In this qualitative investigation, these elderly patients with multimorbidities describe ideal processes of care that are patient centered and individualized and support their unique constellations of problems, shifting priorities and multidimensional decision making. These preferences reflect both their total disease burden and the fact that these participants were often faced with conflicting and complex treatment plans to manage their multimorbidities.
Our results are consistent with previous investigations that have investigated care processes for complex patients. Noel et al.19
recently explored collaborative care needs and preferences in the multimorbid population and concluded that the principles of patient-centered care including facilitating access, communication and continuity can be used as a guide for this population.19
Parchman et al.
found that reports of improved communication and coordination of care were associated with fewer ‘hassles’ with the health care system for veterans with multiple medical conditions, and Jerant has reported poor physician communication as a barrier to active self-management in a population of persons with multiple conditions.23
advocates for an ‘ecosystemic’ approach to the delivery of chronic care that integrates an appreciation of patients’ individual preferences, medical needs and psychosocial environment.
Accounts from our respondents expand on these findings by identifying specific components of patient-centered care and provider skills that may enhance the overall care process for patients with multimorbidities: Convenient access to providers (telephone, internet or in person) so that patients can easily clarify small questions and be promptly assessed for larger concerns, clear communication (preferably written) of individualized care plans that clarify and address potentially conflicting treatment strategies, continuity of relationships with physicians so that they do not have to re-educate providers on their complex care needs, specific continuity with a single coordinator of care who helps patients track all their health-related tasks and an appreciation from providers that patients’ needs are unique and fluctuating and that they will be ‘heard’ when they raise concerns. In instances when these components of the care process are necessary, but missing, most can be addressed by either system redesign or specific provider training.
Although our interview participants were offered the opportunity to discuss the content of their care, they largely focused on the process. For example, a few mentioned a desire for increased information on management of specific conditions such as diabetes or the rationale for certain laboratory tests. However, these requests for a change in content of care were couched in the context of inadequate patient–provider communication, a process of care. This emphasis on process is also important in light of the obvious disease burden carried by many respondents. Although it is possible that none experienced conflicts in symptoms or treatment and therefore did not mention them, we think it is more likely that in the face of complex medical regimens, there is a particular need for specific components of patient-centered care. This observation is particularly important in designing future interventions to improve care for this population as current guidelines for chronic disease care (and associated measures that quantify quality of care) are based almost exclusively on the content of that care rather than the process.
Patient-centered care is essential for patients at all levels of morbidity, not just those with multiple chronic conditions. Our study participants, however, identified components of patient-centered care that they feel are important and had two specific suggestions that may be relevant for their population: the idea of a single coordinator of care (or contact person) and the concept of care that responds to ongoing and fluctuating needs. More complex patients may require a high level of ongoing support that responds to shifting priorities and symptoms, reflecting their heterogeneous disease burden. Although they may not always need the same intensity of support, it must be continuous and not intermittent.
The system desired by these individuals with multimorbidities is a labor-intensive proposition for the health care system and creates a tension between the desire to provide such care and the magnitude of both the care needs and the size of the population. It behooves us to develop systems to help us determine which patients need what sort of support at which times. McCormick and Boling26
recognize the magnitude of this prospect and call for investigation into the size and characteristics of populations most likely to benefit from more intensive care coordination. In addition, Stille et al.27
advocate investigation into the evidence base for coordination of care, with specific attention to the care coordination needs of persons with multimorbidities.
Our investigation is limited in that all our respondents were members of a single HMO and as such reflect the perspectives of that population—specifically their own experience with care management within that care system. However, we believe our findings are likely generalizable to many older adults with multiple chronic conditions as the participants’ desired processes of care fit under the well-established umbrella of patient-centered care. In addition, some of their reported care preferences reflect our participants’ age and functional level rather than purely their disease burden. Given the prevalence of multimorbidity in older adults, it may not be possible to separate the two. Furthermore, lower physical functioning is often a function of disease burden rather than age. As a qualitative investigation, our conclusions are preliminary and will invite further investigation to quantify and confirm our recommendations.