2019
TL;DR: It is social capital and its cognitive elements of trust, sharing and reciprocity that underlie this phenomenon and explain why better health outcomes may be possible via interprofessional collaboration.
Abstract: Introduction Interprofessional interventions improve the ability of health professionals to work in teams, communicate effectively, respect and appreciate each other, and develop shared patient-centric values. While these interventions can change attitudes and beliefs about interprofessional collaboration, the relationship between interprofessional collaboration and patient health outcomes remains poorly understood, particularly for socioeconomically disadvantaged populations. This study sought to explore the relationship between interprofessional collaboration and patient health outcomes in urban disadvantaged settings. Methods Constructivist grounded theory methodology was used to perform 4 focus groups and 19 individual interviews with health professionals working in these settings in the United States. Emergent themes were developed into a conceptual model that captures their views on the link between interprofessional collaboration and patient health outcomes in these settings. Results 114 qualitative themes were identified and collapsed into 10 theoretical categories (interprofessionalism, building trust, coordination, facilitating sharing, patient care, enhancing reciprocity, common goals, effecting change, healthcare system disparities, and patient individual, group or population disparities), all of which were then merged into two theoretical concepts that explain all of the data (social capital and disparities). Conclusion Interprofessional collaboration works via better coordination and optimization of patient care, which explains how better patient health outcomes may be achieved. However, it is social capital and its cognitive elements of trust, sharing and reciprocity that underlie this phenomenon and explain why better health outcomes may be possible via interprofessional collaboration. Additional research studies exploring patient perspectives and the structural elements of social capital in this context are warranted.
3 citations
Cites background or methods or result from "Multidisciplinary care: Experience ..."
..., 2010) and barriers and facilitators to (Maneze et al., 2014) interprofessional collaboration? Although these studies addressed research questions that generated themes related to the relationship between IPCP and patient health outcomes, these themes were incidental findings as none of the studies sought out to explore this relationship explicitly, suggesting that these studies were unlikely to capture the types of rich data that emerge from having implemented an explicit and exhaustive qualitative methodology such as grounded theory (Charmaz, 2006)....
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...…3 studies were done in Canada (Adams et al., 2014; Bajnok et al., 2012; Goldman et al., 2010), 2 studies were from Australia (Chong et al., 2013; Maneze et al., 2014), 2 studies took place in Norway (Bradley Eilertsen et al., 2009; Fredheim et al., 2011), 1 study was from Finland (Eloranta et…...
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...Thus, IPCP is the act of collaboration by continuously learning with, from and about each other, preferably with involvement of the patient, family and community, in the process of improving healthcare quality and optimizing patient health outcomes (Australian Interprofessional Practice and Education Network, 2012; World Health Organization, 2010)....
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...Most of these studies used an unspecified qualitative descriptive methodology (Adams et al., 2014; Bradley Eilertsen et al., 2009; Chong et al., 2013; Eloranta et al., 2010; Fredheim et al., 2011; Goldman et al., 2010; Hjalmarson et al., 2013; Maneze et al., 2014), except one that used a grounded theory approach (Bajnok et al....
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...A search of the literature via Google Scholar, Medline, CINAHL and Scopus, using the key words “interprofessional” and “health” or “patient” or “professional” yielded 9 relevant qualitative research studies (Adams, Orchard, Houghton, & Ogrin, 2014; Bajnok, Puddester, Macdonald, Archibald, & Kuhl, 2012; Bradley Eilertsen et al., 2009; Chong, Aslani, & Chen, 2013; Eloranta, Welch, Arve, & Routasalo, 2010; Fredheim, Danbolt, Haavet, Kjonsberg, & Lien, 2011; Goldman, Meuser, Rogers, Lawrie, & Reeves, 2010; Hjalmarson, Ahgren, & Kjölsrud, 2013; Maneze et al., 2014) that have explored various aspects of this relationship....
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References
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TL;DR: The CCM is described, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process are described, to guide quality improvement.
Abstract: The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.
3,215 citations
TL;DR: The challenge is to organize these components into an integrated system of chronic illness care, which can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care.
Abstract: Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
2,805 citations
"Multidisciplinary care: Experience ..." refers background in this paper
...The Chronic Care Model (CCM) describes six elements that are essential for improving the quality of care for patients with chronic disease (Wagner et al. 1996)....
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TL;DR: Inadequate health literacy may contribute to the disproportionate burden of diabetes-related problems among disadvantaged populations and efforts should focus on developing and evaluating interventions to improve diabetes outcomes among patients with inadequate health literacy.
Abstract: ContextHealth literacy is a measure of patients' ability to read, comprehend,
and act on medical instructions. Poor health literacy is common among racial
and ethnic minorities, elderly persons, and patients with chronic conditions,
particularly in public-sector settings. Little is known about the extent to
which health literacy affects clinical health outcomes.ObjectivesTo examine the association between health literacy and diabetes outcomes
among patients with type 2 diabetes.Design, Setting, and ParticipantsCross-sectional observational study of 408 English- and Spanish-speaking
patients who were older than 30 years and had type 2 diabetes identified from
the clinical database of 2 primary care clinics of a university-affiliated
public hospital in San Francisco, Calif. Participants were enrolled and completed
questionnaires between June and December 2000. We assessed patients' health
literacy by using the short-form Test of Functional Health Literacy in Adults
(s-TOFHLA) in English or Spanish.Main Outcome MeasuresMost recent hemoglobin A1c (HbA1c) level. Patients
were classified as having tight glycemic control if their HbA1c
was in the lowest quartile and poor control if it was in the highest quartile.
We also measured the presence of self-reported diabetes complications.ResultsAfter adjusting for patients' sociodemographic characteristics, depressive
symptoms, social support, treatment regimen, and years with diabetes, for
each 1-point decrement in s-TOFHLA score, the HbA1c value increased
by 0.02 (P = .02). Patients with inadequate health
literacy were less likely than patients with adequate health literacy to achieve
tight glycemic control (HbA1c ≤7.2%; adjusted odds ratio [OR],
0.57; 95% confidence interval [CI], 0.32-1.00; P
= .05) and were more likely to have poor glycemic control (HbA1c ≥9.5%;
adjusted OR, 2.03; 95% CI, 1.11-3.73; P = .02) and
to report having retinopathy (adjusted OR, 2.33; 95% CI, 1.19-4.57; P = .01).ConclusionsAmong primary care patients with type 2 diabetes, inadequate health
literacy is independently associated with worse glycemic control and higher
rates of retinopathy. Inadequate health literacy may contribute to the disproportionate
burden of diabetes-related problems among disadvantaged populations. Efforts
should focus on developing and evaluating interventions to improve diabetes
outcomes among patients with inadequate health literacy.
1,732 citations
TL;DR: In this article, the authors explored the impact of depressive symptoms in primary care patients with diabetes on self-care, adherence to medication regimens, functioning, and health care costs.
Abstract: Background Depression is common among patients with chronic medical illness. We explored the impact of depressive symptoms in primary care patients with diabetes on diabetes self-care, adherence to medication regimens, functioning, and health care costs. Methods We administered a questionnaire to 367 patients with types 1 and 2 diabetes from 2 health maintenance organization primary care clinics to obtain data on demographics, depressive symptoms, diabetes knowledge, functioning, and diabetes self-care. On the basis of automated data, we measured medical comorbidity, health care costs, glycosylated hemoglobin (HbA 1c ) levels, and oral hypoglycemic prescription refills. Using depressive symptom severity tertiles (low, medium, or high), we performed regression analyses to determine the impact of depressive symptoms on adherence to diabetes self-care and oral hypoglycemic regimens, HbA 1c levels, functional impairment, and health care costs. Results Compared with patients in the low-severity depression symptom tertile, those in the medium- and high-severity tertiles were significantly less adherent to dietary recommendations. Patients in the high-severity tertile were significantly distinct from those in the low-severity tertile by having a higher percentage of days in nonadherence to oral hypoglycemic regimens (15% vs 7%); poorer physical and mental functioning; greater probability of having any emergency department, primary care, specialty care, medical inpatient, and mental health costs; and among users of health care within categories, higher primary (51% higher), ambulatory (75% higher), and total health care costs (86% higher). Conclusions Depressive symptom severity is associated with poorer diet and medication regimen adherence, functional impairment, and higher health care costs in primary care diabetic patients. Further studies testing the effectiveness and cost-effectiveness of enhanced models of care of diabetic patients with depression are needed.
1,491 citations
TL;DR: The extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts during outpatient encounters was measured and the association between physicians' application of this interactive communication strategy and patients' glycemic control was examined.
Abstract: Background Patients recall or comprehend as little as half of what physicians convey during an outpatient encounter. To enhance recall, comprehension, and adherence, it is recommended that physicians elicit patients' comprehension of new concepts and tailor subsequent information, particularly for patients with low functional health literacy. It is not known how frequently physicians apply this interactive educational strategy, or whether it is associated with improved health outcomes. Methods We used direct observation to measure the extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts during outpatient encounters, using audiotapes of visits between 38 physicians and 74 English-speaking patients with diabetes mellitus and low functional health literacy. We then examined whether there was an association between physicians' application of this interactive communication strategy and patients' glycemic control using information from clinical and administrative databases. Results Physicians assessed recall and comprehension of any new concept in 12 (20%) of 61 visits and for 15 (12%) of 124 new concepts. Patients whose physicians assessed recall or comprehension were more likely to have hemoglobin A1clevels below the mean (≤8.6%) vs patients whose physicians did not (odds ratio, 8.96; 95% confidence interval, 1.1-74.9) (P= .02). After multivariate logistic regression, the 2 variables independently associated with good glycemic control were higher health literacy levels (odds ratio, 3.97; 95% confidence interval, 1.09-14.47) (P= .04) and physicians' application of the interactive communication strategy (odds ratio, 15.15; 95% confidence interval, 2.07-110.78) (P Conclusions Primary care physicians caring for patients with diabetes mellitus and low functional health literacy rarely assessed patient recall or comprehension of new concepts. Overlooking this step in communication reflects a missed opportunity that may have important clinical implications.
1,139 citations
"Multidisciplinary care: Experience ..." refers background in this paper
...This requires tailored, active, long-term support and regular follow up from health professionals (Schillinger et al. 2003)....
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