Q&A: Multimorbidity intervention is a ‘tremendous step in the right direction’

A team-based intervention in the primary care setting that included motivational approaches and self-management support improved some health behaviors among patients with multimorbidity, a randomized controlled trial showed.

Martin Fortin, MD, MSc, CMFC, a professor and research director in the department of family medicine at the Université of Sherbrooke in Quebec, Canada, told Healio Primary Care that there is a significant need for interventions for patients with multiple chronic conditions.

“Multimorbidity is a growing concern and a research priority internationally, but so far intervention studies conducted in primary care have failed to identify models of care that could really improve patient outcomes,” he said. “As a family physician, I have been challenged and overwhelmed to provide satisfactory care for my patients with multiple chronic conditions, and I felt sad not to be able to respond in a timely manner to the multiple needs.”

Previously, Fortin and colleagues developed an intervention for patients with asthma, COPD, CVD, diabetes and/or heart failure. The initiative, described in BMC Health Sciences Research, provides patients with a variety of educational, counselling and follow-up activities on topics such as following medication/vaccination instructions, eating properly, engaging in physical activity, quitting smoking, handling stress and providing psychosocial support. Ultimately, Fortin and colleagues intend for intervention participants to lessen the number of and rectify changeable risk factors, enhance patients’ self-efficacy; boost patients’ “functional autonomy, biopsychosocial balance and health;” and encourage self-management.

The researchers conducted two trials of the multifaceted intervention in family practices in Quebec and Ontario. In a paper recently published in Annals of Family Medicine, Fortin and colleagues reported on a study involving the intervention done in Quebec, which included 284 patients aged 18 to 80 years (mean age, 61 years) who had three or more chronic conditions. The 4-month intervention required practices to change the way they delivered care — adding a nutritionist and kinesiologist to the primary care team and providing a 2-day training session for health care providers geared toward improving outcomes among patients with multiple chronic conditions.

Fortin and colleagues reported that patients who were randomly assigned to the intervention saw a significant improvement in healthy eating (OR = 4.36) and physical activity (OR = 3.43) — both secondary outcomes — but the intervention had “a neutral effect” on the primary outcome of self-management and self-efficacy for managing chronic conditions.

Healio Primary Care spoke with Fortin for more details about the intervention and how it can be improved.

Healio Primary Care: Why did you come up with this intervention?

Fortin: Our group has received funding for implementing and testing a multifaceted intervention in primary care practices to supplement family physician care by the creation of interprofessional teams. The intervention encompassed three main components. One: training primary care professionals on the four core elements of adapting patient care for multimorbidity, using motivational approaches, interprofessional collaborations and self-management support. Two: a suggested clinical pathway for patients. Three: A community of practice to favor discussion and problem solving.

Healio Primary Care: What is the physician’s role in this intervention?

Fortin: This intervention provided new resources for the family physician to refer to and to work collaboratively with. In this respect, the practices had to welcome new professionals or to modify the role of some professionals already in place. The family physicians continued caring for their patients while the intervention was unfolding.

Healio Primary Care: What resources are needed to implement an intervention like this?

Fortin: The intervention requires the participation of a variety of primary care professionals, among which nurses, kinesiologists and nutritionists are the pillars for this model of care. Other professionals can join the team as needed. The training on the aforementioned four core elements is easy to implement.

Healio Primary Care: Why was it not successful as hoped?

Fortin: There are several hypotheses. Given the nature of the intervention, we thought that patients would improve on self-management and self-efficacy. To our great surprise, patients already scored high on these measures. It may be that the practices where we implemented the intervention were already performing well in terms of quality of care for this clientele. Not so surprising was the finding that health behaviors did improve with the intervention. The qualitative evaluation was also very positive.

Healio Primary Care: How can the intervention be improved?

Fortin: We found that some aspects of the intervention were not implemented to the fullest extent. So, after a careful consideration, we came to the conclusion that access to a professional in the role of clinical facilitation could improve the model by supporting the teams and motivating the professional to effectively deliver the intervention on an ongoing basis. The facilitator could also make sure the community of practice is effective.

Healio Primary Care: What would you say to physicians who might not be receptive to creating and implementing your intervention?

Fortin: It is generally recognized that teamwork is essential to care for patients with multimorbidity. However, teamwork does not happen just by putting professionals in the same physical environment — it requires action in order to organize the delivery of care and to break down the professional silos. We have made a tremendous step in the right direction by implementing this intervention. We still have to learn how to better care for people with multimorbidity in primary care, but this intervention is something we can build on.

References:

Fortin M, et al. Ann Fam Med. 2021;doi:10.1370/afm.2650.

Fortin M, et al. BMC Health Serv Res. 2013;doi:10.1186/1472-6963-13-132.