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

Jonathan Stokes; Mei-See Man; Bruce Guthrie; Stewart W. Mercer; Chris Salisbury; Peter Bower

doi:10.1370/afm.2150

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Author response Re:A Framework for New Models of Care for Multimorbidity: How Can These Models Be Improved With Multimorbidity-specific Elements?
Jonathan Stokes

Published on: 07 December 2017
Author response Re:A Good Start
Jonathan Stokes

Published on: 07 December 2017
A Framework for New Models of Care for Multimorbidity: How Can These Models Be Improved With Multimorbidity-specific Elements?
Christiane Muth

Published on: 30 November 2017
A Good Start
Chad Boult

Published on: 27 November 2017

Published on: (7 December 2017)
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Author response Re:A Framework for New Models of Care for Multimorbidity: How Can These Models Be Improved With Multimorbidity-specific Elements?
Jonathan Stokes, Research Associate
Thanks for your letter, some very good points.
I agree, there is the need to examine the interactions of these conditions and treatments in future research. Hopefully, with more systematically described models of care, this could be achieved in combination with outcomes present in readily available datasets in real-world studies.
I think your point about incorporating patient preferences as much as pos...
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Thanks for your letter, some very good points.
I agree, there is the need to examine the interactions of these conditions and treatments in future research. Hopefully, with more systematically described models of care, this could be achieved in combination with outcomes present in readily available datasets in real-world studies.
I think your point about incorporating patient preferences as much as possible is a good one too, and an important focus. I guess, the difficulties there might come with those most complex patients, as described by Winnie et al. [1], who have less preference for being involved actively in shared decision-making. This would, presumably, make incorporating their preferences more difficult.
Another potential difficulty might arise when patient preferences don't align with, or directly contradict, health system goals. This reminds me of the study by Fenton et al., for example, where they identified increased user satisfaction was associated with "less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality" [2].The problem might be that market failure identified in the field of health economics, 'information assymetry', where physicians generally know more about how health services will affect a patient than the patient does. That, combined with patients acting in an increasingly consumer-focused market where 'the customer is always right'.
The above contradiction also makes me think about a number of new interventions commonly aiming for 'the triple [3] (or quadruple [4]) aim' (i.e. improving the experience of care, improving the health of populations, reducing per capita costs of healthcare for the triple, with the addition of improving the work-life of healthcare professionals for the latter). All noble pursuits, of course, but it is not often that you see all three/four accomplished. For example, delivering better quality care tends to cost more. Perhaps there is the need for trade-offs on occasion?
Interesting potential dichotomies, at least.
REFERENCES 1. Winnie CC, Wolff J, Greer R, Dy S. Multimorbidity and Decision-Making Preferences Among Older Adults. Ann Fam Med. 2017;15:546-551; doi:10.1370/afm.2106
2. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality. Arch Intern Med. 2012;172(5):405-411. doi:10.1001/archinternmed.2011.1662
3. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008;27(3):759-769.
4. Bodenheimer T & Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. The Annals of Family Medicine. 2014;12(6), 573-576.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (7 December 2017)
Page navigation anchor for Author response Re:A Good Start
Author response Re:A Good Start
Jonathan Stokes, Research Associate
Thank you for your comment, Chad.
Myself and my co-authors agree, these are excellent suggestions for future work.
Competing interests: None declared

Competing Interests: None declared.
Published on: (30 November 2017)
Page navigation anchor for A Framework for New Models of Care for Multimorbidity: How Can These Models Be Improved With Multimorbidity-specific Elements?
A Framework for New Models of Care for Multimorbidity: How Can These Models Be Improved With Multimorbidity-specific Elements?
Christiane Muth, Senior Researcher
Other Contributors:
Background: Multimorbidity and the polypharmacy that often accompanies it, are key challenges facing health care, and new models of care for patients with multiple conditions are necessary.[1] The Chronic Care Model (CCM) by Ed Wagner et al.[2, 3] is evidence-based and its implementation has been shown to improve clinical outcomes and processes of care for individual diseases.[4] Stokes et al. [5] have presented a new f...
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Background: Multimorbidity and the polypharmacy that often accompanies it, are key challenges facing health care, and new models of care for patients with multiple conditions are necessary.[1] The Chronic Care Model (CCM) by Ed Wagner et al.[2, 3] is evidence-based and its implementation has been shown to improve clinical outcomes and processes of care for individual diseases.[4] Stokes et al. [5] have presented a new framework to describe care models that have been specifically developed for the care of patients with multimorbidity. They outlined 39 models in terms of theoretical basis and defined target population and classified them according to the elements of care involved in their implementation (clinical focus, organization of care delivery and support for model delivery).[5]
Discussion: The paper is topical and the authors draw attention to the importance and complexity of care for people with multimorbidity. However, their scoping review raises some questions:
Their results show that existing models generally rely on the CCM and rarely incorporate multimorbidity-specific concepts such as minimally disruptive medicine.[6] In models identified as having a clinical focus, they report a broad range of such elements as self-management support, shared decision-making (SDM), mental health and guidelines / protocols. These elements are indeed relevant and widely used in chronic care. However, how do they take account of the complexity of interacting conditions and treatments in patients with multimorbidity?[7] And how can these elements be addressed in older patients with complex care needs who less likely prefer SDM, as pointed out by Winnie et al. in this issue?[8] Can't we achieve an individualized management through a prioritization of health problems and goal setting, and taking into account patients' preferences also by means of other communication styles?[9]
We fully support the authors' demand that new care models and other care innovations should be described in detail and carefully evaluated. This will increase the deterministic and evaluative value of the framework, as well as its utility as a reporting guideline.
REFERENCES
1. Roland M, Paddison C. Better management of patients with multimorbidity. BMJ 2013;346:f2510.
2. Wagner EH, Austin BT, von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74(4):511-544.
3. Wagner EH, Austin BT, Davis C et al. Improving chronic illness care: Translating evidence into action. Health Aff (Millwood) 2001;20(6):64-78.
4. Tsai AC, Morton SC, Mangione CM et al. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care 2005;11(8):478-488.
5. Stokes J, Man MS, Guthrie B et al. The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity. Ann Fam Med 2017;15(6):570-577.
6. May C, Montori VM, Mair FS. We need minimally disruptive medicine. BMJ 2009;339:b2803.
7. Muth C, Kirchner H, van den Akker M et al. Current guidelines poorly address multimorbidity: pilot of the interaction matrix method. J Clin Epidemiol 2014; 67(11):1242-50.
8. Winnie CC, Wolff J, Greer R, Dy S. Multimorbidity and Decision-Making Preferences Among Older Adults. Ann Fam Med 2017 15:546-551; doi:10.1370/afm.2106
9. Muth C, van den Akker M, Blom JW et al. The Ariadne principles: how to handle multimorbidity in primary care consultations. BMC Med 2014;12:223.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (27 November 2017)
Page navigation anchor for A Good Start
A Good Start
Chad Boult, medical director
The recent "Foundations Framework" article by Stokes et al. highlights the importance of describing clearly and completely our innovations in health care for people with multiple chronic conditions. Three recommendations for the future: 1. Craft a more specific proposed glossary of terms, e.g., name and define the major types of care management, home care, and financial incentives. 2. Create increased capacity within our j...
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The recent "Foundations Framework" article by Stokes et al. highlights the importance of describing clearly and completely our innovations in health care for people with multiple chronic conditions. Three recommendations for the future: 1. Craft a more specific proposed glossary of terms, e.g., name and define the major types of care management, home care, and financial incentives. 2. Create increased capacity within our journals to publish "methods papers" that describe new models of care. 3. Consider establishing a registry of multi-morbidity models of care, analogous to the registry for RCTs, which would help structure innovators' descriptions of their models and would thereby help ensure that readers would understand how each model operates.
Competing interests: None declared
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Competing Interests: None declared.