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Journal ArticleDOI

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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Journal ArticleDOI
TL;DR: An overview of how patients with multimorbidity experience a range of system- and professional-related issues with healthcare delivery illustrates the diversity of aspects that should be considered in designing healthcare services for patients with multi- health problems.
Abstract: Background : The number of patients with multimorbidity (two or more conditions) is increasing. Observational research has shown that having multiple health problems is associated with poorer outcomes in terms of health, quality of care, and costs. Thus, it is imperative to understand how patients with multimorbidity experience their healthcare process. Insight into patient experiences can be used to tailor healthcare provision specifically to the needs of patients with multimorbidity. Objective : To synthesize self-reported experiences with the healthcare process of patients with multimorbidity, and identify overarching themes. Design : A scoping literature review that evaluates both qualitative and quantitative studies published in PubMed, Embase, MEDLINE, and PsycINFO. No restrictions were applied to healthcare setting or year of publication. Studies were included if they reported experiences with the healthcare process of patients with multimorbidity. Patient experiences were extracted and subjected to thematic analysis (interpretative), which revealed overarching themes by mapping their interrelatedness. Results : Overall, 22 empirical studies reported experiences of patients with multimorbidity. Thematic analysis identified 12 themes within these studies. The key overarching theme was the experience of a lack of holistic care. Patients also experienced insufficient guidance from healthcare providers. Patients also perceived system-related issues such as problems stemming from poor professional-to-professional communication. Conclusions : Patients with multimorbidity experience a range of system- and professional-related issues with healthcare delivery. This overview illustrates the diversity of aspects that should be considered in designing healthcare services for patients with multimorbidity. Journal of Comorbidity 2017;7(1):11–21

44 citations

Journal ArticleDOI
TL;DR: Investigating the information-seeking experiences of patients with Type 2 diabetes and how these influenced self-management behaviours found inconsistent and insufficient information from healthcare professionals undermined patients' ability to self-manage diabetes.

22 citations

Journal ArticleDOI
TL;DR: The co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently.
Abstract: Several countries have co-located General Practitioners (GPs) in Primary Care Centres (PCCs) with other health and social care professionals in order to improve integrated care. It is not clear whether the co-location of a multidisciplinary team actually facilitates a positive patient experience concerning GP care. The aim of this study was to verify whether the co-location of GPs in PCCs is associated positively with patient satisfaction with their GP when patients have experience of a multidisciplinary team. We also investigated whether patients who frequently use health services, due to their complex needs, benefitted the most from the co-location of a multidisciplinary team. The study used data from a population survey carried out in Tuscany (central Italy) at the beginning of 2015 to evaluate the patients’ experience and satisfaction with their GPs. Multilevel linear regression models were implemented to verify the relationship between patient satisfaction and co-location. This key explanatory variable was measured by considering both the list of GPs working in PCCs and the answers of surveyed patients who had experienced the co-location of their GP in a multidisciplinary team. We also explored the effect modification on patient satisfaction due to the use of hospitalisation, access to emergency departments and visits with specialists, by performing the multilevel modelling on two strata of patient data: frequent and non-frequent health service users. A sample of 2025 GP patients were included in the study, 757 of which were patients of GPs working in a PCC. Patient satisfaction with their GP was generally positive. Results showed that having a GP working within a PCC and the experience of the co-located multidisciplinary team were associated with a higher satisfaction (p < 0.01). For non-frequent users of health services on the other hand, the co-location of multidisciplinary team in PCCs was not significantly associated with patient satisfaction, whereas for frequent users, the strength of relationships identified in the overall model increased (p < 0.01). The co-location of GPs with other professionals and their joint working as experienced in PCCs seems to represent a greater benefit for patients, especially for those with complex needs who use primary care, hospitals, emergency care and specialized care frequently.

21 citations


Cites background from "Multidisciplinary care: Experience ..."

  • ...Because of their complex needs, all these patients use health services frequently, and interact frequently with social and health professionals and in particular with different primary and secondary care providers, with a high risk of experiencing fragmentation in their care pathway [19]....

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  • ...These patients have a greater risk of fragmentation in their care pathway [19], and they require a more coordinated and comprehensive care [10]....

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Journal ArticleDOI
TL;DR: In this paper, the authors identify the underlying program theories for the Multispecialty Community Provider (MCP) model of care, identify sources of theoretical, empirical and practice evidence to test the programme theories, and explain how mechanisms used in different contexts contribute to outcomes and process variables.
Abstract: Background The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations. Objectives The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables. Design There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components. Main outcome measures The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience. Data sources Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence. Review methods A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities. Results Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models. Strengths and limitations The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change. Conclusions Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working. Future work A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

20 citations

Journal ArticleDOI
TL;DR: Coordinated, multidisciplinary diabetes team care is understood by and acceptable to patients with type 2 diabetes.

20 citations

References
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Journal ArticleDOI
TL;DR: The purpose of this systematic review was to examine the effectiveness of community health workers in supporting the care of persons with diabetes.
Abstract: Aims The purpose of this systematic review was to examine the effectiveness of community health workers in supporting the care of persons with diabetes. Methods Computerized searches were conducted of multiple electronic bibliographic dababases until March 2004. We identified studies in any language and of any design that examined the effectiveness of diabetes-related interventions involving community health workers and reported outcomes in persons with diabetes. Results were synthesized narratively. Results Eighteen studies were identified, including eight randomized controlled trials. Most studies focused on minority populations in the USA. The roles and duties of community health workers in diabetes care were varied, ranging from substantial involvement in patient care to providing instrumental assistance in education sessions taught by other health professionals. Participants were generally satisfied with their contacts with community health workers and participant knowledge increased. Improvements in physiological measures were noted for some interventions and positive changes in lifestyle and self-care were noted in a number of studies. There were few data on economic outcomes, but several studies demonstrated a decrease in inappropriate health care utilization. Conclusions Diabetes programmes include community health workers as team members in a variety of roles. There are some preliminary data demonstrating improvements in participant knowledge and behaviour. Much additional research, however, is needed to understand the incremental benefit of community health workers in multicomponent interventions and to identify appropriate settings and optimal roles for community health workers in the care of persons with diabetes.

406 citations


"Multidisciplinary care: Experience ..." refers background in this paper

  • ...Working in collaboration with community health providers to increase patient engagement in the community (Dennis et al. 2008; Norris et al. 2006; Portillo and Waters 2004) may maximise the impact of specialist community health providers in tailoring culturally and clinically appropriate care (Metghalchi et al....

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  • ...Working in collaboration with community health providers to increase patient engagement in the community (Dennis et al. 2008; Norris et al. 2006; Portillo and Waters 2004) may maximise the impact of specialist community health providers in tailoring culturally and clinically appropriate care…...

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Journal ArticleDOI
TL;DR: Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.
Abstract: BACKGROUND The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.

296 citations


"Multidisciplinary care: Experience ..." refers background in this paper

  • ...The effect of co-morbidities in patient management As demonstrated in our patients, those with multiple co-morbid conditions often find it difficult to juggle many health care appointments and needs (Bayliss et al. 2003; Kerr et al. 2007)....

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  • ...As demonstrated in our patients, those with multiple co-morbid conditions often find it difficult to juggle many health care appointments and needs (Bayliss et al. 2003; Kerr et al. 2007)....

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Journal Article
TL;DR: Although it adds complexity to clinical intervention, this approach increases clinical flexibility, addresses the important players in disease management, and accounts for a significant number of risk and protective factors that affect outcome.
Abstract: The management of patients with chronic disease constitutes the largest single cost to the health care system in the United States. New approaches and methods are needed to reduce preventable complications and to enhance the health and well-being of patients with chronic disease and their families. Interventions that target the family setting in which disease management takes place have emerged as an alternative to traditional strategies that focus only on the individual patient or that consider the family only as a peripheral source of positive or negative social support. In this approach, the educational, relational, and personal needs of all family members are emphasized. Data reviewed by the National Working Group on Family-Based Interventions in Chronic Disease identified potential mechanisms by which the relational context of the family affects disease management and how characteristics of family relationships serve as risk or protective factors. In this paper we describe the major forms of family-based interventions, review the results of selected clinical trials, and present applications for clinical practice. The data suggest that approaches to the management of chronic disease should be expanded to include the broader relational context in which disease management takes place. Although it adds complexity to clinical intervention, this approach increases clinical flexibility, addresses the important players in disease management, and accounts for a significant number of risk and protective factors that affect outcome.

177 citations

Journal ArticleDOI
TL;DR: Providers in health centers indicate a need to enhance behavioral change in diabetic patients, and better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are likely to help health centers meet ADA standards of care.
Abstract: OBJECTIVE — We aimed to identify barriers to improving care for individuals with diabetes in community health centers. These findings are important because many such patients, as in most other practice settings, receive care that does not meet evidence-based standards. RESEARCH DESIGN AND METHODS — In 42 Midwestern health centers, we surveyed 389 health providers and administrators about the barriers they faced delivering diabetes care. We report on home blood glucose monitoring, HbAlc tests, dilated eye examinations, foot examinations, diet, and exercise, all of which are a subset of the larger clinical practice recommendations of the American Diabetes Association (ADA). RESULTS — Among the 279 (72%) respondents, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important (overall mean on 30-point scale: providers 26.8, patients 18.2, P = 0.0001). Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. Ratings of the importance of access to care and finances as barriers varied widely; however, >25% of the providers and administrators agreed that significant barriers included affordability of home blood glucose monitoring, HbAlc testing, dilated eye examination, and special diets; nonproximity of ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers. CONCLUSIONS — Providers in health centers indicate a need to enhance behavioral change in diabetic patients. In addition, better health care delivery systems and reforms that improve the affordability, accessibility, and efficiency of care are also likely to help health centers meet ADA standards of care.

172 citations

Journal ArticleDOI
TL;DR: The Chronic Care Model provides a useful framework for understanding the impact of chronic disease management interventions and highlights the gaps in evidence.
Abstract: Objectives To review the effectiveness of chronic disease management interventions for physical health problems in the primary care setting, and to identify policy options for implementing successful interventions in Australian primary care. Methods We conducted a systematic review with qualitative data synthesis, using the Chronic Care Model as a framework for analysis between January 1990 and February 2006. Interventions were classified according to which elements were addressed: community resources, health care organisation, self-management support, delivery system design, decision support and/or clinical information systems. Our major findings were discussed with policymakers and key stakeholders in relation to current and emerging health policy in Australia. Results The interventions most likely to be effective in the context of Australian primary care were engaging primary care in self-management support through education and training for general practitioners and practice nurses, and including self-management support in care plans linked to multidisciplinary team support. The current Practice Incentives Payment and Service Incentives Payment programs could be improved and simplified to encourage guideline-based chronic disease management, integrating incentives so that individual patients are not managed as if they had a series of separate chronic diseases. The use of chronic disease registers should be extended across a range of chronic illnesses and used to facilitate audit for quality improvement. Training should focus on clear roles and responsibilities of the team members. Conclusion The Chronic Care Model provides a useful framework for understanding the impact of chronic disease management interventions and highlights the gaps in evidence. Consultation with stakeholders and policymakers is valuable in shaping policy options to support the implementation of the National Chronic Disease Strategy in primary care.

162 citations


"Multidisciplinary care: Experience ..." refers background in this paper

  • ...Working in collaboration with community health providers to increase patient engagement in the community (Dennis et al. 2008; Norris et al. 2006; Portillo and Waters 2004) may maximise the impact of specialist community health providers in tailoring culturally and clinically appropriate care (Metghalchi et al....

    [...]

  • ...Patients often claimed to have had no help from the health professionals in these areas where, if the help had been provided, assistance could have improved the process of care and patient outcomes (Dennis et al. 2008)....

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  • ...A feature of theCCM that has been shown to be effective is delivery system design and the important role of themulti-disciplinary team in planned followup to support self-management (Dennis et al. 2008) The Innovative Care for Chronic Conditions (ICCC) further expanded this to include the patient’s support networks, such as their family, with the aim of shifting the patient from being a passive recipient of care to being an active member of the care team (Epping-Jordan et al....

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  • ...Working in collaboration with community health providers to increase patient engagement in the community (Dennis et al. 2008; Norris et al. 2006; Portillo and Waters 2004) may maximise the impact of specialist community health providers in tailoring culturally and clinically appropriate care…...

    [...]

  • ...…shown to be effective is delivery system design and the important role of themulti-disciplinary team in planned followup to support self-management (Dennis et al. 2008) The Innovative Care for Chronic Conditions (ICCC) further expanded this to include the patient’s support networks, such as their…...

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