Search results
The four systematic reviews [20, 23, 24, 27] identified 98 original studies. Fifty-two were included in the scoping review. Figure 1 shows the detailed flow chart of the selection process of the studies included in this scoping review.
The studies included were published between 1995 and 2015, 85% of them after 2000. Appendix 1 (see Additional file 1) provides details of the studies included. The studies included for each initial systematic review are identified by asterisks i.e. a (De Bruin); b (Smith 2012); c (Dwamena 2012); and d (Smith 2016). No duplicates were found among studies. Studies used quantitative or qualitative designs and were mainly from the United States, followed by Canada, United Kingdom and the Netherlands. All studies were published in English. Patients of the included studies were adults, mostly 50 years and older.
Interventions, elements of interventions and positive health-related outcomes
This scoping review identified seven types of interventions that could be further synthesized into three categories according to Smith et al. (2012;2016): patient-oriented interventions; professional interventions; and organisational interventions. The following section presents the three categories and seven types of interventions and their most important elements. Details and health-related outcomes linked to these elements are presented in Fig. 2.
Patient-oriented interventions
Providing a patient-centered approach
Providing a patient-centered approach was one of the most important interventions in terms of positive health-related outcomes for patients with chronic diseases. A total of 37 studies used patient-centered interventions to enhance health-related outcomes for patients with chronic diseases [31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67]. Elements of the interventions were grouped into eight sub-categories. Of these sub-categories, three were more common: 1) Performing regular face-to face clinical evaluations and follow-up [31, 34,35,36,37,38,39, 42,43,44,45,46,47,48, 50,51,52,53,54,55,56,57,58,59,60,61,62, 64, 67]; 2) Creating individualized and adapted interventions [31, 36, 38, 41, 44, 47, 48, 51, 55, 57, 58, 62, 64, 65, 67]; and 3) Considering family or relatives needs [34, 37,38,39, 42,43,44,45,46, 49, 50, 52, 55, 56, 60, 62, 66]. Performing regular face-to-face clinical evaluations and follow-up was undoubtedly the element most frequently found in the literature. For example, Wright et al. (2007) used nurse case managers to follow low-income elderly patients with chronic conditions and functional impairment at high risk for rehospitalization or nursing home placement. The nurse case managers were required to call or visit patients as needed to ensure that care plans were implemented. They also accompanied patients to their healthcare visits if necessary [62]. Several studies also highlighted the importance of adapted and individualized interventions; an example being Dorr and al. (2006) who implemented a Chronic Care Model-based program including care managers located within multiplayer primary care clinics collaborating with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. One element of the intervention was the creation of an individualized care plan structured to reflect patient needs, specific conditions, personal challenges and goals [40]. Eakin et al. (2007) went one step further and included family and relatives needs’ in an individualized and culturally-adapted care plan in a program enhancing self-management with patients with multiple chronic diseases [44].
Supporting patient self-management
Self-management support interventions were included in 37 studies [25, 33, 35, 36, 38,39,40,41,42,43,44,45,46,47,48, 50,51,52,53, 55, 57, 58, 60, 61, 64,65,66,67,68,69,70,71,72,73,74,75,76]. The most frequently reported element was Providing educational resources and skills [40, 44,45,46,47,48, 51, 53, 57, 64, 65, 67, 69,70,71,72, 76]. This element was the basis for the majority of the self-management support interventions that could be done during individual or group meetings. For example, Ory et al. (2013) implemented a Chronic Disease Self-Management Program (CDSMP) among a national sample of patients with chronic diseases to improve patient health, healthcare services and healthcare utilization [72]. More specifically, this program supported patients by integrating small group workshops lead by peer leaders and face-to-face self-management meetings. Katon et al. (2010) preferred to use a 12-month individual follow-up with nurses in collaboration with primary care physicians [48]. The self-management intervention combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia [48]. Another example, not frequently found in literature, was a participatory approach to use empowerment strategies designed to promote positive attitudes, knowledge and skills to maintain and to enhance health, self-efficacy and patient participation. This approach with patients seemed to be a relevant and innovative element to consider. [53]
Professional interventions
Developing training for healthcare providers
Supporting healthcare providers (HCP) through appropriate training was one of the most popular interventions in the literature associated with positive health-related outcomes. This scoping review found 34 studies reporting this intervention as an effective approach for people with multimorbidity [31,32,33, 36, 40, 41, 43, 46, 48, 52,53,54,55, 57, 58, 60, 62,63,64,65,66,67,68,69, 73,74,75, 77,78,79,80,81,82,83]. Adapting training to patient and program needs was the most frequent element found in 10 studies [32, 33, 36, 40, 41, 43, 58, 62, 64, 65, 77, 82]. For example, many studies in this category included comprehensive training for the healthcare professional to act as care manager [41, 58, 68]. Trainers providing feedback to HCP was also relevant to maximising impact on the patient health. [46, 48, 53, 64, 78, 80]. Among the six studies referring to this element, Gitlin (2006) described a process where the provider submitted taped treatment sessions to the investigators for review, received feedback and improved the intervention. The use of technology was also mentioned by others [32, 78, 80, 82]. Finally, three studies reported that the progressive integration of case/care manager in the clinical setting [32, 33, 40, 41, 53, 77] was having an impact on patient health-related outcomes and was appreciated by healthcare providers. For example, Boyd (2008) highlighted the success of involving the guided care nurse in a 3-month integration process into the practice through working with two physicians. This progressive integration into the work flow of the practice allowed to resolve problems and was essential to developing effective teamwork.
Organisational interventions
Enhancing interdisciplinary team approach
Enhancing interdisciplinary team approach was the object of 24 studies [25, 34, 38,39,40,41,42,43, 48, 50, 51, 53,54,55,56, 58, 59, 61,62,63,64, 67, 74, 76]. Some of them highlighted the relevance of performing frequent team meetings [37, 43, 50, 51, 55, 58, 59, 76]. One particular aspect was including the patient in the team [50, 54, 56]. Patients were then involved in the different steps of their care. By being part of the process, their expectations were considered and the providers were able to personalize and maximize their approach. Four studies reported on the use of co-located teams and stressed the importance of supporting them [34, 37, 40, 43]. A typical organisation was an interdisciplinary team clinic including several healthcare professionals working together for a common group of patients.
Supporting the decision-making process and evidence-based practice
Supporting the decision-making process and evidence-based practice were included in 19 studies [32, 40, 41, 44, 47, 48, 54,55,56, 59, 60, 62,63,64, 69, 71, 75, 78, 79]. The development, the integration and the use of clinical guidelines, algorithms and decision support tools were the most frequently cited element [32, 40, 41, 44, 47, 48, 54,55,56, 59, 60, 62,63,64, 69, 71, 78, 79, 81]. For example, in a study to evaluate the efficacy of a nurse-care management system designed to improve outcomes in patients with complicated cases of diabetes, Taylor et al. (2003) specified that nurse-care managers used treatment algorithms developed by the Kaiser Permanente Medical panels based on national guidelines to titrate patient medications for diabetes, cholesterol, and hypertension [60]. Dorr et al. (2006), for their part, offered a clear evidence-based job description to facilitate the care manager’s integration and role development inside a co-located interdisciplinary team clinic for patients with multimorbidity. They also referred to protocols to help healthcare providers plan and coordinate care for patients with chronic diseases.
Providing case/care management
Including case/care management interventions in programs for patients with multiple chronic diseases was an innovative aspect found in literature but not frequently. Nineteen studies presented case/care management elements in their intervention. They were all published after 2003 [32, 34, 35, 38, 39, 41,42,43, 49, 50, 53,54,55,56,57, 62, 64, 67, 76]. The most important element found was the coordination of healthcare providers, care and services [20, 32, 38, 39, 42, 43, 53, 55, 57, 62, 64, 67, 76]. Douglas et al. (2007) provided a rich example of an inclusive case/care management intervention [42]. Advanced practice nurses had to coordinate follow-up services for patients, facilitate communication among patient families and healthcare providers, and provide supportive services for family members after hospital discharge [42]. The timeline for the follow-up varied greatly among interventions. For some, follow-up was maintained indefinitely [34, 54]. For most of the studies, the follow-up ended when patient objectives were reached [35, 38, 39, 41,42,43, 49, 50, 53, 55,56,57, 62, 64, 68, 76].
Integrating information technology
The use of information technology was included in 13 studies [32, 35, 40, 41, 49, 52, 54, 56, 63, 66, 76, 81, 82]. Using electronic medical records with system reminders and alerts was the most recurrent element [40, 41, 52, 54, 56, 63]. For example, Dorr et al. (2006) found that a comprehensive and locally developed electronic health record system with reminders and notes available to all clinicians had a positive impact on patient health. Finally, the last element found was the use of home telehealth [35, 49, 52, 56, 76]. Liddy et al. (2008), found that tele-homecare units installed in patient homes by nurse practitioners and a pharmacist had a positive impact on patient health. Using instructions integrated into individualized care plans, the participants of this study, with the support of a nurse practitioner, learned to use the units and peripheral devices in order to enter daily physiological values that were sent to a secure internet application allowing access to HCP. The technology was described as user-friendly by caregivers and patients and found to be useful in reducing the number of office visits while improving the tracking of patient health.