The development and optimisation of a primary care-based whole system complex intervention (CARE Plus) for patients with multimorbidity living in areas of high socioeconomic deprivation.

Stewart William Mercer,Maria Higgins,Rosaleen O'Brien,Graham Watt,Bruce Guthrie,Bridie Fitzpatrick,Sally Wyke

doi:10.1177/1742395316644304

Abstract

ObjectivesTo develop and optimise a primary care-based complex intervention (CARE Plus) to enhance the quality of life of patients with multimorbidity in the deprived areas.MethodsSix co-design discussion groups involving 32 participants were held separately with multimorbid patients from the deprived areas, voluntary organisations, general practitioners and practice nurses working in the deprived areas. This was followed by piloting in two practices and further optimisation based on interviews with 11 general practitioners, 2 practice nurses and 6 participating multimorbid patients.ResultsParticipants endorsed the need for longer consultations, relational continuity and a holistic approach. All felt that training and support of the health care staff was important. Most participants welcomed the idea of additional self-management support, though some practitioners were dubious about whether patients would use it. The pilot study led to changes including a revised care plan, the inclusion of mindfulness-based stress reduction techniques in the support of practitioners and patients, and the stream-lining of the written self-management support material for patients.DiscussionWe have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas. CARE Plus will next be tested in a phase 2 cluster randomised controlled trial.

Highlights

Multimorbidity is usually defined as the coexistence of two or more long-term conditions within an individual, and is increasing common in populations across the world.[1]
We have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas
The current work was part of our programme of research called ‘Living Well with Multimorbidity,’ and was the second iteration of the development of a whole system primary care-based complex intervention for multimorbid patients living in Intervention aspects Intervention name

Summary

Introduction

Multimorbidity is usually defined as the coexistence of two or more long-term conditions within an individual, and is increasing common in populations across the world.[1] In a large nationally representative study of the epidemiology of multimorbidity in Scotland, we found that multimorbidity was present in almost 25% of the population.[2] In the 10% most deprived areas, multimorbidity occurred 10–15 years earlier than in the 10% least deprived areas.[2] A similar social gradient has been found in several other studies.[1,3] The burden of multimorbidity is higher in those living in more deprived areas in terms of effect on quality of life.[4] The combination of mental and physical conditions (mental– physical multimorbidity) is 2–3 fold higher in the most deprived compared with the least deprived areas[2] and this is most pronounced in younger patients.[5] Mental–physical multimorbidity is associated with high levels of unplanned hospital admissions in the deprived areas.[6] Primary care staff recognise the ‘endless struggle’ that multimorbid patients living in the deprived areas face in terms of managing daily life.[7] Patients have described in detail the burdens that managing the ‘everyday life work’ and living with complex social, psychological and physical problems can create.[8]

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