The provision of comprehensive, integrated primary care for older adults living with multiple long-term conditions (MLTCs) presents significant challenges for both patients and healthcare providers. Juggling the complex care needs of individuals with multiple co-occurring chronic illnesses is time-consuming and often leaves little opportunity for meaningful patient engagement or shared decision-making.
However, a team of researchers in South Africa have developed an innovative clinical decision support tool – the ENHANCE guide – that aims to reshape the MLTC consultation experience. By consolidating evidence-based recommendations for the routine care of 11 common long-term conditions, the ENHANCE guide encourages a more streamlined, person-centred approach to managing the health of older adults.
Rethinking MLTC Care Through a Consolidated, Evidence-Aligned Approach
The ENHANCE study, funded by the UK’s National Institute for Health and Care Research, explores how to best support integrated clinical care for patients with MLTCs in low-resource primary care settings. A key component of the study is the development of the ENHANCE guide – a 40-page clinical decision support tool that covers the routine care of 11 common long-term conditions, including hypertension, HIV, diabetes, depression/anxiety, cardiovascular disease, stroke, epilepsy, asthma, COPD and chronic arthritis.
The guide was developed through a collaborative, stakeholder-engaged process that aimed to consolidate clinical content from the existing, evidence-based Practical Approach to Care Kit (PACK) guide. By combining recommendations for multiple conditions, the ENHANCE guide encourages clinicians to address a patient’s full health picture, rather than addressing each condition in isolation.
“The PACK guide is a comprehensive clinical decision support tool, but it still guides providers to address one condition at a time,” explains Ruth Cornick, a co-author of the ENHANCE study. “This can be onerous on providers and patients, as time is limited in busy primary care settings, and inefficient if certain assessment or treatment recommendations are repeated or incompatible across conditions.”
The ENHANCE guide tackles this challenge by integrating key screening, monitoring and health education activities that can be shared across a patient’s multiple long-term conditions. This streamlines the clinical workflow and empowers the broader primary care team – including nurses, community health workers and other providers – to support various aspects of MLTC care.
“The ENHANCE intervention aims to support integrated clinical care for multiple long-term conditions while encouraging task-sharing among the primary care team,” says Cornick. “This helps to lessen the clinician’s load and creates more opportunities for patient engagement and shared decision-making.”
Putting the Person at the Centre of MLTC Care
A key feature of the ENHANCE guide is its person-centred approach to the MLTC consultation. Rather than structuring the guide around individual conditions, the content is organized to encourage clinicians to first understand the patient’s priorities and concerns.
The guide includes a dedicated section on “identifying and addressing patient priorities” that prompts clinicians to explore five key issues with the patient at the start of the consultation: symptoms, medication adherence, social problems, mental health concerns, and substance use. This agenda-setting exercise empowers the patient to drive the discussion and ensures that their most pressing needs are addressed.
“We wanted to shift the focus away from a purely biomedical approach and give more agency to the patient,” explains Cornick. “By starting the consultation by exploring the patient’s priorities, we create an opportunity for shared decision-making and a more collaborative care experience.”
The guide also includes visual aids, such as icons representing each of the five priority areas, that can be used by clinicians to facilitate the agenda-setting discussion. A matching waiting room poster asks patients “What is the most important thing you would like to talk about today?”, further preparing them to participate actively in the consultation.
Beyond the initial priority-setting, the ENHANCE guide consolidates routine screening, monitoring and health education activities across conditions in a way that encourages clinicians to address the patient’s full health picture. For example, prompts to screen for common comorbidities or deterioration in known conditions are integrated throughout the guide, rather than being siloed by disease.
“We wanted to create a tool that would support a more holistic, integrated approach to MLTC care,” says Cornick. “By prompting clinicians to consider the patient’s complete health status – not just one or two conditions – we hope to foster a more person-centred consultation experience.”
Navigating the Complexities of MLTC Care
The development of the ENHANCE guide was not without its challenges. The research team grappled with the sheer volume of clinical content required to comprehensively address 11 long-term conditions, and had to carefully balance the need for detailed, evidence-based guidance with the imperative for a user-friendly, streamlined tool.
“Trying to distill all of that information into a concise, usable format was really difficult,” admits Cornick. “We had to make tough decisions about what to include and what to leave out, and there were tensions around prioritizing certain conditions or treatment approaches over others.”
The team also faced the challenge of ensuring that the guide remained firmly grounded in patient-centred principles, even as they worked to consolidate and streamline the clinical content. Navigating the potential disconnect between clinician and patient priorities was an ongoing consideration.
“Clinicians often have a biomedical focus and can be reluctant to deviate from evidence-based guidelines, even if those guidelines don’t fully align with what matters most to the patient,” explains Cornick. “We had to be really intentional about maintaining a person-centred approach throughout the development process.”
To address these challenges, the research team adopted a collaborative, stakeholder-engaged approach. They convened learning collaboratives, advisory boards, and lived experience groups to gather input from patients, community members, and healthcare providers at every stage of the guide’s development.
“Involving all of those stakeholders was critical,” says Cornick. “It helped us to balance the clinical content with the need for a user-friendly, patient-centred tool, and ensured that the final product would be truly responsive to the needs of both providers and patients.”
Expanding the Reach of the ENHANCE Guide
While the ENHANCE guide was developed specifically for the South African context, the research team believes that the methodology and principles underlying its creation could be applicable to other low-resource settings grappling with the challenges of MLTC care.
“There’s a real dearth of consolidated, person-centred clinical guidance for MLTC care, especially in primary care settings,” notes Cornick. “The ENHANCE guide provides a potential model for how to develop such tools in a way that is grounded in evidence, responsive to local needs, and centred on the patient experience.”
The team is currently evaluating the effectiveness of the ENHANCE intervention, which includes the guide as a key component, through a large-scale study in two South African provinces. If proven successful, the guide could be adapted and expanded to address additional long-term conditions, further enhancing its utility for clinicians and patients alike.
“Ultimately, our goal is to create a tool that can truly transform the MLTC consultation experience,” says Cornick. “By streamlining the clinical decision-making process and putting the patient at the centre, we hope to empower both providers and patients to engage in more meaningful, collaborative care.”
As the global population continues to age and the burden of chronic disease grows, innovations like the ENHANCE guide will become increasingly crucial. By rethinking how we approach the complexities of MLTC care, we can work towards a more clinically sound, person-centred model that better serves the needs of older adults and their healthcare providers.
