Generalist redesign of primary healthcare for people living with multimorbidity: work from the TIMES study

Problem

People living with multimorbidity need a different type of healthcare. Single disease focused care, however well integrated/coordinated, leads to both overmedicalisation (burden) and under recognition of needs. We aim to describe the new complex intervention needed to deliver advanced generalist primary healthcare to this patient group. Past work, based largely on secondary analyses, developed a provisional logic model. Here, we critically examine front-line practice to understand the utility and gaps of our draft model.

Approach

Design: Normalisation Process Theory (NPT) informed analysis of front-line general practice to identify enablers and barriers to delivery of whole person, tailored care for people living with multimorbidity. Focused ethnography across 5 sites including observation of patient-facing care, staff interactions, and mini focus groups with staff and patients. 100 hours in the field. Two stage analysis: inductive thematic analysis (Braun&Clark) describing enablers/barriers to tailored care; NPT analysis of implications for draft logic model. Ethics: HCRW REC approval 22/WA/0148. Patients and carer representatives have been actively involved in all stages of the design, delivery and analysis of this work.

Findings

Observed enablers/barriers related to 3 themes: i) understanding the patient in context (communication and practical issues) ; ii) delivering tailored management (shared decision making and supportive collaboration); iii) learning from and evaluation of care (skills and culture).Critical comparison with our provisional logic model recognised 3 additional elements: the practical resources and skills needed to do this work confidently; active engagement of both patients/carers and multidisciplinary professionals to create and use tailored management plans; continuous fostering of/permission for a culture of tailored primary healthcare with permission to go beyond single disease care

Consequences

Our work supports and develops our understanding of the advanced generalist complex intervention needed to deliver tailored healthcare for people living with multimorbidity. We describe how this can be delivered in practice: at patient, professional and organisational levels.This study allowed us to explore tailored care in depth. We are now undertaking a nationwide survey of GPs to re-examine our findings in breadth.And so use all our findings to inform development and testing of a new model of advanced generalist care for a specific group of patients living with multimorbidity – those living with dementia - TIMES. The TIMES study will examine tailored care in the management of sleep problems for people living with dementia or mild cognitive impairment.