Editorial
Caring for patients with multiple chronic conditions: Moving from morbidities to person needs
Atención a los pacientes crónicos complejos: de las morbilidades a las necesidades de las personas
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id="par0005" class="elsevierStylePara elsevierViewall">Multimorbidity, considered as the coexistence of two or more chronic health conditions, is a growing public health challenge.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> It is common among all adults, and the norm among older populations. Its care leads to some limitations,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> such as uncertain of applicability of interventions, risk of drug–drug interactions, inadequacy of prescribing based on survival or disease-specific outcomes, lack of attention to potential harms, reductions in benefits that led to burden of treatment and low adherence, inattention to time to treatment benefit in the context of limited life expectancy and poor use of methodologies for incorporating patients’ preferences and priorities.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The management of populations with multiple chronic conditions has urged as a problem for hyperspecialized health systems organised around single-disease-based approaches. It is required a generalist understanding of illness, recognition of the role of social issues, and the treatment of morbidities as a unified experience.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> Last decade, different authors have studied the interrelationships between multimorbidity, frailty, social factors and system complexity, to identifying patients with complex needs,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> and the risk of becoming high-need high-cost patients.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> One of the most studied interactions is the association between multimorbidity and frailty. Frailty is a multisystem state of increased vulnerability to poor resolution of homoeostasis after a stressor event increasing the risk of disability and poorer clinical outcomes.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> According to longitudinal studies, multimorbidity is associated with an increasing risk of developing frailty and vice versa, suggesting a bidirectional association between the two conditions.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> In the case of the interaction between multimorbidity and frailty,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> patients are at risk of a declining trajectory in health and functional status, and a greater likelihood of disability, leading to high level of health and social needs, and they are candidate to receive individualised care plans until end-of-life.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In a previous editorial in this journal, it was urged, based on an analysis of evidence-based meso level programmes and micro level interventions, the reorientation of the systems to more integrated approaches in which multidisciplinary care was provided across the whole care trajectory of high-need patients.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Several authors support the implementation of complex care management programmes, based on value-based payments for high-need, high-cost populations. Different systematic reviews on tailored interventions, including studies mainly from US providers, showed that care and case management, as well as disease management, are promising models of care for these populations, with limited evidence on the impact on cost and health services use.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10,11</span></a> The majority of evidenced programmes are community-based, with intensive primary care input pivoted at home, and outpatient and crises support by specialised services. They are designed to address health and social needs and coordinate care across settings, with a broad range of services.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Several integrated care experiences<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> have included key elements of validated programmes such as comprehensive assessment and care by multidisciplinary teams based on an individualised care plans focused on health education, with periodic monitoring of patient outcomes, with people's implication on care decisions and advanced care planning, and with high levels of coordination between services in health crises response and end-of-life progression. In the Metropolitan area of Barcelona, the ProPCC Programme was designed tailored to high-need patients combining input from patients, caregivers, and healthcare and social care professionals.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> It was designed and implemented in the public health system of Catalonia by the Institut Català de la Salut to improve the quality of care to complex chronic patients and advanced chronic disease patients. Data from a pre–post study analysing early implementation of the ProPCC, show the impact of the programme on increasing the time spent at home (up to 3%), and on reducing emergency department referrals (up to 37%), and time of hospitalisation (up to 38%). The study population include patients with multimorbidity and a high risk of readmission, living with complex functional dependency and suffering advanced complex conditions. Increasing the proactivity of the primary care teams and improving their collaboration between different community teams and hospital services, focusing efforts and resources on maintaining older people with high needs at home, was found associated with a reduction of direct costs in healthcare visits of 46%.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The future of the care of complex patients’ populations is to target individuals with multiple chronic conditions, building relationships with them, and gaining their trust to success fully change their behaviours. After the identification of high needs, the second step is the development of strategies for care providers, such as gaining support of clinicians, and managing, and relieving their workload and stress, by maintaining regular open communication. The third step is to improve patient engagement, by implementing navigational assistance through the system, acknowledge and address life circumstances and experience with care systems, and provide emotional support and self-management skills building.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Different authors have analysed what are the health and social care needs of older adults with multiple chronic conditions and their caregivers.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Five main areas of needs that have been identified are the following: need for information; coordination of services and supports; preventive, maintenance, and restorative strategies; training to help manage the complex conditions; and the need for person-centred approaches. Some experts have standardised the core elements of person-centred care in these populations. Person-centred care means that individuals’ values and preferences are elicited and, once expressed, they guide all aspects of their health care, supporting their realistic health and life goals. Key elements to support person-centred care are<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a>: developing an individualised, goal-oriented care plan based on the person's preferences; reviewing of the person's goals and care plan; supporting care by interprofessional teams in which the person is an integral team member with one lead point of contact on the healthcare team; providing active coordination among all healthcare and supportive service providers, continual information sharing and integrated communication; training providers and patients, and performing quality improvement by using feedback from the person and caregivers.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The new approaches for better care provision to people with multiple chronic conditions would focus on patients’ individual goals within or across different dimensions, such as symptoms, functional status, and social and role functions, and determine how well these goals are being met.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> Matching the optimal management strategy requires that we better understand the heterogeneity, personal values, and care needs of this population.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> We should capture the voice of the patients with different combinations of health, behavioural, and social needs, by identifying their unmet care needs and what they consider most important for their health and well-being to improve care for patients. Identifying patients’ health priorities is key to initiating patient priorities-aligned decision-making, by tailoring the care plans based on what matters most to each individual.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0040" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Defining and measuring multimorbidity: a systematic review of systematic reviews" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.C. 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