Meeting the needs of a complex population: a functional health- and patient-centered approach to managing multimorbidity

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.

[1]  L. Edwards,et al.  A Patient-Centred Redesign Framework to Support System-Level Process Changes for Multimorbidities and Chronic Conditions. , 2015, Healthcare quarterly.

[2]  Tara Sampalli,et al.  Improving wait times to care for individuals with multimorbidities and complex conditions using value stream mapping. , 2015, International journal of health policy and management.

[3]  S. Mercer,et al.  Epidemiology of multimorbidity in China and implications for the healthcare system: cross-sectional survey among 162,464 community household residents in southern China , 2014, BMC Medicine.

[4]  M. Fortin,et al.  Lifestyle factors and multimorbidity: a cross sectional study , 2014, BMC Public Health.

[5]  Martin Fortin,et al.  ABC of Multimorbidity , 2014 .

[6]  Chan Zeng,et al.  Assessment of Morbidity Over Time in Predicting Health Outcomes , 2014, Medical care.

[7]  M. Jakovljevič,et al.  Comorbidity and multimorbidity in medicine today: challenges and opportunities for bringing separated branches of medicine closer to each other. , 2013, Psychiatria Danubina.

[8]  P. Bower,et al.  The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature. , 2013, Journal of the American Medical Directors Association.

[9]  J. Fox,et al.  Proposed model of integrated care to improve health outcomes for individuals with multimorbidities , 2012, Patient preference and adherence.

[10]  Chris Salisbury,et al.  Multimorbidity: redesigning health care for people who use it , 2012, The Lancet.

[11]  J. Fox,et al.  A Proposed Care Model for Complex Chronic Condition: Multiple Chemical Sensitivity , 2010 .

[12]  B. Starfield,et al.  Defining Comorbidity: Implications for Understanding Health and Health Services , 2009, The Annals of Family Medicine.

[13]  Andrew Eller,et al.  Rapid Assessment and Disposition: Applying LEAN in the Emergency Department , 2009, Journal for healthcare quality : official publication of the National Association for Healthcare Quality.

[14]  Sally Wyke,et al.  Multimorbidity in primary care: developing the research agenda. , 2009, Family practice.

[15]  Gregg Warshaw,et al.  Introduction: Advances and Challenges in Care of Older People with Chronic Illness , 2006 .

[16]  C. Tam,et al.  Measuring the Outcomes of Word Cueing Technology , 2005, Canadian journal of occupational therapy. Revue canadienne d'ergotherapie.

[17]  Victoria Barr,et al.  The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. , 2003, Hospital quarterly.

[18]  J. Ware,et al.  Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment. , 1998, Journal of clinical epidemiology.

[19]  L. Edwards,et al.  A Chronic Disease Prevention and Management Corridor© to Supporting System-Level Transformations for Chronic Conditions. , 2015, Healthcare quarterly.