Archive | November, 2017

The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity

15 Nov

by Jonathan Stokes, Research Associate in the Manchester Centre for Health Economics

J Stokes_Foundations Framework diagram

With colleagues at the Universities of Bristol, Glasgow and Dundee, we have published a framework aimed at improving care for patients with multimorbidity (two or more long-term conditions).

Long-term conditions and multimorbidity are a global health priority. Patients with multimorbidity receive more fragmented care and have worse health outcomes, and health systems struggle to address their needs. We need new ways of delivering care to address this.

To date, there has been limited success at delivering care that improves outcomes for these patients. One major problem is that there is no agreement on how to describe care for patients with multimorbidity. This makes it difficult for researchers to talk about their work, and to explain these new ways of delivering care to patients and policy makers. Our framework offers a starting point for addressing this issue.

Our framework describes care for multimorbidity in terms of the foundations:

  •  the theory on which it is based
  • ·         the target population (‘multimorbidity’ is a vague term, so we need to define the group carefully, e.g. a patient with diabetes and hypertension might have very different care needs than a patient with dementia and depression)
  • the elements of care implemented to deliver the model.

We categorised 3 elements of care: (1) the clinical focus (e.g. a focus on mental health), (2) how care was organised (e.g. offering extended appointment times for those who have multimorbidity), and (3) what was needed to support care (e.g. changing the IT system to better share electronic records between primary and secondary care).

We used our framework to look at current approaches to care for multimorbid patients. We found:

  • Care for multimorbidity is mostly based on the well-known Chronic Care Model (CCM). This was designed for people with single diseases, and may not be fit for purpose for patients with multimorbidity.
  • Much care is focussed on elderly or high-risk patients, although there are actually more people aged under 65 with multimorbidity. We need to make sure that models don’t neglect the needs of younger patients, or those who are at lower risk, who might have most to gain in preventing future health problems.
  • We need to look more at the needs of low-income populations (where multimorbidity is known to be more common), and those with mental health problems (multimorbid patients with a mental health issue are at increased risk for worse health outcomes).
  • There is an emphasis on self-management, but patients with multimorbidity frequently have barriers to self-managing their diseases.
  • The emphasis on case management (intensive individual management of high-risk patients) should take into account the evidence that while patient satisfaction can be improved, cost and self-assessed health are not significantly affected.

Health systems have only recently begun to implement new models of care for multimorbidity, with limited evidence of success. Careful design and reporting can help develop evidence more rapidly in this important area. We hope our framework can encourage better research which is urgently needed to improve care for those who use it most.

This free to read article can be found at the following link:

Stokes J, Man M-S, Guthrie B, Mercer SW, Salisbury C, Bower P. The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity. The Annals of Family Medicine. 2017;15(6):570-7.

Diagnostic Error in Medicine: key topics

2 Nov

by Sudeh Cheraghi-Sohi, Research Fellow in Safety in Marginalised Groups: Patients and Carers theme

DEM 10th conference_cropped

I recently attended the 10th International Conference on Diagnostic Error in Medicine (DEM) held in Boston and organised by the Society to Improve Diagnosis in Medicine (SIDM).  I was invited to attend the research summit as well as to display some of my work from the 2012-2017 NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (PSTRC).

The research summit was an excellent forum for discussing the key areas of interest in the field of DEM research.   This year’s topics of interest were around uncertainty and the role of the team and teamwork. For the first topic, I was really interested to participate in discussions as I have already done some work in the area of uncertainty in terms of a review[1] around the various aspects of uncertainty and the PSTRC has also developed a training package[2] to help peoples’ awareness of the issues and in managing their uncertainty.  The discussions were very lively and a keynote speech at the conference given by Dr Arabella Simpkin also resonated with the conference delegates.

The second topic is an area that the Institute of Medicine, in their 2015 report on Improving Diagnosis, placed a focus on. The role of team in making a diagnosis may not be obvious to many people, particularly in the context of UK general practice where patients probably think about the one-to-one consultation with their general practitioner, but even in general practice, there are often multiple people involved in making a diagnosis. For example, the phlebotomist and the practice nurse/nurse practitioner may have already seen a patient prior to the GP consultation and performed certain tasks and provided prior information for the GP to work with. Also, when GPs make referrals, they are seeking the expertise of others and then utilising all the gathered information to inform their diagnostic thinking and hopefully coming up with an accurate diagnosis. This is certainly an area that I would like to explore more.

Finally, the main conference itself was fascinating. There was a superb talk given by Don Berwick, one the world’s leading patient safety experts, as well as many interesting workshops to attend. I am also happy to say people were very interested in the Greater Manchester PSTRC’s work around Missed Diagnostic Opportunities[3] and I will write another blog when we are able to share more of our findings from this project.