Improving clinical decisions and multidisciplinary team-working with older adults with multimorbidity? Co-designing a facilitated education programme.
As life expectancy rises, increasing proportions of older people are living with multiple long-term conditions that need coordinated care across different services. Yet (i) such services are often fragmented, leading to confusion of responsibility, silo-thinking, contradictory instructions, and over- or under-treatment; (ii) guidelines are inadequate for managing unique combinations of conditions; (iii) patients often feel excluded from decisions; (iv) staff report time- and resource-constraints; and (v) there is little guidance on how to address these challenges in an integrated, person-centred way.Primary care is pivotal to improving care for older patients with multimorbidity but effective primary care-based multidisciplinary team-working across agencies is still rare in England. We are developing an intervention targeted at the multidisciplinary workforce based around GP practices, consisting of primary care, community services and social care staff. The intervention seeks to improve clinical decisions and multidisciplinary team-working for the most complex group of older patients (55+ years) with at least three long-term conditions who require multidisciplinary care, as they stand to gain substantially from improved care.
Through a series of workshops with patients, staff and education experts in three regions of England - Birmingham, Devon and Staffordshire - we are co-designing a facilitated education programme. We are drawing on concepts of explicit knowledge and skills, which can be externalized and written down, and tacit knowledge and skills which are internalised and based on intuition. Social practices e.g. peer learning, can stimulate the tacit to become more explicit and open to codification. Our intervention involves updating explicit knowledge and using case study-based interactive peer learning to make tacit knowledge and skills more explicit, with team facilitation to support the implementation of improvements to care.We are also interviewing staff and stakeholders, analysing published research, and reviewing available evidence to ensure a feasible, relevant intervention that is grounded in, and responsive to, the realities of patients and multidisciplinary primary teams.
While still under design, the intervention will comprise team education, using interactive case-based peer learning to build on existing tacit knowledge and skills in managing multimorbidity amongst older adults; and GP practice-based facilitation, supporting implementation of improvements to care designed by each team.We anticipate that staff and managers will be keen to extend their existing expertise and promote team-work but recognise that staff in all community settings face considerable work pressures. We will therefore also identify and seek to minimise potential barriers to intervention uptake with intended users.
This intervention is being developed towards a trial that will be underpinned by a critical primary care question: To what extent can a multi-component intervention, which combines education and facilitation of change, develop team-working across services, and improve care and outcomes for older people with multimorbidity needing multidisciplinary care?