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Module 3: Knowledge for Practice in Complex Care for Persons Living With Multiple Chronic Conditions (KNOW)

Thumbnail of downloadable Module 3 PPT Presentation.

The application of established and evolving biopsychosocial, clinical and epidemiological sciences to the care of persons living with multiple chronic conditions (PLWMCC)1.

Making the Case for Knowledge for Practice in Complex Care for PLWMCC

Evidence-based treatment is the gold standard in healthcare, and new evidence is continually emerging. Historically, the evidence for managing complex chronic conditions is based largely on clinical trials of single disease conditions, from which people with multi-morbidity are often excluded2,3. Research evidence and clinical guidelines for a specific combination of chronic diseases may be sparse or nonexistent. Basing care decisions on clinical guidelines developed for single chronic conditions may be impractical, irrelevant, or even harmful for PLWMCC4,5,6. The U.S. Department of Health and Human Services, in partnership with the Institute of Medicine, identified eleven principles for developing guidelines appropriate for PLWMCC to improve the stakeholder technical process for developing guidelines, to strengthen content of guidelines in terms of MCC, and to increase focus on person-centered care7. In addition, new research methods, such as comparative effectiveness research (CER)8 and new research foci, such as patient engagement and health literacy are adding to the knowledge base on caring for PLWMCC. It is important for healthcare teams to develop strategies for continuously incorporating new knowledge into practice.

Healthcare teams face complex clinical decision-making in assessing the evidence and the preferences of PLWMCC. In order to provide appropriate care, healthcare teams must evaluate and interpret clinical evidence; frame clinical management decisions within the contexts of risks, burdens, benefits and prognosis9,10; consider relevant interactions between the chronic conditions, their treatments and outcomes; and take into account the preferences of PLWMCC and their families and caregivers. Special consideration of polypharmacy, or concurrent use of multiple drugs, may be necessary.

It is crucial to understand the personal goals, priorities, and contextual factors of PLWMCC in recommending treatment options. Healthcare providers may initially prioritize treatment that is biased towards medical aspects of PLWMCC such as symptoms, severity and prognosis11, while PLWMCC may prioritize functional outcomes and quality of life. Person-centered care has been shown to improve PLWMCC’ health status, lessen symptom burden, and reduce the chance of misdiagnosis due to poor communication12. Differences among PLWMCC and providers on priorities for diagnoses, diagnostic evaluation, and treatment plans can hamper effective disease management13,14,15. Treatment complexity and burden for PLWMCC should be considered when negotiating therapies to optimize benefit, minimize harm and increase quality of life16. This requires clinical teams to be flexible, and to take into account their knowledge about PLWMCC characteristics and preferences for medical interventions and health outcomes17.

Health professionals need to be knowledgeable about specific person-centered strategies and tools that are employed by interprofessional teams such as shared decision making7, self-management support, goal setting, and the development of action plans and ongoing care plans. The use of a decision aid may facilitate shared decision making and priority-setting18. Supporting self-management in PLWMCC who are trying to balance complex health care needs and the social, emotional and financial demands of their daily lives is a key skillset for clinicians. Self-management is supported by a care plan that is shared between PLWMCC and providers and that documents PLWMCC’s priorities. These plans document health behavior change priorities and promote self-efficacy for improved long-term clinical outcomes in chronic illness care and disease prevention19. Care plans that prioritize PLWMCC’s goals such as maintaining independence, providing service in home and community based settings, reducing or eliminating pain and/or other symptoms20 should be reviewed regularly and updated as healthcare and daily living goals change. The care plan should provide PLWMCC with meaningful information using plain language and take into account more than PLWMCC’s clinical status.

PLWMCC with challenges such as a disability*, behavioral, and/or cognitive disorder have special needs (e.g., vision, hearing, mobility, cognitive, communication)21,22 that members of the interprofessional team need to understand and address in the care plan. Knowledge of the services and supports (e.g., SSI, vocational rehabilitation, community-based services) utilized by this group and how to coordinate them with other programs and services23,24 is critical for high quality care. Familiarity with the responsibilities of the guardians/ Power of Attorney of PLWMCC with cognitive and behavioral disorders, who cannot represent themselves in care planning,25,26,27 is also important.

* In providing care for individuals with MCC, healthcare workers should be aware of the United States’ Supreme Court’s Olmstead decision which states that public entities are required to provide community-based services to persons with disabilities when (a) such services are appropriate; (b) the affected persons do not oppose community-based treatment; and (c) community-based services can be reasonably accommodated, taking into account the resources available to the entity and the needs of others who are receiving disability services from the entity.48 As individuals with MCC are at particular risk of institutionalization, the healthcare workforce should focus on caring for individuals with MCC from a community inclusion and integration perspective.

Learning Objectives by Competency

Competencies and associated learning objectives are presented below for use by educators. The competencies apply to a wide variety of health professions students, faculty, and practitioners including physicians, nurses, psychologists, psychiatrists, dentists, pharmacists, social workers, allied health professionals, care coordinators, as well as interprofessional teams. These competencies apply across the educational continuum, and can be discipline specific or interprofessional. Examples of learning objectives are provided below. Educators may tailor objectives for a specific healthcare discipline and for a specific phase of education.

KNOW 1. Critically evaluate emerging evidence-based practices to improve healthcare for PLWMCC.

Learning Objectives

  1. Evaluate the applicability of new clinical evidence on chronic condition(s).
  2. Continuously review the literature to identify newly reported treatment, medications, and drug-drug interactions.

 

 


KNOW 2. Provide effective medication management for PLWMCC, as well as continuous monitoring, follow-up and reassessment.

Learning Objectives

  1. Assess the indication, effectiveness, and safety of the medication regimen for PLWMCC.
  2. Document collaboration with PLWMCC in prioritizing prescribed medications.
  3. Develop and modify the care plan as needed to reflect the assessment of PLWMCC medication needs.

 

 


KNOW 3. Provide care that includes clinical decision-making and assessment of the impact of barriers to contextual considerations on health, disease, care seeking, and attitudes towards care.

Learning Objectives

  1. Demonstrate the ability to provide person-centered care and modify treatment regimen(s) to reduce burden for PLWMCC.
  2. Demonstrate the ability to incorporate PLWMCC’s unique perspectives and circumstances into clinical decisions.

 

 


KNOW 4. Optimize care management by identifying treatment goals and management strategies that address more than one of the existing chronic conditions.

Learning Objectives

  1. Collaborate with PLWMCC to jointly create treatment goals that address their multiple chronic conditions.
  2. Discuss tradeoffs in functional status, social life, and/or spiritual goals in prioritizing one chronic condition over another and incorporate solutions that best address these needs in PLWMCC’s care plan.

 

 


KNOW 5. Integrate care of PLWMCC, as appropriate, with the services and supports provided to special populations, including persons with disabilities, behavioral health challenges, cognitive disorders and other populations with unique needs.

Learning Objectives

  1. Identify unique needs (e.g., vision, hearing, mobility, cognitive, communication) of PLWMCC in disabled or other special populations and ensure the interprofessional care team comprises specialists and others that can address these needs.
  2. Understand the roles and responsibilities of guardians who oversee the lives of PLWMCC with cognitive or physical disabilities and incorporate these guardians into the interprofessional care team.
  3. Identify community resources and the available home and community based supports for these special populations.

 

 


Selected Curricular Resources

The following is a select list of curricular resources that address, at least in part, Knowledge for Practice in Complex Care for PLWMCC. Additional resources can be found in the MCC Education and Training Repository with live links.

Polypharmacy in Older Adults Teaching Module

Alliance for Geriatric Education in Specialties (AGES) Curriculum

Decision-making in Multimorbid Patients

 

 


References

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Content created by Assistant Secretary for Health (ASH)
Content last reviewed on July 1, 2015