Meeting the Needs of a Complex Population: A Functional Health- and Patient-Centered Approach to Managing Multimorbidity

Abstract

Individuals with multimorbidity have complex care needs along with significant impacts to their functional health and quality of life. Recent evidence-based and experience-based explorations have revealed the importance of patient perspectives and functional health management in improving care delivery and health outcomes for individuals with multimorbidity. The impact of managing multimorbidity is evident at multiple levels of healthcare – the individual, the provider, and the system. Our local experience dealing with these challenges has led to the development of a functional health model that includes patient perspectives in care delivery within the Integrated Chronic Care Service (ICCS) of the health authority in Nova Scotia. In this paper, we present a discussion of the challenges, guiding models, and service-level transformations that have been integrated into care delivery at the ICCS to meet the healthcare needs of people with multiple health conditions. We describe our redesign strategies for care team planning, treatment approach, and patient inclusion.

Development of indicators to assess quality and patient pathways in interdisciplinary care for patients with 14 ambulatory-care-sensitive conditions in Germany

“…One important argument against this approach is the focus on patients who have more than one disease. Their health care outcomes may not only be dependent on the treatment of one disease, but the interplay of different disciplines [ 38 , 39 ]. Indeed, in the Accountable Care study first results show that more than 50% of the patients have more than one of the fourteen diseases.…”

Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome

“…In the UK, the National Health Service's (NHS) long-term plan 2019 [142] lays down the foundation for an integrated care where various care providers working together to meet patients' individual needs and preferences provide the most cost and resource effective high standard care across systems: a stepped care model [143]. This would allow a joined-up multi-disciplinary, multi-agency pathway to offer a seamless journey to Mrs T where she would not feel lost in the system like so many patients feel within the current traditional care pathways [25,38,144]. The fundamental role of organisational factors (collaboration across teams, organisations, parts of the health care system) has been consistently highlighted in the evidence base [22,24,38,144].…”

“…This would allow a joined-up multi-disciplinary, multi-agency pathway to offer a seamless journey to Mrs T where she would not feel lost in the system like so many patients feel within the current traditional care pathways [25,38,144]. The fundamental role of organisational factors (collaboration across teams, organisations, parts of the health care system) has been consistently highlighted in the evidence base [22,24,38,144]. Mrs T would ideally have a care coordinator as her main point of contact who helps her navigate the system and who also provides advocacy with the various health care professionals [38].…”

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“…These tools should be designed according to the users' lived experience and validated by the users themselves [6]. Furthermore, a number of articles suggests that care providers "meet patients where they are" by combining strategies to improve health literacy with the Chronic Care Model approach [7].…”