The development and optimisation of a primary care-based whole system complex intervention (CARE Plus) for patients with multimorbidity living in areas of high socioeconomic deprivation

Abstract

ObjectivesTo develop and optimise a primary care-based complex intervention (CARE Plus) to enhance the quality of life of patients with multimorbidity in the deprived areas.MethodsSix co-design discussion groups involving 32 participants were held separately with multimorbid patients from the deprived areas, voluntary organisations, general practitioners and practice nurses working in the deprived areas. This was followed by piloting in two practices and further optimisation based on interviews with 11 general practitioners, 2 practice nurses and 6 participating multimorbid patients.ResultsParticipants endorsed the need for longer consultations, relational continuity and a holistic approach. All felt that training and support of the health care staff was important. Most participants welcomed the idea of additional self-management support, though some practitioners were dubious about whether patients would use it. The pilot study led to changes including a revised care plan, the inclusion of mindfulness-based stress reduction techniques in the support of practitioners and patients, and the stream-lining of the written self-management support material for patients.DiscussionWe have co-designed and optimised an augmented primary care intervention involving a whole-system approach to enhance quality of life in multimorbid patients living in the deprived areas. CARE Plus will next be tested in a phase 2 cluster randomised controlled trial.

Exploring the utility of self-determination theory in complex interventions in multimorbidity: A qualitative analysis of patient experiences of the CARE Plus intervention

“…Our findings of patient experience of CARE Plus are similar to those reported by the early pilot work conducted during the design of the CARE Plus intervention, where increased consultation times, continuity of practitioner and referral to community resources were all valued by participating patients. 20 Our findings are also consistent with previous work looking at SDT in relation to health behaviours, showing that satisfaction of psychological needs is associated with more purposeful, consistent and sustained health behaviour changes. 16,24 Previous work looking at multimorbidity in areas of high socio-economic deprivation has demonstrated the impact mental health co-morbidity has on wellbeing and the patient's everyday work.…”

“…It was developed through a codesign process involving researchers, patients, voluntary groups and primary care practitioners, and informed by the existing evidence of managing multimorbidity in this context rather than a single theory. 20 It provided the financial resource to allow GP practices to offer longer consultations to targeted participants. The number of consultations was not set in advance, to allow flexibility; on average, participants in the intervention arm received three CARE Plus consultations during the 12-month trial period.…”

“…9,11 In addition, SDT was not an underlying theory used in the development of the topic guide meaning findings were not influenced by interviewer bias. It was part of a broader programme of work (thus allowing it to be placed in a wider context), much of which has already been published 1,3,7,19,20 .…”

“…The CARE Plus intervention was a whole system primary care-based intervention targeting patients with complex multimorbidity living in areas of high socio-economic deprivation: its development and optimisation is described in detail elsewhere. 19,20 CARE Plus aimed to improve patient's well-being and quality of life by encouraging empathic patient-centred care and relational continuity, and supporting practitioners to focus on identifying patient priorities and setting goals (for practitioners and patients) to support self-management. A phase 2 exploratory cluster randomised controlled trial (RCT) indicated likely effectiveness and cost-effectiveness.…”

Primary care consultation length by deprivation and multimorbidity in England

“…The Royal College of GPs, based on this premise, recommend longer consultations for patients with multimorbidity in order to reduce burden on the rest of the NHS (12). People living with multimorbidity, likewise, have identified longer primary care appointments as an optimal way of improving the quality of their care (13).…”