These results suggest that the self-management learning needs of veterans with multimorbidity are more extensive than those of patients with single chronic illnesses. Disease-specific skills such as blood glucose monitoring for diabetes or inhaler use for asthma are important aspects of chronic care, but the “generic” self-management skills assessed in our survey are relevant to most chronic illnesses. Although standardized group classes such as Lorig’s Chronic Disease Self-Management Program can be an efficient method to teach generic self-management skills,14
they may not adequately address all of the concerns of complex patients with multimorbidity. Of the 20 self-management skills endorsed by a significantly higher percentage of multimorbidity patients, several (e.g., improving sexual relationships) are not included among the topics covered in Lorig’s program.14
This underscores the importance of the collaborative exploration of patient-identified problems and the development of individualized treatment plans.
Although the number of self-management skills endorsed by multimorbidty patients is quite large, it is not our intent to suggest that patients want to, or should even try to, learn 20 self-management skills at once. Indeed, recent research suggests that patients should focus on 1 behavior change at a time.16
It is our hope instead that primary care providers will be more cognizant of the broad range of needs and help patients prioritize skills training. Complex patients and their physicians, however, may disagree about which problems are most important to target.9
Selecting the wrong target or initiating too many changes at once may overwhelm patients and lead to poor adherence.16,17
Ideally, targets should be selected on the basis of importance, patient motivation, and readiness for change.
Significantly more multimorbidity patients also reported a greater willingness to see 6 of 11 different types of nonphysician professionals to support their care, teach self-management skills, and provide follow-up monitoring. Furthermore, the willingness to see all 11 types of nonphysicians was significantly associated with patients’ self-management learning needs, although multimorbidity patients gave significantly better ratings on 3 of the 4 care components they received from their primary care physicians (PCP). The finding that multimorbidity patients gave higher ratings of their providers in terms of coordination of care, preference for usual provider, and accumulated knowledge is interesting, given that other studies suggest that chronic disease patients are usually less satisfied with their care.18
The CPCI appears to measure constructs that are independent from patient satisfaction.19
This may because, in part, of the fact that their frames of reference differ. Most satisfaction scales ask patients to rate a single visit or overall care, whereas the CPCI refers to experiences with a single physician.19
The results suggest that multimorbidity patients may understand that their PCPs often do not have the time to teach self-management skills or to check on patients’ progress between scheduled appointments. It is also possible that quality interactions with their PCP increased patients’ trust to see other providers.
It is important to note, however, that a significantly higher percentage of multimorbidity patients actually received care from 6 of the 11 types of nonphysicians in the last 6 months. Although it is possible that willingness to see nonphysician providers was associated with prior exposure, the percentages of patients who were definitely willing to see nonphysicians greatly exceeded the percentage of patients who had actually seen the same provider types by up to 30%. While this suggests that patients desire to have more contact with nonphysicians than they currently do, at some point, multiple appointments might become burdensome. We did not assess how many different providers patients would find acceptable to receive care from at once, but presumably care from nonphysicians should also be prioritized to patient needs.
The finding that multimorbidity patients are willing to receive care from nonphysicians such as pharmacists is consistent with our earlier focus groups, which indicated that multimorbidity patients were very willing to work with nonphysicians as long as the care supplemented, but not eliminated, physician care.9
This is underscored by the fact that almost 50% of multimorbidity patients (versus 32% of single morbidity patients) were definitely willing to receive care from “any healthcare provider who works closely with and communicates with” their PCP. It is increasingly recognized that physicians need not, and should not, be the sole healthcare provider in primary care.20
Although multimorbidity patients appear willing to accept “team-based” care, they definitely want their PCP to be the team “leader.”
The present study is limited by the self-report nature of the data, which may not reflect actual behavior. Moreover, our sample was derived from 1 healthcare system, making it difficult to generalize these results to other populations because VHA patients tend to be older, male, and to have more comorbid conditions.21,22
Unlike many studies that rely upon samples of convenience, however, the participants in the present study were randomly selected based upon encounter diagnoses representing specific “clusters” of multiple chronic illnesses. Although it is possible that the likelihood of being classified with multimorbidity based upon ICD-9 coding is confounded with increased healthcare contacts, our focus was on recognized chronic illness, not just symptom complaints. Furthermore, the significant differences in SF-12V scores increase our confidence that the multimorbidity group had significantly greater morbidity. We have no reason to believe that our findings of multimorbidity patients’ willingness to learn self-management skills will not be true of other patients with multimorbidity, but we hope that others will replicate our work in different populations in different healthcare systems.
Despite the extent of multimorbidity in its patient population, the VHA has demonstrated continued improvements in quality and patient-reported satisfaction.23,24
Although these gains are largely attributed to the VHA’s implementation of performance measurement and comprehensive electronic medical record, the VHA also transformed its care in the 1990s by shifting emphasis from the inpatient to the outpatient setting and assigning every patient a PCP. As the largest integrated healthcare system in the USA, the VHA also employs a large contingent of interdisciplinary, allied healthcare providers. The self-reported needs and preferences of patients with multimorbidity suggest that the integration of team-based care within primary care may help address the challenges of these complex patients.
Currently, however, two thirds of PCP work in autonomous solo or small group practices with limited support staff or capacity to provide skills training and proactive follow-up.25
Failure of third-party payers to reimburse these crucial components of chronic illness care is a contributing factor to the relative lack of this support in most primary care settings.17
Increasingly, resources for patient self-management support are available from government and not-for-profit foundation Web sites such as National Institutes of Health and the American Diabetes Association. Ultimately, new models of delivering comprehensive chronic illness care such as group clinics, automated telephone disease management programs, or home visits by physician extenders may help to expand these services to patients who need them.