This study used a qualitative descriptive approach to understand how an innovative interprofessional team consultation addressed the needs of patients with multimorbidity who are vulnerable (24).
Setting
Four TIP Programs in Toronto, Canada providing a team consultation to patients with multimorbidity.
Participants
Participants were initially recruited by the TIP Program Coordinator and the Program Leads who had developed TIP. Allied healthcare providers (e.g., social work, nursing, pharmacy), and physicians (e.g., family medicine, internal medicine, psychiatry) currently participating at one of the four main TIP Program sites were selected to reflect the team composition at each site. Family Physicians who had referred their patients to the Program, were approached by the Program Coordinator. Decision makers were defined as individuals who had a connection to the TIP Program, either at a managerial, municipal or provincial level, and were recruited by the TIP Program Leads. Contact with all participants was made either by phone or email. Subsequently, their contact information was sent to the study’s Research Assistant who organized the time and date of the interview. Informed consent was received from each participant before the interview began. Confidentially was assured.
Data Collection
Semi-structured individual interviews were conducted with each participant at their work location by three of the female researchers (XXX, XXX, XXX). Some interview questions were generic for each group of participants such as their length of involvement with the Program, while other questions and prompts were tailored to their specific involvement in the Program (e.g., healthcare provider, decision maker). The interviews, lasting from 30-60 minutes in duration, were audiotaped and transcribed verbatim by a professional transcription service. NVivo 10 software was used in the organization of the data.
Data Analysis
The thematic analysis was both iterative and interpretative (25). During the initial step of the analysis, three of the researchers (XXX, XXX, XX) independently reviewed and coded each transcript by to identify key concepts emerging from the data. They then met to examine their independent coding, which culminated in a consensus that informed the development of the coding template. This process analysis continued until all the transcribed interviews had been analyzed. Next the research team reviewed the main themes and sub-themes that had been inputted into NVivo. This step in the analysis facilitated the identification of the overarching themes and accompanying exemplar quotes. This final stage of the analysis helped determine they had sufficient data to understand and interpret the themes. The analysis for this paper specifically focused on understanding the participants' experiences in caring for patients with multimorbidity who are vulnerable.
Trustworthiness and Credibility
The trustworthiness and credibility of the analysis were ensured by using field notes following each interview, audio recording and verbatim transcripts, and independent and team analysis. Careful attention to how the researchers’ professional backgrounds (i.e., social work, family medicine), could influence the findings were taken into consideration particularly during the coding and interpretation of the data. This required an ongoing commitment to reflexivity (26).
Final Sample
The sample consisted of 48 participants. There were 20 allied healthcare providers (AHP) (e.g., nurses, social workers, pharmacists and dieticians) and 10 physicians (MD) (e.g., psychiatrists, general internists, and family physicians) who were part of the TIP team; 9 decision makers (DM); and 9 family physicians who had referred a patient to the Program (RFP). The average age was 46 years (range 23-70 years). There were 15 male and 33 female participants with an average years in practice of 20 years (range 2-46 years). Participants' length of involvement with the Program ranged from 4 months to 9 years.
Ethics Approval
This study was approved by the Health Sciences Research Ethics Board of The University of Western Ontario (#106921) and all the methods were performed in accordance with the relevant guidelines and regulations of the Health Sciences Research Ethics Board of The University of Western Ontario.
FINDINGS
Understanding participants’ experiences of how the TIP Program addresses the needs of patients who have multimorbidity and are vulnerable was reflected by two overarching themes. First, their perceptions of the reasons certain patients with multimorbidity are vulnerable. Second, were the approaches participants used in caring for these vulnerable patients which included: recognizing the social determinants of health; maximizing professional team collaboration; demonstrating cultural sensitivity, compassion and advocacy.
The reasons some patients with multimorbidity are vulnerable
Overall, participants described patients referred to the TIP Program as those who typically fall through the cracks: “I think they fall through the cracks because they are overwhelmed. They have a low health literacy. You can give them the information but they don’t understand”. (MD10). They were patients who also face major challenges with accessing the healthcare system: “People who have the hardest time in accessing care.” (HCP14), and furthermore vulnerable patients were described as being unsure about how to navigate the healthcare system, “They don’t know how to pound the pavement and figure out the system. We are here for them.” (DM06).
Mental health issues were identified as a major contributor to patients being vulnerable: “Consistently across the board is mental health.” (DM05). Many family physicians referring patients to the TIP Programs observed that: “The patients usually have a big psychiatric overlay.” (RFP07). A specialist provider explained: “Medicine is often the easiest part of the job. It’s all of the social context and quite often the psycho-social context that makes all of this stuff challenging.” (MD09). Participants viewed mental health issues as often linked to the common social determinants of health such as the “extremely poor” (RFP02); “homeless” (DM03); or “the immigrant population” (DM04).
Cultural issues including language, different values and beliefs were identified as potential aspects of patients being vulnerable. “If their culture or their habits were different or they didn’t have money to implement some of these lifestyle things, I could see how that could be difficult.” (RFP08). A specific group noted as being vulnerable were seniors who were socially isolated. “And we have a fairly large percentage of seniors that don’t have any family members. So that are just struggling on their own.” (DM03).
Approaches used in caring for these vulnerable patients
In caring for these vulnerable patients the Program used specific approaches including recognizing the social determinants of health, maximizing a collaborative interprofessional team approach, emphasizing cultural sensitivity, as well as exhibiting compassion and advocacy.
Recognizing the social determinants of health
The TIP interprofessional teams collectively fostered a detailed approach to understanding the patient’s vulnerability, paying specific attention to the social determinants of health: “I do think we do a pretty good job of identifying those social determinants of health and those barriers in our discussions.” (MD09). Another participant stated: “Addressing the determinants of health is critical and we end up doing that.” (DM02).
Maximizing a collaborative interprofessional team approach
The collaborative nature of the team supported sharing ideas about how to overcome some of the barriers experienced by these patients and facilitated creative recommendations.
“This is a skill building exercise for all of us… the people who need our help, like people with complex care needs often are the ones with low SES, low health literacy, not speaking English etc. So maybe it means … let’s get creative.” (DM06).
Having the interprofessional healthcare teams physically together and sharing a collaborative focus on the patient supported system navigation was one approach: “Because I have got a lot of people around the table, we are able to kind of help them [patients] navigate through the health system a bit better.” (DM08). Some family physicians who referred to the TIP Program viewed the connections with the interprofessional team as extremely valuable for their vulnerable patients. “It would be great for that kind of vulnerable patient to have access to all these people, otherwise they might not be able to make those connections. So, if we can make those connections for them that’s great.” (RFP08).
In addition, many participants acknowledged the invaluable role played by team members representing social work and home care: “As physicians we have some knowledge of these resources but having a knowledgeable social worker is huge in terms of the actual nitty-gritty of who’s going to intervene at what time and where.” (MD09). Through the strong support of home care and social work, access to needed resources for these vulnerable patients could be expedited: “They can give them really specific resources that they can literally tap into the same day.” (HCP04). Social work and home care also helped the team in being realistic: “So they get us [the team] back on track when the recommendations are not financially feasible.” (HCP08)
Culture Sensitivity
Participants' responses reflected the teams’ cultural sensitivity and commitment to addressing specific cultural issues: “Cultural beliefs, I think the teams are all very sensitive to that so, we know that if we are dealing with a certain culture and their attitude towards medication or a certain treatment might be different we respect that and work around that.” (HCP15). When possible, teams made an effort to familiarize themselves with the patients’ cultural background: “I think when there are different cultures then we try to learn more prior to the session or we just ask the patient when we are in the session.” (HCP19)
Compassion and advocacy
Participants viewed the patients’ struggles of vulnerability through a compassionate lens: “People have often been minimally engaged for reasons beyond their control and now are really struggling often with difficulties as a result of that.” (HCP19). Participants acted as advocates for these vulnerable patients: “They don’t necessarily demand care, but we advocate this care for them because we see they are in need and if we don’t give it to them they will just keep on returning to the emergency room.” (MD10).
Overall, participants believed that the Program was specifically useful for vulnerable patients: “It opens up doors for the most vulnerable.” (HCP14). Another participant explained: “I would say those vulnerable populations are the ones who likely need our help most… it’s exactly what they need. If you do have a lot of bio-psycho-social challenges this is really the way that care would probably be best delivered.” (DM08). Participants noted how the main issues experienced by patients with multiple chronic conditions often had little to do with the medical comorbidities but rather with barriers outside of the medical model. Consequently, addressing these issues was frequently “The first step to that patient addressing their chronic illness.” (DM05). They described the Program as often being the first time patients experienced feeling heard: “I think a lot of them felt really heard and I have had a patient say directly to me ‘I am so glad you found me”. (HCP09).