Implementing patient-centred integrated care for multiple chronic conditions

Abstract

F ifteen years ago, the term multimorbidity rarely appeared in chronic disease health care policies. Today, research has revealed very high rates of multimorbidity, leading to it being labeled the number one challenge in developed countries.1-5 Paradoxically, chronic disease prevention and management (CDPM) programs of integrated care have popped up in all health care systems but they mainly follow a single-disease approach in their interventions. In this article, we define CDPM programs broadly as any interventions intended to improve care for patients with chronic diseases and risk factors; these are added to usual care and are typically delivered by a team. Even though the number of publications on multimorbidity has increased substantially in the past 10 years,6 intervention studies have, so far, been scarce and demonstrated inconsistent results.7 In general, naturally occurring CDPM programs of integrated care for multimorbidity do not produce evidence strong enough to support their scaling up. A consensus has, however, emerged among researchers on the need for more integrated and patient-centred approaches.4,8 Some evidence supporting the effectiveness of patient-centred care has been generated9 but, until recently, it has been limited. Various experts have made suggestions for the care of patients with multimorbidity but these take the form of general guiding principles for addressing priorities and interactions or for avoiding harm and polypharmacy.10-12 The chronic care model (CCM) is the most inspiring organizational framework for guiding care for people with chronic disease, but it lacks detail on how to create “productive interactions” with patients and how to be a “prepared, proactive practice team.”13 The implementation of new models of patient-centred care for persons with multimorbidity in primary health care faces additional challenges mostly related to a lack of readiness or competing demands. Change management theory and models14 might help circumvent some challenges but these lack specificity for the implementation of integrated care for persons with multimorbidity at the clinical level. We propose a new framework that specifies effective, evidence-informed components of interventions in patient-centred integrated care that can improve outcomes for patients with multimorbidity.