Development of a shared decision-making intervention ‘VOLITION’ for older people with multimorbidity: An Intervention Mapping approach.

Problem

The population is ageing and two thirds of those in the UK have multimorbidity. These patients consult frequently and live with a heavy burden of illness, associated with poor quality of life and increased mortality, along with a high treatment burden and associated healthcare costs. Ensuring the provision of high quality person-centred care for these patients poses a real challenge for primary care clinicians, researchers and policy-makers alike. There are few existing interventions in this emerging field.

Recently, the potential benefits to older patients with multimorbidity, from participating in decision-making about their healthcare, have been acknowledged in UK health policy. The aim of VOLITION is to facilitate the involvement of older people with multimorbidity in decision-making about their healthcare during general practice consultations.

Approach

An Intervention Mapping (IM) framework was followed as a means of systematically applying existing literature, new data and relevant theory to six iterative steps in the development, refinement and planning for the evaluation of VOLITION. Patient and public involvement (PPI) was central. We also sought expert stakeholder opinion e.g. through the international symposium on multimorbidity and the RCGP’s Network of Champions for patient centred care. We published a Cochrane systematic review of similar interventions. A qualitative focus group study validated our proposed ‘performance’ and ‘change’ objectives e.g. by asking patients whether objectives matched their preferences for GP consultations, and asking GPs how they might perform changed behaviours. A mixed-methods exploratory-explanatory study informed plans to implement VOLITION in the context of remote vs. face-to-face GP consultations.

Findings

Whilst patient involvement is advocated by experts and recent guidelines on multimorbidity, few studies exist that evaluate interventions to facilitate the involvement of older patients with multimorbidity in primary care. Additionally, potential barriers are perceived by GPs and patients when considering patient involvement in the current context of GP consultations.

Our IM approach to development ensured that VOLITION took into account all of the above. VOLITION consists of a handout to prompt patients to express their preference for involvement; and a GP training workshop in shared decision-making, tackling the perceived challenges of applying these skills when consulting with this patient group.

Consequences

VOLITION adheres to core components of NHS England’s current universal personalised care plan; to empower patients in the management of their own healthcare and to train more clinicians in patient-centred skills. The stakeholder involvement, established through our IM approach, provides a platform for dissemination of our findings.

A full, definitive trial of VOLITION is planned. An effective intervention in this area, designed and refined using end-user perspectives, has the potential to influence policy makers as well as clinicians, towards ensuring high quality patient-centred care for older people with multimorbidity.