The use of metaphors by service users with diverse long-term conditions: a secondary qualitative data analysis

Long-term conditions and accompanied co-morbidities now affect about a quarter of the UK population. Enabling patients and caregivers to communicate their experience of illness in their own words is vital to developing a shared understanding of the condition and its impact on patients' and caregivers' lives and in delivering person-centred care. Studies of patient language show how metaphors provide insight into the physical and emotional world of the patient, but such studies are often limited by their focus on a single illness. The authors of this study undertook a secondary qualitative data analysis of 25 interviews, comparing the metaphors used by patients and parents of patients with five longterm conditions. Analysis shows how similar metaphors can be used in empowering and disempowering ways as patients strive to accept illness in their daily lives and how metaphor use depends on the manifestation, diagnosis, and treatment of individual conditions. The study concludes with implications for how metaphorical expressions can be attended to by healthcare professionals as part of shared care planning.

Multimorbidity among People Experiencing Homelessness-Insights from Primary Care Data

Background: Although the poor health of people experiencing homelessness is increasingly recognised in health discourse, there is a dearth of research that has quantified the nature and magnitude of chronic health issues and morbidity among people experiencing homelessness, particularly in the Australian context. Methods: Analysis of the medical records of 2068 “active” patients registered with a specialist homeless health service in Perth, Western Australia as of 31 December 2019. Results: Overall, 67.8% of patients had at least one chronic physical health condition, 67.5% had at least one mental health condition, and 61.6% had at least one alcohol or other drug (AOD) use disorder. Nearly half (47.8%) had a dual diagnosis of mental health and AOD use issues, and over a third (38.1%) were tri-morbid (mental health, AOD and physical health condition). Three-quarters (74.9%) were multimorbid or had at least two long-term conditions (LTCs), and on average, each patient had 3.3 LTCs. Conclusions: The study findings have substantial implications from both a health risk and healthcare treatment perspective for people experiencing homeless. The pervasiveness of preventable health conditions among people experiencing homelessness also highlights the imperative to improve the accessibility of public health programs and screening to reduce their morbidity and premature mortality.

Changes over time in the management of long-term conditions in primary health care for adults with intellectual disabilities, and the healthcare inequality gap

BACKGROUND

Quality of primary healthcare impacts on health outcomes. This study aimed to quantify trends in good practice and the healthcare inequalities gap.

METHOD

Indicators of best-practice management of long-term conditions and health promotion were extracted from primary healthcare records on 721 adults with intellectual disabilities in 2007-2010, and 3638 in 2014. They were compared over time, and with the general population in 2014, using Fisher's Exact test and ordinal regression.

RESULTS

Management improved for adults with intellectual disabilities over time (OR = 5.32; CI = 2.69-10.55), but not for the general population (OR = 0.74; CI = 0.34-1.64). However, it remained poorer, but to a lesser extent, compared with the general population (OR = 0.38; CI = 0.20-0.73 in 2014, and OR = 0.05; CI = 0.02-0.12 in 2007-2010). In 2014, health care was comparable to the general population on 49/78 (62.8%) indicators.

CONCLUSIONS

The extent of the healthcare inequality gap reduced over this period, but remaining inequalities highlight that further action is still necessary.

The Individual Profile of Pathology as a New Model for Filling Knowledge Gaps in Health Policies for Chronicity

Chronicity is the real challenge for public healthcare systems especially in relation to multi-morbidity. The growing demand for multidisciplinary care could be addressed by implementing integrated programs in the primary care field and facilitating other specific care only as necessary. Some models of long-term management have been suggested since the 2000s. The objective here is to propose the Individual Profile of Pathology (IPP) model as the preliminary step for identifying groups of population which shares health and social needs and for optimizing the management of chronicity, referring to the Kaiser Permanente Pyramid paradigm. The IPP model is able to inform a data feedback system for improving performances at the patient's individual level and for addressing and evaluating health policies. The stratification of needs comes out of the IPP algorithm. It works on patient information databases based on the logic of disease as a process that evolves over time and interacts with many factors unique to that patient. Individual patients' data used in this work refers to 138,859 subjects from a large area in Italy and concerns hospitalization, outpatient drug prescriptions, access to the emergency room and outpatient prescriptions for visits, laboratory/imaging tests, and medications. The IPP model allows to identify for each subject a complexity level, taking into account the weight of groups of pathologies, both in terms of absorption of resources and the level of severity. Costs and healthcare performances have been analyzed taking into account the complexity levels. The IPP model can be an efficient methodology for (a) improving performances at the patient's individual level (b) allowing standardized comparison among different geographical areas (c) supporting large population-focused surveillance programs and (d) providing knowledge to identify and fill the gaps in public health policies. Currently, the IPP algorithm is limited by data availability, restricted to the administrative databases processing, but the theoretical model is able to include more data dimensions providing the potential to identify homogeneous groups of subjects with a higher level of precision.

Electronic, mobile and telehealth tools for vulnerable patients with chronic disease: a systematic review and realist synthesis

OBJECTIVES

The objective of this review was to assess the benefit of using electronic, mobile and telehealth tools for vulnerable patients with chronic disease and explore the mechanisms by which these impact patient self-efficacy and self-management.

DESIGN

We searched MEDLINE, all evidence-based medicine, CINAHL, Embase and PsychINFO covering the period 2009 to 2018 for electronic, mobile or telehealth interventions. Quality was assessed according to rigour and relevance. Those studies providing a richer description ('thick') were synthesised using a realist matrix.

SETTING AND PARTICIPANTS

Studies of any design conducted in community-based primary care involving adults with one or more diagnosed chronic health condition and vulnerability due to demographic, geographic, economic and/or cultural characteristics.

RESULTS

Eighteen trials were identified targeting a range of chronic conditions and vulnerabilities. The data provided limited insight into the mechanisms underpinning these interventions, most of which sought to persuade vulnerable patients into believing they could self-manage their conditions through improved symptom monitoring, education and support and goal setting. Patients were relatively passive in the interaction, and the level of patient response attributed to their intrinsic level of motivation. Health literacy, which may be confounded with motivation, was only measured in one study, and eHealth literacy was not assessed.

CONCLUSIONS

Research incorporating these tools with vulnerable groups is not comprehensive. Apart from intrinsic motivation, health literacy may also influence the reaction of vulnerable groups to technology. Social persuasion was the main way interventions sought to achieve better self-management. Efforts to engage patients by healthcare providers were lower than expected. Use of social networks or other eHealth mechanisms to link patients and provide opportunities for vicarious experience could be further explored in relation to vulnerable groups. Future research could also assess health and eHealth literacy and differentiate the specific needs for vulnerable groups when implementing health technologies.

New ways of working; delivering better care for people with long-term conditions

Background

The cost-effectiveness of the traditional outpatient model for specialist care provision is increasingly being questioned in view of the changing patient needs, workforce challenges and technological advances.

Setting

This report summarises two RCGP London events showcasing new ways of delivering care for long-term conditions.

Questions

What are the alternative approaches to the traditional outpatient model and do they have common themes? What are the challenges and opportunities of these new models of care?

Methods

Presentation of examples of new ways of long-term condition care delivery and round-table facilitative discussion and reflection on the challenges and solutions around service re-design and implementation, the commissioning and funding of new models of care, the facilitation of system-wide learning and the collection of data for evaluation.

Results

Different ways of delivering care for people with Chronic Kidney Disease (CKD) and Chronic Obstructive Pulmonary Disease (COPD) were presented. Most of the interventions included virtual clinics (during which patient care was reviewed by a specialist remotely without the need for a face-to-face consultation), improved communication between primary and secondary care clinicians, an element of referral triage/prioritisation, the use of trigger tools to identify people at risk of deterioration, patient education and a multi-disciplinary approach.

Discussion-conclusions

Different models to the traditional outpatient long-term condition care are feasible and can result in improvements in the quality of care and staff satisfaction. However, such initiatives require careful planning, close collaboration between health care professionals and allocation of appropriate resources and training within primary care. There is also a need for systematic evaluation of such pilots to assess their cost-effectiveness and their acceptability to clinicians and patients. This requires systematic collection of population level data, agreement on the key outcomes for evaluation and a commitment of all stakeholders to sharing learning and resources to enable continuous improvement.

Supporting shared decision-making for older people with multiple health and social care needs: a protocol for a realist synthesis to inform integrated care models

INTRODUCTION

Including the patient or user perspective is a central organising principle of integrated care. Moreover, there is increasing recognition of the importance of strengthening relationships among patients, carers and practitioners, particularly for individuals receiving substantial health and care support, such as those with long-term or multiple conditions. The overall aims of this synthesis are to provide a context-relevant understanding of how models to facilitate shared decision-making (SDM) might work for older people with multiple health and care needs, and how they might be applied to integrated care models.

METHODS AND ANALYSIS

The synthesis draws on the principles of realist inquiry, to explain how, in what contexts and for whom, interventions that aim to strengthen SDM among older patients, carers and practitioners are effective. We will use an iterative, stakeholder-driven, three-phase approach. Phase 1: development of programme theory/theories that will be tested through a first scoping of the literature and consultation with key stakeholder groups; phase 2: systematic searches of the evidence to test and develop the theories identified in phase 1; phase 3: validation of programme theory/theories with a purposive sample of participants from phase 1. The synthesis will draw on prevailing theories such as candidacy, self-efficacy, personalisation and coproduction.

ETHICS AND DISSEMINATION

Ethics approval for the stakeholder interviews was obtained from the University of Hertfordshire ECDA (Ethics Committee with Delegated Authority), reference number HSK/SF/UH/02387. The propositions arising from this review will be used to develop recommendations about how to tailor SDM interventions to older people with complex health and social care needs in an integrated care setting.

Improving health outcomes for young people with long term conditions: The role of digital communication in current and future patient-clinician communication for NHS providers of specialist clinical services for young people - LYNC study protocol

BACKGROUND

Young people living with long term conditions are vulnerable to health service disengagement. This endangers their long term health. Studies report requests for digital forms of communication - email, text, social media - with their health care team. Digital clinical communication is troublesome for the UK NHS.

AIM

In this article we aim to present the research protocol for evaluating the impacts and outcomes of digital clinical communications for young people living with long term conditions and provide critical analysis of their use, monitoring and evaluation by NHS providers (LYNC study: Long term conditions, Young people, Networked Communications).

METHODS

The research involves: (a) patient and public involvement activities with 16-24 year olds with and without long term health conditions; (b) six literature reviews; (c) case studies - the main empirical part of the study - and (d) synthesis and a consensus meeting. Case studies use a mixed methods design. Interviews and non-participant observation of practitioners and patients communicating in up to 20 specialist clinical settings will be combined with data, aggregated at the case level (non-identifiable patient data) on a range of clinical outcomes meaningful within the case and across cases. We will describe the use of digital clinical communication from the perspective of patients, clinical staff, support staff and managers, interviewing up to 15 young people and 15 staff per case study. Outcome data includes emergency admissions, A&E attendance and DNA (did not attend) rates. Case studies will be analysed to understand impacts of digital clinical communication on patient health outcomes, health care costs and consumption, ethics and patient safety.

The association between perseverative negative cognitive processes and negative affect in people with long term conditions: a protocol for systematic review and meta-analysis

BACKGROUND

Depression is common in people with long term conditions (LTCs) and is associated with worse medical outcomes. Understanding the mechanisms underpinning this relationship could help predict who is at increased risk of adverse medical outcomes, and lead to the development of novel interventions. Perseverative negative cognitive processes, such as worry and rumination, involve repetitive and frequent thoughts about oneself and one's concerns. These processes have been associated with negative affect, and also adverse medical outcomes. The results of prospective studies, which would allow causal inferences to be drawn, are more equivocal however. Furthermore, the majority of studies have been conducted in physically healthy individuals, and we do not know to what extent these findings will generalise to people with LTCs.

METHODS/DESIGN

Electronic databases will be searched using a search strategy including controlled vocabulary and text words related to perseverative negative cognitive processes (such as worry and rumination) and negative affect (including depression and anxiety). Records will be hand-searched for terms related to LTCs. Citation and bibliography searching will be conducted, and authors of included studies will be contacted to identify unpublished studies. Studies will be included if they contain a standardised measure of the prospective association between perseverative negative cognitive processes and negative affect, or vice versa, in people with LTCs. Narrative and meta-analytic methods will be used to synthesize the data collected.

DISCUSSION

This review will identify and synthesise studies of the prospective association between perseverative negative cognitive processes and negative affect among people with LTCs. The findings will help to identify whether worry and rumination could cause depression and anxiety in people with LTCs, and might indicate whether perseverative negative cognitive processes are appropriate targets for treatment.

Learning from the integrated care pilot in west london

KEY MESSAGES

We implemented a system to integrate care for patients with diabetes and/or over the age of 75 in an urban area with a population of 1.2 million. Within five months, all the acute, mental health and community trusts, and all the local authorities had signed up to participate, along with 84% of GP practices in the area. Patients and practitioners found the system of benefit in improving communication and collaboration. The first phase of the Outer North West London Integrated Care Pilot (ONWL ICP) has shown that it is possible to implement large-scale, multi-agency change in a short time to enable coordinated care for patients with long-term conditions.The second phase needs to more purposefully integrate with local programmes of work, including training the chairs of the monthly case conferences as leaders of transformational change who can lead annual cycles of interorganisational continuous quality improvement.

WHY THIS MATTERS TO US

We are clinicians and managers who have been closely involved in the planning and implementation of the integrated care system described here. We feel that current systems are fragmented and do not support delivery of holistic, coordinated care. We are convinced of the benefits of multiple agencies working together to share their expertise of patients' social, psychological and physical needs.

Informing the development of services supporting self-care for severe, long term mental health conditions: a mixed method study of community based mental health initiatives in England

BACKGROUND

Supporting self-care is being explored across health care systems internationally as an approach to improving care for long term conditions in the context of ageing populations and economic constraint. UK health policy advocates a range of approaches to supporting self-care, including the application of generic self-management type programmes across conditions. Within mental health, the scope of self-care remains poorly conceptualised and the existing evidence base for supporting self-care is correspondingly disparate. This paper aims to inform the development of support for self-care in mental health by considering how generic self-care policy guidance is implemented in the context of services supporting people with severe, long term mental health problems.

METHODS

A mixed method study was undertaken comprising standardised psychosocial measures, questionnaires about health service use and qualitative interviews with 120 new referrals to three contrasting community based initiatives supporting self-care for severe, long term mental health problems, repeated nine months later. A framework approach was taken to qualitative analysis, an exploratory statistical analysis sought to identify possible associations between a range of independent variables and self-care outcomes, and a narrative synthesis brought these analyses together.

RESULTS

Participants reported improvement in self-care outcomes (e.g. greater empowerment; less use of Accident and Emergency services). These changes were not associated with level of engagement with self-care support. Level of engagement was associated with positive collaboration with support staff. Qualitative data described the value of different models of supporting self-care and considered challenges. Synthesis of analyses suggested that timing support for self-care, giving service users control over when and how they accessed support, quality of service user-staff relationships and decision making around medication are important issues in supporting self-care in mental health.

CONCLUSIONS

Service delivery components - e.g. peer support groups, personal planning - advocated in generic self-care policy have value when implemented in a mental health context. Support for self-care in mental health should focus on core, mental health specific qualities; issues of control, enabling staff-service user relationships and shared decision making. The broad empirical basis of our research indicates the wider relevance of our findings across mental health settings.

Does the professional and working context of United Kingdom clinicians predict if they use practices to support patients with long term conditions to self manage?

INTRODUCTION

Our study examines how the professional and employment context may influence clinicians' practice self management support for patients with long term conditions (LTC).

MATERIAL AND METHODS

We surveyed clinicians working with patients with depression, chronic obstructive pulmonary disorder (COPD), chronic musculo skeletal pain and diabetes.

RESULTS

Clinicians most frequently endorsed items on a scale concerned with patient centeredness, and less frequently endorsed items concerned with clinical and organizational self management support. The most important factors predicting these latter activities were the intensity of working experience with patients with LTC and attending professional training addressing the principles and practice of self management support. Practicing patient centeredness was endorsed by nearly all respondents, and so was not sensitive to variation on work variables.

CONCLUSIONS

The interaction of training and intensity of work with patients with LTC seems to have the most powerful effect on undertaking clinical and organizational self management support practices. To facilitate clinicians' practice of self management support for patients with LTC it is very important to provide relevant professional training and to build specialized patient care teams with professionals having complimentary skills.