Feature: Enhancing care for patients with multiple chronic conditions

Image representing multiple medications, and a stethescope

By Crystal Mackay, MA’05

A growing number of patients suffer from multiple chronic conditions including diabetes, arthritis, high blood pressure and anxiety or depression. They are often seeing a number of different medical specialists, taking a more than one medication and are balancing a multitude of important and sometimes conflicting health advice.

In an effort to help these patients improve their quality of life and better manage their health, Dr. Moira Stewart and a team of researchers at Schulich Medicine & Dentistry’s Centre for Studies in Family Medicine tested a multi-provider case conference as part of their care. The conference includes all of the patient’s treating physicians and other providers, as well as the patient.

“Multi-morbidity is much more common than we thought, and is surprisingly prevalent in younger patients, so it is a very important health issue,” said Stewart, Professor in the Department of Family Medicine at Schulich Medicine & Dentistry. “We are looking for a transformation in the health care system, and our research on the multi-provider case conference is one piece of the puzzle.”

Many health care providers are beginning to see the importance of working together for patients with multiple conditions, but they each approach it in different ways. The multi-provider case conference is unique because of its patient-centred approach.

Photo of Dr. Moira StewartA multi-provider case conference brings together a range of health care providers involved with patient’s care from the social worker to the family physician to the internist, virtually or in person. The patient is in the driver’s seat and leads off the discussion with their goals, priorities and major concerns, Stewart said. “The aim of the conference is to co-create an integrated care plan to better support the patient.”

Stewart and the research team tested the case conference with 163 patients (half of whom were in the control group) and their care teams, interviewing the patients afterward to understand their experiences and what aspects they felt were beneficial to their care.

Their results were published in the British Journal of General Practice.

On average, the patients in the study had six chronic issues they were managing, and were from a range of age groups.

“The participants were seeking help to be able to cope with all of these conditions. It gets complicated because some of the solutions for one condition are problematic because of another condition.” For example, exercise is beneficial for mental health and blood pressure management, but is difficult for patients managing arthritis or low back pain, she said.

The study found that the case conference was helpful for patients especially with respect to mental health outcomes, but this was only true for patients with mid to high incomes. Those with incomes under $50,000 did not report a similar improvement. The research team dug into their interview data to try to understand why.

“This study helped us identify a previously invisible factor that our evidence suggests plays a role – the financial ability to pay for health care recommendations not covered by public health care in Ontario,” said Stewart.

What the team discovered through their interviews with patients was the things they found to be the most useful from the case conference were recommendations for allied health professionals, such as psychotherapy, social work, and physiotherapy. But these are things that aren’t necessarily covered under provincial health care and may have to be paid for out of pocket.

Given these findings, Stewart says policy-makers and clinicians should be encouraged to seek ways to enhance care for patients with lower incomes through tailoring care and providing more robust follow-up care. “Stronger and longer follow-up would likely be a benefit,” she said.

Next the research team will be working with physicians, patients and policy makers to strengthen the care, especially for low income patients, and test the new care using better patient reported outcome measures that are more relevant to the patient with multiple chronic conditions.