Background
Methods
Design
Sample and setting
Recruitment
Data collection
Experiences in Supporting Older Adults to Manage Multiple Chronic Conditions | |
1. Tell me about your experiences in delivering care for older adults who have three or more chronic conditions. | |
2. How do you help them manage multiple chronic conditions? | |
3. How do you help older adults prevent their conditions from worsening or developing? | |
4. How do you make decisions about managing multiple medications? | |
5. What are the most important needs of family caregivers of older adults with multiple chronic conditions? | |
6. How do you support family members of older adults with multiple chronic conditions? | |
Facilitators in Managing Multiple Chronic Conditions | |
7. What resources help you to manage multiple chronic conditions among older adults (e.g., people, community services, and financial resources)? | |
Challenges in Managing Multiple Chronic Conditions | |
8. What is your greatest challenge in supporting older adults to manage multiple chronic conditions? | |
9. What makes it difficult to deliver care for them? | |
Health and Social Services | |
10. Do you refer older adults with multiple chronic conditions to any health and social services? If so, what are the services? | |
11. What mechanisms are in place to enhance collaboration and coordination of care among multiple providers, services, settings, and sectors? | |
Treatment Decisions | |
12. How do you make decisions about managing more than one chronic condition at a time? | |
13. How do you involve older adults and their family caregivers in making treatment decisions? | |
Goals of Care | |
14. What are your goals when caring for older adults with multiple chronic conditions? | |
15. How do you develop these goals? | |
16. What do you consider when developing these goals? |
Data analysis
Methodological rigour
Ethics
Results
Demographic characteristics
Category | n (%) |
---|---|
Sex | |
Female | 40 (95.2) |
Male | 2 (4.8) |
Age (years) | |
18–44 | 17 (40.5) |
45–64 | 25 (59.5) |
Province | |
Ontario | 22 (52.4) |
Alberta | 20 (47.6) |
Highest Education Completed | |
Secondary School | 1 (2.4) |
Diploma | 7 (16.7) |
Bachelor’s Degree | 17 (40.5) |
Master’s Degree | 7 (16.7) |
MD | 4 (9.5) |
Certificate | 6 (14.3) |
Professional Background | |
Exercise Therapist | 1 (2.4) |
Nurse Case Manager | 1 (2.4) |
Nurse Practitioner | 1 (2.4) |
Personal Support Worker | 6 (14.3) |
Pharmacist | 1 (2.4) |
Physician | 4 (9.5) |
Physiotherapist | 3 (7.1) |
Registered Dietitian | 1 (2.4) |
Registered Nurse | 12 (28.6) |
Registered/Licensed Practical Nurse | 7 (16.7) |
Speech Language Pathologist | 1 (2.4) |
Social Worker | 4 (9.5) |
Years of Experience in Current Role | |
0–5 years | 7 (16.7) |
6–10 years | 7 (16.7) |
11–15 years | 8 (19.0) |
16–20 years | 3 (7.1) |
20+ years | 17 (40.5) |
Work Setting | |
Primary Care | 20 (47.6) |
Home Care | 19 (45.2) |
Other (e.g., rehabilitation service, outreach clinic) | 3 (7.1) |
Themes
Themes | Sub-Themes |
---|---|
1. 1. 1. Managing the Complexity Associated with MCC | • Optimizing medication use: “simplify their dosing regimens” |
• Being proactive to promote health and prevent disease: “minimize the risk factors with lifestyle” | |
• Recognizing and addressing the interrelatedness of health and social conditions: “reducing the physical and social barriers” | |
2. 1. Implementing Person-Centred Care | • Individualizing care: “[care] catered to their individual needs” |
• Enhancing quality of life: “number one goal is to improve their quality of life” | |
3. 1. Supporting Caregivers | • Educating caregivers to support older adults with MCC: “it’s about education” |
• Providing support and services for caregivers: “linking caregivers to resources” | |
4. 1. Using a Team Approach for Holistic Care Delivery | • Collaborating with multiple disciplines to provide holistic care: “interdisciplinary collaboration is helpful and essential” |
• Encountering poor team communication: “information is not transferred in a timely fashion” | |
5. 1. Encountering Challenges and Rewards | • Facing challenges in caring: “the complexity in itself is more time consuming” |
• Reaping the rewards of caring: “seeing them stabilize or improve is always rewarding” | |
6. 1. 1. Recommending Ways to Address the Challenges of the Healthcare System | • Improving care coordination: “a more streamlined healthcare system” |
• Improving primary care: “longer more regular visits” | |
• Increasing home care supports: “they need more home care” |
Managing the complexity associated with MCC
(Dietitian 6).“…it becomes clear that compliance is an issue or there’s confusion about what they’re taking and they don’t understand, you know, what this medication is for, so they didn’t take it. I mean that happens a lot.”
(Physician 1).“I think it’s always a balance between over and under treating, certainly the frail elderly, we have to be careful about putting them on too many medications and then we actually cause more side effects that worsen their functional levels. But at the same time, you don’t want to under treat people who could benefit from medication.”
(Social Worker 30).“We find out financing; we find out when they’re really taking their medications, which ones are being skipped; then we will work with our wonderful pharmacist to see which other meds that we can get them on that are paid and we can try and simplify their dosing regimens.”
Being proactive to promote health and prevent disease: “minimize the risk factors with
(Nurse 12).“So things that we would do under the Chronic Disease Management Model may be refer them to an exercise specialist. Using the example of obesity, you say, “Can we refer you to an exercise specialist? Can we refer you to a dietitian?” And that way it’s not costing the patient any money; all they have to do is get themselves to and from the appointment. We find out, “Do you drive? If you don’t drive, here’s some resources that we have here.”
(Physician 11).“First of all, you want to ensure the person understands what their conditions are and so the more they understand it, hopefully the more ownership they’ll take over the condition and the better control they’ll have.”
(Physiotherapist 8).“I have a patient right now who was referred to me because of slight general mobility, she had pulled and hurt her ankle...and she has severe Alzheimer’s but she also has rheumatoid arthritis. So, just her husband...her spouse...and the caregiver stress that he has because there are certain things she can’t do and can’t manage because of the rheumatoid arthritis.”
(Social Worker 30).“But the honest truth is, to help their conditions from getting worse; it is usually, in our experience, helped by breaking their social isolation or by reducing the physical and social barriers to doing what they already know they should do. They already have very good information on what they should do but very often, they can’t do it. But they don’t want to tell the doctor that. “I can’t go out and buy this because I don’t have money for that,” or “I can’t go out and buy this because I don’t go out and buy anything anymore; it’s delivered.” So, it’s trying to reduce the physical and the barriers that they feel stigmatize them.”
Implementing person-centred care
(Speech Language Pathologist 2).“So, if somebody comes with multiple comorbidities…they’ve had a stroke, they have dementia, they have diabetes, there is an anxiety we’ll have to talk through it and say, “Okay, what’s at the front…what worries you the most?” And, we could get discussion from the patient, discussion from the family member and then determine what the issue is and what the goals are.”
(Nurse 25).“I offer them a bunch of options, whatever I can offer to them. I ask them to narrow it down and I give them my opinion which I think would be the best. And I’d say, “But the final decision is up to you, because if we offer you something that you’re not whole-heartedly wanting, then the chances of you continuing with that will be low, and we want to know that you [have] a care plan that’s going to work for you and you’re going to be happy with and you’re going to continue”
(Nurse 4).“I think optimizing their quality of life. Certainly we like to achieve the targets that our clinical practice guidelines suggest. But we always have to weigh that, you know, it’s quality over quantity in terms of years of life saved or what is the patient’s goal? It’s about what’s important to them.”
Supporting caregivers
(Nurse Practitioner 9).“They [caregivers] need education and support. It’s very valuable for them to understand the medications and understand how the medications work for their family member. For example, patients can quickly turn [for the worse] and we can have more problems if the patient continues to take the medication if they’re ill.”
(Social Worker 30).“So they need peer support but they also need respite. They need to be able to leave the person at home for seven or eight hours and go to their children or go and do whatever they want, so they need respite...not every day but for how often they want it, once every week, a four-hour block or twice a week.”
(Physiotherapist 8).“We have a long list of resources in the community that we can provide for them; Meals on Wheels, transportation issues, voluntary visitors, all of those things that can make their life a little bit easier. If there was, like a direct need...if the caregiver agrees to have the client go to an adult day program once or twice a week that will give them time to do their own thing; give them a break...in this area, like yoga or exercise and that type of thing...support groups, caregiver support groups.”
Using a team approach for holistic care delivery
“We have a good team kind of approach in that we all collaborate together and we come.together all in a day to work together and come up with kind of care plans and meet with the.family and the patient and the physician...and it truly is more of a team approach.”
Encountering challenges and rewards
“I think it’s allowing the patient to make bad choices...what we consider bad choices. Watching someone progress becomes a challenge. Watching someone losing their limbs one at a time becomes a challenge. When you try to do what you can but you know it’s ultimately the choices that people make; choices that we disagree with is really almost an ethical dilemma. So that is really hard. That would be our biggest [challenge].” (Nurse 12).
(Physiotherapist 27).“Family relations...sometimes you get a lot of guilt, you know, coming from the caregiver as, you know, “I can’t do it anymore and I just feel awful but I can’t do it.” And they’re crying and it’s overwhelming and I have to sit and I have to console. You cannot walk away from that personal, emotional situation; no matter how late you are, you cannot walk out the door.”
(Social Worker 30).“I have been talking with the [agency] on and on and on...they have no volunteers here for that so I can’t get anyone to go into his home and wheel him out the front door and down the street once a week. I can’t get anyone to do that. So then I figured I would advertise that, so those kinds of things are very frustrating for us when it sounds like we have all these resources...and I know I’ve said we have tons...but some of them are bare.”
(Exercise Specialist 7).“I get impact on people’s quality of life...oftentimes where I’m seeing them is they’re not able to do certain things, they’ve stopped doing things that they enjoy because of the physical and mental health issues or they’re finding things much harder to do than what they once did. And to be able to impact on that and give them a little bit of that back it adds to the quality of life and that’s meaningful to me.”
(Personal Support Worker 16).“The rewards are watching the improvements, if there’s any improvement at all in their condition. Restoring their confidence and dignity and their abilities to do as much for themselves as they can and stay in their own home. It’s hard to put into words.”
(Personal Support Worker 10).“I guess mostly comfort; making them feel comfortable in their own home; making them happy to see you; getting rid of uneasiness, because a lot of times especially at that age where less and less people are coming to visit them and what not; socialization; just improving their state of mind and physical comfort.”
(Nurse 4).“Getting their appreciation is always rewarding. Sometimes they even will appreciate as much as you calling to check in and see how things are going. For example, if they’ve recently started insulin, they enjoy that follow-up phone call and also the opportunity to ask questions.”
(Physician 18).“Sometimes they feel like they’re kind of getting ignored by the system a bit, I think. Like, they’re sort of getting left in the dust or they’re not as important anymore because they’re older and so, they’re very appreciative; they can be very appreciative. The family can be very appreciative, too.”
Recommending ways to address the challenges of the healthcare system
(Home Care Case Manager 19).“Definitely a more streamlined healthcare system. Like there’s a lot of hoops to jump through and papers to fill out and this person has to refer to this. Like it’s just not very easy for people to navigate. It’s just not an easy system and there’s a lot of wasted time with repeat assessments or two people doing the same job. It’s like a process that just makes the healthcare system not really time effective and cost effective. It’s a lot of wasted time.”
(Social Worker. 30)“The elder person or even the young senior, when they’ve got a whole bunch of things going on and they all meld together as they do, when they see the doctor or the nurse practitioner, even frequently once a month, they have a million things to tell them and for the doctor or the nurse practitioner, it’s overwhelming. And what we have certainly found works best is seeing.the elder once a week routinely, and addressing in small bits, their needs.”
(Nurse 20).“There’s so many medical conditions to look at and the visits, in order to service them properly I always feel the visits need to be much longer than is allotted to answer questions with very long answers to questions or lack of understanding of their diseases.”
(Home Care Case Manager 20).“It just seems we are always short-staffed, the caseloads sometimes are really high numbers. It’s hard to accommodate everybody’s needs in terms of agency services. I think we just need more people in the workforce with this aging population.”