Caring for patients with multiple chronic conditions: Moving from morbidities to person needs

Àngel Mas, Miquel
doi:10.1016/j.medcli.2024.06.010
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    "titulo" => "Caring for patients with multiple chronic conditions&#58; Moving from morbidities to person needs"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Multimorbidity&#44; considered as the coexistence of two or more chronic health conditions&#44; is a growing public health challenge&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> It is common among all adults&#44; and the norm among older populations&#46; Its care leads to some limitations&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> such as uncertain of applicability of interventions&#44; risk of drug&#8211;drug interactions&#44; inadequacy of prescribing based on survival or disease-specific outcomes&#44; lack of attention to potential harms&#44; reductions in benefits that led to burden of treatment and low adherence&#44; inattention to time to treatment benefit in the context of limited life expectancy and poor use of methodologies for incorporating patients&#8217; preferences and priorities&#46;</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&#46; It is required a generalist understanding of illness&#44; recognition of the role of social issues&#44; and the treatment of morbidities as a unified experience&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> Last decade&#44; different authors have studied the interrelationships between multimorbidity&#44; frailty&#44; social factors and system complexity&#44; to identifying patients with complex needs&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> and the risk of becoming high-need high-cost patients&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> One of the most studied interactions is the association between multimorbidity and frailty&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> According to longitudinal studies&#44; multimorbidity is associated with an increasing risk of developing frailty and vice versa&#44; suggesting a bidirectional association between the two conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> In the case of the interaction between multimorbidity and frailty&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> patients are at risk of a declining trajectory in health and functional status&#44; and a greater likelihood of disability&#44; leading to high level of health and social needs&#44; and they are candidate to receive individualised care plans until end-of-life&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In a previous editorial in this journal&#44; it was urged&#44; based on an analysis of evidence-based meso level programmes and micro level interventions&#44; the reorientation of the systems to more integrated approaches in which multidisciplinary care was provided across the whole care trajectory of high-need patients&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Several authors support the implementation of complex care management programmes&#44; based on value-based payments for high-need&#44; high-cost populations&#46; Different systematic reviews on tailored interventions&#44; including studies mainly from US providers&#44; showed that care and case management&#44; as well as disease management&#44; are promising models of care for these populations&#44; with limited evidence on the impact on cost and health services use&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">10&#44;11</span></a> The majority of evidenced programmes are community-based&#44; with intensive primary care input pivoted at home&#44; and outpatient and crises support by specialised services&#46; They are designed to address health and social needs and coordinate care across settings&#44; with a broad range of services&#46;<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&#44; with periodic monitoring of patient outcomes&#44; with people&#39;s implication on care decisions and advanced care planning&#44; and with high levels of coordination between services in health crises response and end-of-life progression&#46; In the Metropolitan area of Barcelona&#44; the ProPCC Programme was designed tailored to high-need patients combining input from patients&#44; caregivers&#44; and healthcare and social care professionals&#46;<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 Catal&#224; de la Salut to improve the quality of care to complex chronic patients and advanced chronic disease patients&#46; Data from a pre&#8211;post study analysing early implementation of the ProPCC&#44; show the impact of the programme on increasing the time spent at home &#40;up to 3&#37;&#41;&#44; and on reducing emergency department referrals &#40;up to 37&#37;&#41;&#44; and time of hospitalisation &#40;up to 38&#37;&#41;&#46; The study population include patients with multimorbidity and a high risk of readmission&#44; living with complex functional dependency and suffering advanced complex conditions&#46; Increasing the proactivity of the primary care teams and improving their collaboration between different community teams and hospital services&#44; focusing efforts and resources on maintaining older people with high needs at home&#44; was found associated with a reduction of direct costs in healthcare visits of 46&#37;&#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&#8217; populations is to target individuals with multiple chronic conditions&#44; building relationships with them&#44; and gaining their trust to success fully change their behaviours&#46; After the identification of high needs&#44; the second step is the development of strategies for care providers&#44; such as gaining support of clinicians&#44; and managing&#44; and relieving their workload and stress&#44; by maintaining regular open communication&#46; The third step is to improve patient engagement&#44; by implementing navigational assistance through the system&#44; acknowledge and address life circumstances and experience with care systems&#44; and provide emotional support and self-management skills building&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Five main areas of needs that have been identified are the following&#58; need for information&#59; coordination of services and supports&#59; preventive&#44; maintenance&#44; and restorative strategies&#59; training to help manage the complex conditions&#59; and the need for person-centred approaches&#46; Some experts have standardised the core elements of person-centred care in these populations&#46; Person-centred care means that individuals&#8217; values and preferences are elicited and&#44; once expressed&#44; they guide all aspects of their health care&#44; supporting their realistic health and life goals&#46; Key elements to support person-centred care are<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a>&#58; developing an individualised&#44; goal-oriented care plan based on the person&#39;s preferences&#59; reviewing of the person&#39;s goals and care plan&#59; supporting care by interprofessional teams in which the person is an integral team member with one lead point of contact on the healthcare team&#59; providing active coordination among all healthcare and supportive service providers&#44; continual information sharing and integrated communication&#59; training providers and patients&#44; and performing quality improvement by using feedback from the person and caregivers&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The new approaches for better care provision to people with multiple chronic conditions would focus on patients&#8217; individual goals within or across different dimensions&#44; such as symptoms&#44; functional status&#44; and social and role functions&#44; and determine how well these goals are being met&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> Matching the optimal management strategy requires that we better understand the heterogeneity&#44; personal values&#44; and care needs of this population&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> We should capture the voice of the patients with different combinations of health&#44; behavioural&#44; and social needs&#44; by identifying their unmet care needs and what they consider most important for their health and well-being to improve care for patients&#46; Identifying patients&#8217; health priorities is key to initiating patient priorities-aligned decision-making&#44; by tailoring the care plans based on what matters most to each individual&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0040" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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