What are the benefits of a comprehensive template to support personalised care for patients with Multiple Long-Term Conditions: a mixed methods study in general practice.
Problem
The management of patients with multiple long-term conditions (MLTCs) poses one of the greatest challenges facing primary care services with an increasing population prevalence of those living with multiple long-term conditions (MLTCs) and a decline in the skilled and experienced generalist workforce. Existing primary care systems dominated by a single disease approach are inefficient for managing the complex health needs of patients with MLTCs. A personalised approach to care is advocated for managing patients with MLTCs. Previous work to implement comprehensive multimorbidity reviews within primary care has delivered improvements in patients experience of personalised care but not in patient health-related quality of life, or burden of illness or treatment. Multimorbidity annual reviews using a ‘smart’ template were implemented in general practices in three areas of England. The objectives of this study were to explore whether use of the multimorbidity template improved patient experience of personalised care, facilitated staff benefits, and offered service benefits related to clinical quality, efficiencies, and workload.
Approach
A convergent mixed methods research design was used. Staff and patients involved in a multimorbidity annual review were interviewed. An abductive thematic codebook approach was used to analyse the interviews. A self-report questionnaire (PC3EQ) measured patient experiences of person-centered care and was completed before and after their review. Questionnaires were analysed using mixed-effects linear regression. Routinely collected medical data was extracted from the electronic records of eligible participants for variables of interest and analysed descriptively.
Findings
Sixteen general practices agreed to take part in the study across the three areas of England. Eligible patients with MLTCs and identified as having an annual review during the study period (n=5060) were made up of patients of whom 90% had at least one coronary vascular disease diagnosis, more than half had diabetes (62.8%), respiratory disease (53.9%) and/or a mental health diagnosis (56.8%).A pre- and post-review survey was completed by n=117 patients who had received a multimorbidity review. There was a small, statistically significant increase in the overall PC3EQ score post review (Mean difference,1.31 (95% CI, 0.31, 2.30)). From a staff and patient perspective, whether the template supported personalised care depended on the skills and approach of the staff conducting the review. The template can be used as a tick box exercise, whilst the personalisation of care emanated from the staff delivery approach and their knowledge and skills around multiple long-term conditions. For patients personalised care was experienced in the context of a reciprocal dialogue between them and staff and a genuine interest and effort to respond to their needs.
Consequences
The multimorbidity template can facilitate a more personalised care approach, however the delivery approach, knowledge and skills of staff appear to be a key determinant in patients experiencing personalised care.