Developing an interprofessional people-centred care model for home-living older people with multimorbidities in a primary care health centre: A community-based study

Abstract

BackgroundThe ageing population with multiple conditions and complex health needs has forced healthcare systems to rethink the optimal way of delivering services. Instead of trying to manage numerous diseases in a siloed approach, the emphasis should be on people-centred practice, in which healthcare services are tailored to people's needs and provided in partnership with them. ObjectiveThe aim was to develop an interprofessional people-centred care model (PCCM), including the contribution of a clinically trained pharmacist for home-living multimorbid older people in primary care. MethodsParticipatory action research method, including the active involvement of healthcare professionals, was utilised to develop the PCCM in a public health centre in Finland. The data comprised interview transcripts, workshop materials, field notes, surveys, and memos and were analysed using inductive content analysis. ResultsThe PCCM was developed in iterative phases, including planning, acting, observing, and reflecting. The PCCM comprised: 1) A self-management evaluation questionnaire sent before a home visit; 2) A person-centred patient interview at home with a named nurse and a pharmacist; 3) A nurse-led health review and a pharmacist-led clinical medication review; 4) An interprofessional (a GP, a pharmacist and a named nurse) case conference meeting; 5) A care plan, including health and medication plans; and 6) Health support and empowerment interventions. The PCCM shifted working practices in the health centre from parallel and consultative practice towards interprofessional people-centred practice and more holistic care. The patient's active involvement in their own care was encouraged. Healthcare professionals appreciated the advantages of the new skill-mix, including the clinically trained pharmacist. Building trust among healthcare professionals and between the professionals and the patients was essential. ConclusionThe successfully developed PCCM improved holistic and more people-centred care in primary care. Healthcare professionals appreciated the advantages of the skill mix and found that trust was essential for implementing the PCCM.