Patients, caregivers and health-care professionals' experience with an interdisciplinary intervention for people with multimorbidity in primary care: A qualitative study

Multimorbidity Management: A Scoping Review of Interventions and Health Outcomes

Multimorbidity, defined as the co-occurrence of two or more chronic conditions in an individual, has emerged as a worldwide public health concern contributing to mortality and morbidity. This complex health phenomenon is becoming increasingly prevalent worldwide, particularly as populations continue to age. Despite the growing burden of multimorbidity, the development and implementation of interventions published by scholars are still in their early stages with significant variability in strategies and outcomes. The variability in strategy and outcome may result from factors such as lack of infrastructure, socioeconomic status and lifestyle factors. The review aims to synthesize interventions designed to manage and mitigate multimorbidity and explore a range of approaches, including pharmacological treatments, lifestyle modifications, care coordination models, and technological innovations. The scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. It included 1,553,877 individuals with multimorbidity with no age restriction; in the studies that included gender difference, 463,339 male participants and 1,091,538 female participants were involved. Multimorbidity interventions were defined as strategies or programs designed to manage and improve the health and quality of life of individuals with multiple chronic conditions. Of the downloaded articles, those that met the inclusion criteria were published between 2012 and 2024. The final analysis included 100 articles from 3119 published articles, which resulted in 9 themes and 15 subthemes. Themes on the need for lifestyle and behavioural interventions, patient empowerment and engagement, multimorbidity management, health integration, pharmacotherapy optimization, community and policy interventions, healthcare system improvements, technology and digital health, as well as research and evidence-based practice interventions, emerged. The reviewed literature emphasizes the necessity of multidisciplinary approaches to effectively combat the growing public health challenge of multimorbidity.

Exploring Hospital Healthcare Providers' Approaches to Multidisciplinary Initiatives and Complex Care Collaboration: A Qualitative Study

Background

Despite well-documented factors influencing collaboration, healthcare providers' perspectives remain limited. These perspectives are key for understanding how they manage complex patient care effectively. This study explores hospital healthcare providers' views on multidisciplinary collaboration and their openness to an intervention for managing complex care in patients with diabetes and multiple chronic conditions.

Methods

An interview study. The Interpretive Description approach was employed as the research methodology, with Boundary Work as the analytical framework. Purposive sampling was utilised, with data consisting of 22 semi-structured, face-to-face individual and two focus group interviews with nurses, junior physicians, and physicians at Aarhus University Hospital, Denmark.

Results

Three main themes emerged: Wide Support and Need for Multidisciplinary Collaboration; Existing Collaboration Between Clinics - and Their Limitations; and Introducing a Collaborative Initiative: the Intervention. The informants agreed that collaboration and coordination - both broadly and in relation to the specific intervention - are important and could improve care coordination, enhance patients' sense of security, clarify professional roles, enrich expertise, and streamline resource use. However, organisational structures and professional dynamics often hinder such efforts. A key challenge related to the intervention was identifying patients with complex cases for referral.

Conclusion

This study highlights hospital healthcare providers' recognition of the critical need to strengthen collaboration across specialties to manage complex cases effectively. Significant barriers, such as siloed specialisation and heavy workloads, call for targeted political and managerial action. Challenges in identifying complex cases point to the need for methods that adopt a holistic, patient-centred approach to gain a nuanced understanding of the challenges individuals face in living with multiple chronic conditions and receiving care across different hospital clinics. In the future, this approach could streamline the referral of complex cases, with additional research required to explore the potential of flexible multidisciplinary team meetings in enhancing collaboration within complex care pathways.

Implementation of the virtual transitional care stroke intervention for older adults with stroke and multimorbidity: A qualitative descriptive study

Background

Older adults with stroke and multimorbidity experience frequent care transitions, which are often poorly coordinated and fragmented. We conducted a pragmatic randomized controlled trial (RCT) to test the implementation and effectiveness of the Transitional Care Stroke Intervention (TCSI), a 6-month, multi-component, evidence-informed intervention to support older adults with stroke and multimorbidity using outpatient stroke rehabilitation services. The TCSI was designed to support self-management, improve health outcomes, and enhance the quality and experience of care transitions.

Objective

To explore the facilitators and challenges to implementing the TCSI, from the perspective of healthcare providers (HCPs) (n = 12) and Managers (n = 3).

Methods

Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Data were collected from study documents, individual and group interviews conducted with HCPs and a Care Coordinator, and surveys from managers. Data were analyzed using thematic analysis.

Results

Intervention implementation was facilitated by: a) strong collaborative and interdependent HCP team relationships, b) dedicated resources (funding, staffing) to support intervention delivery, c) training and ongoing support, customized to individual HCP needs, d) organizational readiness, strong leadership, and effective champions, e) structures to facilitate virtual information-sharing, and f) regular monitoring of intervention implementation. Implementation challenges included: a) COVID-19 related challenges (staff turnover, community service disruptions), b) poor communication with community service providers, c) documentation burden (intervention-related), and d) virtual care delivery.

Conclusions

This research enhances understanding of the diversity of factors influencing implementation of the TCSI, and the conditions under which implementation is more likely to succeed.

Perceived benefits and barriers of multidisciplinary teams in the management of diabetes and comorbidities among physicians: A qualitative double-center study

Background

The dynamics of working within multidisciplinary teams (MDTs) to manage diabetes and comorbidities remain underexplored. Investigating physicians' experiences provide insights into the benefits and challenges of MDTs in this complex context, paving the way for improving current practices and shaping future interventions to better address the needs of this patient population.

Aim

To explore perceived benefits and barriers of MDTs in the management of people with diabetes and comorbidities among physicians.

Methods

Eleven semi-structured interviews (duration 26-38 min) were conducted online among physicians. Criterion sampling of physicians from relevant medical specialties and with experience from MDTs were included. Interviews were analyzed using thematic analysis.

Results

Four major themes emerged from the thematic analysis: (1) benefits of MDT, (2) challenges related to MDT, (3) the need for MDTs and cross-sectorial work, and (4) prerequisites for successful MDTs. Improved professional learning and relationships, enhanced capacity leverage, and optimized treatment were some of the major benefits. Siloed healthcare systems and cultures and resource demanding MDTs were considered barriers. Composition and outline of the MDTs, including the role of general practitioners (GPs), were considered important aspects of MDTs. The increase in multimorbidity, polypharmacy, and complexity in patient pathways necessitates MDTs and cross-sectorial work.

Conclusion

Our findings indicate several benefits and barriers of MDTs. MDTs and cross-sectorial work are needed prospectively in healthcare and hold the potential to embrace some of the challenges encountered by people with diabetes and comorbidities. Understanding and incorporating experiences of physicians could inform future improvements in care management.

Barriers and facilitators for strengthening primary health systems for person-centred multimorbid care in low-income and middle-income countries: a scoping review

OBJECTIVE

To understand barriers and facilitators for strengthening health systems for person-centred care of people with multiple long-term conditions-multimorbidity (MLTC-M) at the primary healthcare (PHC) level in low-income and middle-income countries (LMICs).

DESIGN

A scoping review.

METHODS

We adopted a systematic scoping review approach to chart literature guided by Arksey and O'Malley's methodological framework. The review focused on studies conducted in LMICs' PHC settings from January 2010 to December 2023. Papers were extracted from the following databases: PubMed, EBSCOhost and Google Scholar. Framework analysis was undertaken to identify barriers and facilitators for strengthening MLTC-M primary care according to the five health system pillars in the Lancet Global Health Commission on High-Quality Health Systems Framework.

RESULTS

The literature search yielded 4322 citations, evaluated 202 studies and identified 36 for inclusion. Key barriers within the people pillar included poverty, low health education and low health literacy; within the platform pillar, fragmented services and lack of multimorbid care guidelines were mentioned; within the workforce pillar, lack of required skills and insufficient health workers; and in the tools pillar: a shortage of essential medicines and adverse polypharmacy effects were prominent. A lack of political will and the absence of relevant national health policies were identified under the governance pillar. Facilitators within the people pillar included enhancing self-management support; within the platforms, pillar included integration of services; within the tools pillar, included embracing emerging technologies and information and communication technology services; and governance issues included upscaling interventions to respond to multimorbid care needs through enhanced political commitment and financial support.

CONCLUSIONS

Potential solutions to strengthening the healthcare system to be more responsive to people with MLTC-M include empowering service users to self-manage, developing multimorbid care guidelines, incorporating community health workers into multimorbid care efforts and advocating for integrated person-centred care services across sectors. The need for policies and procedures in LMICs to meet the person-centred care needs of people with MLTC-M was highlighted.

Allied health professionals' views on important outcomes of children's elective lower limb orthopaedic surgery: a qualitative interview study to inform a core outcome set

PURPOSE

A common methodological limitation of research that guides surgical procedure selection for children's elective lower limb orthopaedic surgeries is inconsistent outcome selection. Improving outcome consistency can be achieved through the development of a core outcome set (COS). The aim of this study is to identify which outcomes are considered important for children's elective lower limb orthopaedic surgeries by allied health professionals (AHPs) and explore why they select these outcomes, to inform a COS development project.

METHODS

Online semi-structured interviews were conducted with relevant AHPs. Participants were selected using maximum variation purposive sampling; selection was based on profession and inpatient/outpatient role. The data set was analysed using an inductive and deductive approach to thematic analysis.

RESULTS

Four physiotherapists, three orthotists, three prosthetists, and two occupational therapists were interviewed. Most identified outcomes of importance related to "activities and participation". From the data, we conceptualised that AHPs with effective multidisciplinary communication focused on child-centred outcomes, while clinicians with limited multidisciplinary teamwork focused on role-based outcomes.

CONCLUSIONS

There is concurrence between outcomes identified as important in this study, and other qualitative studies in similar populations. These important outcomes were seldom measured in previous studies or in routine clinical practice.Implications for rehabilitationAllied health professionals (AHPs) prioritise activity and participation outcomes after children's elective lower limb orthopaedic surgery.It is important to the rehabilitation of children after elective lower limb orthopaedic surgery that all involved AHPs collaborate with the wider multidisciplinary team.Multidisciplinary team communication encourages collaborative outcome identification, and discourages role defined outcome focus.

Provider-Perceived Value of Interprofessional Team Meetings as a Core Element of a Lifestyle Medicine Program: A Mixed-Methods Analysis of One Center's Experience

Interprofessional care improves outcomes for medically complex patients and may be a valuable addition to standard lifestyle medicine practice, but implementation barriers exist. The purpose of this study was to explore the key features, perceived impact, and implementation considerations related to holding interprofessional team meetings as part of an intensive lifestyle medicine program. In this mixed-methods study, focus groups were conducted with 15 lifestyle medicine clinicians from various healthcare disciplines who had participated in interprofessional team meetings. Quantitative descriptive statistics of the meeting minutes were also calculated. Clinician-perceived benefits from participating in interprofessional team meetings included increased acquisition of knowledge, access to other clinicians, collaborative decision-making, patient satisfaction, and achievement of patient-centered goals. Participants described the importance of preparing an agenda for the interprofessional team meetings in advance, but a major implementation challenge was the time required to prepare for and conduct the meetings. Commitment and financial support by organization and program leadership were reported as key facilitators to implementing the meetings. Clinicians perceive significant value from incorporation of interprofessional team meetings into an intensive lifestyle medicine program, but successful implementation of meetings requires investment from all levels within a healthcare system.

Patient engagement in interprofessional team-based chronic disease management: A qualitative description of a Canadian program

OBJECTIVE

To explore how patients with chronic obstructive pulmonary disease (COPD) perceive their engagement and roles within an interdisciplinary team-based care model.

METHODS

A single intrinsic case study was used. Focus group participants were recruited from the Best Care COPD program across nine sites. Transcripts from patient focus groups were supplemented by healthcare provider focus group transcripts and thematically analysed.

RESULTS

The majority of patients viewed themselves as having an inherent or central role on the team, which was corroborated by healthcare providers. Both positive (e.g., a desire to learn) and negative drivers (e.g., fear of inadequate care without self-advocacy) of active engagement were identified, for which patient-led communication was key. Components of the interdisciplinary team-based care model, including provider coordination and action planning, enabled positively driven active engagement and increased self-management.

CONCLUSION

Although patients had heterogenous perspectives about engagement, most patients viewed themselves as, and were satisfied with, having a central role in their care. Active and passive engagement preferences were influenced by personal motivations and past experiences, amongst other factors.

PRACTICE IMPLICATIONS

This study demonstrates how interdisciplinary chronic disease management programs can support patient engagement. Clarity of provider expectations, and communication about patients' roles and preferences, are recommended.

User Testing of the Veteran Delegation Tool: Qualitative Inquiry

BACKGROUND

Informal caregivers, or care partners, provide critical support to care recipients when managing health care. Veterans Health Administration (VHA) priorities identify care partners as vital in supporting veterans' care management. The Veteran Delegation Tool (VDT) is VHA's Health Insurance Portability and Accountability Act-compliant solution for care partners to comanage veterans' care through VHA's electronic health portal. Human-centered design approaches in VDT development are needed to inform enhancements aimed at promoting uptake and sustained use.

OBJECTIVE

The objective of this prospective descriptive quality improvement project was to use a human-centered design approach to examine VDT use perceptions and practical experiences.

METHODS

This project was conducted using a 4-phase approach: frame, discover, design, and deliver. The frame phase designed the protocol and prepared the VDT system for testing. This paper reports on the discover phase, which used semistructured and follow-up interviews and user testing to examine VDT's benefits, facilitators, and barriers. The discover phase data informed the design and deliver phases, which are underway.

RESULTS

Veterans (24/54, 44%), care partners (21/54, 39%), and individuals who represented dual roles (9/54, 17%)-namely veteran care partner (4/54, 7%), veteran clinical provider (2/54, 4%), and care partner provider (3/54, 6%)-participated in semistructured interviews in the discover phase. A subsample of these participants (3/54, 6%) participated in the follow-up interviews and user testing. Analysis of the semistructured interviews indicated convergence on the respondents' perceptions of VDT's benefits, facilitators, and barriers and recommendations for improving VDT. The perceived benefits were authorized access, comanagement of care needs on the web, communication with the clinical team, access to resources, and ease of burden. Perceived barriers were nonrecognition of the benefits of VDT, technical literacy access issues, increased stress in or burden on care partners, and personal health information security. Participant experiences across 4 VDT activity domains were upgrade to My HealtheVet Premium account, registration, sign-in, and use. User testing demonstrated users' challenges to register, navigate, and use VDT. Findings informed VDT development enhancements and recommendations.

CONCLUSIONS

Care partners need Health Insurance Portability and Accountability Act-compliant access to electronic health portals to assist with care management. VDT is VHA's solution, allowing communication among delegates, veterans, and clinical care teams. Users value VDT's potential use and benefits, while access and navigation improvements to ensure uptake and sustained use are needed. Future efforts need to iteratively evaluate the human-centered phases, design and deliver, of VDT to target audiences. Continued efforts to understand and respond to care partners' needs are warranted.

Primary healthcare personnel challenges and barriers on the management of patients with multimorbidity in Albania

The number of people living with chronic conditions is increasing worldwide with most of these people receiving the needed healthcare services in primary healthcare (PHC) settings. The objective of this study was to explore the main challenges and barriers that PHC providers confront while treating multimorbid patients. This is a qualitative study utilising semi-structured individual in-depth interviews. The study took place in Vlora City, which is the biggest city located in south Albania. Τhe two biggest PHC centres of the city were enrolled. Purposive sampling method was used to recruit PHC practitioners. Main criteria of participation in the study were being fully employed at the enrolled primary care centres, having worked for at least 1 year and to deal with multimorbid patients in daily practice. Data collection took place from September 2019 to January 2020. In total, 36 semi-structured interviews took place with 23 (63.9%) nurses and 12 (33.3%) physicians (general practitioners/family doctors). Communication problems and disputes, lack of materials/equipment and the inappropriate infrastructure, miscommunication and problems in doctor-nurse relationships, coordination problems, lack of protocols and problems in the referral system were reported as the main challenges and barriers that the PHC personnel confront. The findings of this study are critical in understanding challenges that PHC personnel face when dealing with multimorbid patients in PHC settings. The emerged knowledge contributes significantly in a better understanding of the actual situation and to inform health policy makers on how to deal with the existing problems.

Scaling Up Patient-Centered Interdisciplinary Care for Multimorbidity: A Pragmatic Mixed-Methods Randomized Controlled Trial

PURPOSE

To measure the effectiveness of a 4-month interdisciplinary multifaceted intervention based on a change in care delivery for patients with multimorbidity in primary care practices.

METHODS

A pragmatic randomized controlled trial with a mixed-methods design in patients aged 18 to 80 years with 3 or more chronic conditions from 7 family medicine groups (FMGs) in Quebec, Canada. Health care professionals (nurses, nutritionists, kinesiologists) from the FMGs were trained to deliver the patient-centered intervention based on a motivational approach and self-management support. Primary outcomes: self-management (Health Education Impact Questionnaire); and self-efficacy.

SECONDARY OUTCOMES

health status, quality of life, and health behaviors. Quantitative analyses used multi-level mixed effects and generalized linear mixed models controlling for clustering within FMGs. We also conducted in-depth interviews with patients, family members, and health care professionals.

RESULTS

The trial randomized 284 patients (144 in intervention group, 140 in control group). The groups were comparable. After 4 months, the intervention showed a neutral effect for the primary outcomes. There was significant improvement in 2 health behaviors (healthy eating with odds ratios [OR] 4.36; P = .006, and physical activity with OR 3.43; P = .023). The descriptive qualitative evaluation revealed that the patients reinforced their self-efficacy and improved their self-management which was divergent from the quantitative results.

CONCLUSIONS

Quantitatively, this intervention showed a neutral effect on the primary outcomes and substantial improvement in 2 health behaviors as secondary outcomes. Qualitatively, the intervention was evaluated as positive. The combination of qualitative and quantitative designs proved to be a good design for evaluating this complex intervention.

Understanding the positive outcomes of discharge planning interventions for older adults hospitalized following a fall: a realist synthesis

BACKGROUND

Older adults hospitalized following a fall often encounter preventable adverse events when transitioning from hospital to home. Discharge planning interventions developed to prevent these events do not all produce the expected effects to the same extent. This realist synthesis aimed to better understand when, where, for whom, why and how the components of these interventions produce positive outcomes.

METHODS

Nine indexed databases were searched to identify scientific papers and grey literature on discharge planning interventions for older adults (65+) hospitalized following a fall. Manual searches were also conducted. Documents were selected based on relevance and rigor. Two reviewers extracted and compiled data regarding intervention components, contextual factors, underlying mechanisms and positive outcomes. Preliminary theories were then formulated based on an iterative synthesis process.

RESULTS

Twenty-one documents were included in the synthesis. Four Intervention-Context-Mechanism-Outcome configurations were developed as preliminary theories, based on the following intervention components: 1) Increase two-way communication between healthcare providers and patients/caregivers using a family-centered approach; 2) Foster interprofessional communication within and across healthcare settings through both standardized and unofficial information exchange; 3) Provide patients/caregivers with individually tailored fall prevention education; and 4) Designate a coordinator to manage discharge planning. These components should be implemented from patient admission to return home and be supported at the organizational level (contexts) to trigger knowledge, understanding and trust of patients/caregivers, adjusted expectations, reduced family stress, and sustained engagement of families and professionals (mechanisms). These optimal conditions improve patient satisfaction, recovery, functional status and continuity of care, and reduce hospital readmissions and fall risk (outcomes).

CONCLUSIONS

Since transitions are critical points with potential communication gaps, coordinated interventions are vital to support a safe return home for older adults hospitalized following a fall. Considering the organizational challenges, simple tools such as pictograms and drawings, combined with computer-based communication channels, may optimize discharge interventions based on frail patients' needs, habits and values. Empirically testing our preliminary theories will help to develop effective interventions throughout the continuum of transitional care to enhance patients' health and reduce the economic burden of avoidable care.

Fragmentation of care: a major challenge for older people living with multimorbidity

As the world’s aging population is rising, so too is the prevalence of multimorbidity increasing among older adults. Multimorbidity is therefore a growing public health challenge among the older population. Researchers have reported fragmentation of care to be one of the major problems facing this population. The leading factors responsible for this issue are use of disease-centered approaches and specialism to manage people living with multimorbidity; poor communication between professionals and people with multimorbidity; and poor communication among the professionals caring for these people. Failure to address this problem leads to increased treatment burden, including polypharmacy. There is therefore a need for all healthcare professionals caring for older people living with multimorbidity to address this problem by providing continuous, coordinated person-centered care. For the person-centered care approach to be well-coordinated and continuous, there is a need for effective means of sharing information among healthcare providers, to facilitate inter-professional collaboration; extension of consultation time to better enable healthcare providers to understand the patient's needs; review of organizational frameworks and policies where necessary; and development of new guidelines for the management of multimorbidity.

Patients, caregivers and health-care professionals' experience with an interdisciplinary intervention for people with multimorbidity in primary care: A qualitative study

Background

Multimorbidity challenges the health‐care system and requires innovative approaches. In 2015, a 4‐month patient‐centred interdisciplinary pragmatic intervention was implemented in primary care with the aim of supporting self‐management for patients with multimorbidity.

Objective

To explore the perceptions and experiences of health‐care professionals, patients and their caregivers with a 4‐month patient‐centred interdisciplinary pragmatic intervention in primary care.

Design

A descriptive, qualitative study using semi‐structured interviews was conducted.

Setting and participants

A purposive sample of 30 participants was recruited from seven family medicine groups including patients, caregivers and health‐care professionals (HCPs). Interviews were analysed using Thorne's interpretive description approach.

Results

Findings were grouped into the benefits and challenges of participating in the intervention. The programme allowed patients to adopt realistic and adapted objectives; to customize interventions to the patient's reality; and to help patients gain confidence, improve their knowledge, skills and motivation to manage their condition. Interprofessional collaboration eased the exchange of information via team meetings and electronic medical records. Challenges were related to collaboration, communication, coordination of work and integration of newly relocated HCPs mainly due to part‐time assignments and staff turnover. HCPs part‐time schedules limited their availability and hindered patients’ follow‐up.

Discussion and conclusion

This intervention was useful and rewarding from the HCPs, patients and caregivers’ perspective. However, to ensure the success of this complex interdisciplinary intervention, implementers and managers should anticipate organizational barriers such as availability and time management of relocated HCPs.