Learning and Caring in Communities of Practice: Using Relationships and Collective Learning to Improve Primary Care for Patients with Multimorbidity

Abstract

We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires fl exibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and fl exible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would defi ne common goals, cocreate care plans, and engage in refl ective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients. INTRODUCTION Delivering primary care to patients with multiple morbidities is challenging.1 These patients typically consult multiple clinicians, use multiple medications, and compared with patients with a single chronic illness, have higher psychological distress, longer hospital stays, increased use of emergency facilities, and higher rates of mortality. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] Clinicians who care for them face competing demands, complexities of polypharmacy, diffi culties in applying practice guidelines, and increased potential for errors. 22,23 Clinicians also face increased diagnostic and treatment challenges as different combinations of conditions can interact in unpredictable ways. [24][25][26] These challenges occur in the context of comprehensive primary care that includes preventive care, coordination of specialist care, and consideration of patients' priorities in a longitudinal, mutually trusting relationship. 26,27 These challenges are only partially addressed by accurate disease-specifi c data and clinical guidelines: the former cannot guide comprehensive decision making that acknowledges patients' preferences and life context, while the latter are often irrelevant for patients with multimorbidity.28 Our guiding premise in this article is that caring for these patients is often a Hassan Soubhi, MD C A R ING F OR PAT IENT S WI T H MULT IM OR BIDI T Yknowledge-intensive activity which requires amplifi cation of existing professional know-how and insights into coordinating complex assessments and continuous interprofessional care that often goes beyond biomedical needs. We propose a practice m...

Effects of Facilitated Team Meetings and Learning Collaboratives on Colorectal Cancer Screening Rates in Primary Care Practices: A Cluster Randomized Trial

“…These approaches move beyond fi lling a knowledge defi cit on the part of patients or clinicians to enhancing the organization's capacity and resources for change. [13][14][15][16][17] Research on stakeholders-those individuals and groups who have an interest in and are infl uenced by the organization 18 -suggests that when stakeholders identify problems and generate their own solutions, they are more likely to engage in and sustain change processes. 19 Without the engagement, motivation, and commitment of key stakeholders within an organization, even meritorious innovations may be abandoned before they have had the chance to be effective.…”

Multidisciplinary Discourse

“…24 A very interactive discussion 25 about collective learning in communities of practice 26 yielded a primer and useful references on the application of systems and complexity science to collaborative care of patients with multimorbidity. 27 This discussion with the author expands understanding of how communities of practice and leadership may work to balance cooperative and competitive behaviors to enhance care of people and populations.…”

Prescribing for patients with multimorbidity: aiming to tailor to patient-set goals

“…Making such tacit ideas explicit is important in developing skills to care for patients with multimorbidity, for the education of professionals caring for them, and to be able to maintain accountability by more accurately documenting the rationale behind decisions made. 11 Sinnott et al's rigorously conducted qualitative study, which appears in this issue, 12 seeks to understand how GPs make prescribing decisions in patients with multimorbidities. They describe this decision-making process as 'satisficing', where doctors accept care that is satisfactory and sufficient for particular patients.…”