As healthcare systems worldwide grapple with the growing burden of multiple long-term conditions (MLTCs), a paradigm shift is underway to provide more streamlined, person-centred care. Recognizing the complexities faced by both patients and providers, a dedicated team at the Knowledge Translation Unit (KTU) in South Africa has embarked on a groundbreaking initiative to revolutionize the way clinical decision-making is approached for those living with MLTCs.
Navigating the Challenges of Multimorbidity
The care of individuals with MLTCs is a daunting task, often denying them the agency to effectively self-manage their conditions while overwhelming the clinicians tasked with providing comprehensive, coordinated care. Typical clinical practice guidelines, focused on single disease states, fall short in guiding providers through the intricate web of symptom overlap, medication interactions, and differing treatment thresholds that characterize multimorbidity.
“The clinician’s workload is similarly overwhelming,” explains Ruth Cornick, Head of Knowledge Translation at the KTU. “Time-constrained primary care consultations struggle to address the multitude of screening, monitoring, and health education activities required for effective MLTC management.”
Recognizing this pressing need, the KTU embarked on a journey to reconfigure their established, evidence-based Practical Approach to Care Kit (PACK) – a clinical decision support tool used in primary care across low-resource settings. The result is the ENHANCE guide, a consolidated, person-centred approach to streamlining MLTC consultations.
Consolidating Clinical Guidance for a Seamless Patient Journey
The ENHANCE guide consolidates recommendations for 11 of the most common long-term conditions in South Africa, including hypertension, HIV, diabetes, depression, cardiovascular disease, and chronic respiratory conditions. By integrating this comprehensive content, the guide places the patient at the centre of their care journey, shifting the burden of screening, monitoring, and health education more equitably among the primary care team.
“Unlike most clinical guidance, the ENHANCE guide follows a symptom-based approach,” explains Cornick. “This encourages patients to set the agenda, identifying their top priorities for the consultation, rather than the clinician simply addressing one condition at a time.”
The guide features a user-friendly format, drawing on the trusted design elements of the PACK brand. Key components include:
- Agenda-Setting: A discussion tool using simple icons to prompt patients to share their top concerns, such as symptoms, medication adherence, social issues, mental health, or substance use.
- Comprehensive Screening: Consolidated examination and investigation recommendations to identify comorbidities or deterioration in known conditions, streamlining the routine check-up process.
- Integrated Treatment Guidance: An overview of pharmacological and non-pharmacological management for each condition, along with a medication table outlining prescribing considerations.
- Referral and Linkage to Care: Prompts to engage the broader primary care team and community resources to support the patient’s MLTC journey.
Navigating the Complexities of MLTC Care Development
The development of the ENHANCE guide was no easy feat, as the KTU team navigated the intricate challenges of consolidating clinical content for multiple long-term conditions. “A key challenge was sifting through the large volume of clinical content to produce guidance that addresses the complexity of multimorbidity safely, while remaining usable at the point of care,” Cornick shares.
The team adopted a coproduction approach, engaging a diverse range of stakeholders – from clinicians and policy-makers to patients with lived experience of MLTCs. This collaborative process highlighted the tensions inherent in prioritizing one condition over another, balancing curative and preventive treatment, and navigating the trade-offs between pharmacological therapies and advice-giving.
“Attempting to adopt a coproduction approach to the guide’s development strengthened the process and the end product, by ensuring key decision-maker input, alignment with policy, and drawing on the knowledge and experience of both patients and providers,” Cornick explains. “However, it presented its own challenges, as time pressures and competing priorities meant variable engagement from stakeholders.”
Towards a Future of Streamlined, Person-Centred MLTC Care
The ENHANCE guide represents a pioneering step in addressing the pressing need for consolidated, person-centred clinical decision support for MLTC care in low-resource settings. By drawing on the robust evidence and policy alignment of the PACK guide, the KTU team has created a tool that could significantly augment the response to the MLTC burden in South Africa and beyond.
“To our knowledge, there is no other clinical guidance available that provides detailed clinical decision-making support for an MLTC consultation in an LMIC primary care setting,” Cornick notes. “The ENHANCE guide combines features that may be key elements to support clinicians and patients: its comprehensive content is integrated for 11 conditions that contribute to common MLTC clusters, it provides a person-centred structure that encourages priority-setting with the patient, and it is policy-aligned and tailored to be integrated alongside other health system initiatives.”
As the ENHANCE study progresses, the effectiveness of the guide will be rigorously evaluated, assessing its impact on the detection and management of comorbidities, health-related quality of life, healthcare utilization, and costs. If proven successful, the ENHANCE guide could serve as a blueprint for expanding the clinical decision support offerings to address the growing challenge of multimorbidity in low-resource settings worldwide.
“Further work is needed to limit the volume of recommendations in the ENHANCE guide to allow clinicians and patients to focus on patient priorities and the key activities that mitigate the impact of the person’s MLTCs,” Cornick acknowledges. “But the potential of this tool to transform MLTC care is undeniable.”
Through the ENHANCE guide, the KTU is pioneering a new era of clinically sound, person-centred care that promises to empower both patients and providers navigating the complexities of multiple long-term conditions. As healthcare systems strive to deliver integrated, holistic support, the ENHANCE guide stands as a shining example of what can be achieved when clinical expertise, policy alignment, and patient-centricity converge.
