Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 17177, Stockholm, Sweden.
Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden.
BMC Fam Pract. 2020 Nov 17;21(1):233. doi: 10.1186/s12875-020-01290-y.
Multimorbidity, the co-existence of two or more chronic conditions in an individual, is present in most patients over 65 years. Primary health care (PHC) is uniquely positioned to provide the holistic and continual care recommended for this group of patients, including support for self-management. The aim of this study was to explore professionals', patients', and family caregivers' perspectives on how PHC professionals should support self-management in patients with multimorbidity. This study also includes experiences of using telemedicine to support self-management.
A mixed qualitative method was used to explore regular self-management support and telemedicine as a tool to support self-management. A total of 42 participants (20 physicians, 3 registered nurses, 12 patients, and 7 family caregivers) were interviewed using focus group interviews (PHC professionals), pair interviews (patients and family caregivers), and individual interviews (registered nurses, patients, and family caregivers). The study was performed in urban areas in central Sweden and rural areas in southern Sweden between April 2018 and October 2019. Data were analyzed using content analysis.
The main theme that emerged was "Standing on common ground enables individualized support." To achieve such support, professionals needed to understand their own views on who bears the primary responsibility for patients' self-management, as well as patients' self-management abilities, needs, and perspectives. Personal continuity and trustful relationships facilitated this understanding. The findings also indicated that professionals should be accessible for patients with multimorbidity, function as knowledge translators (help patients understand their symptoms and how the symptoms correlated with diseases), and coordinate between levels of care. Telemedicine supported continual monitoring and facilitated patient access to PHC professionals.
Through personal continuity and patient-centered consultations, professionals could collaborate with patients to individualize self-management support. For some patients, this means that PHC professionals are in control and monitor symptoms. For others, PHC professionals play a less controlling role, empowering patients' self-management. Development and improvement of eHealth tools for patients with multimorbidity should focus on improving the ability to set mutual goals, strengthening patients' inner motivation, and including multiple caregivers to enhance information-sharing and care coordination.
多种疾病共存，即一个人同时患有两种或两种以上的慢性疾病，这种情况在 65 岁以上的患者中较为常见。基层医疗保健（PHC）在为这组患者提供整体和持续的护理方面具有独特的优势，包括对自我管理的支持。本研究的目的是探讨专业人员、患者和家庭照顾者对 PHC 专业人员应如何支持患有多种疾病的患者进行自我管理的看法。本研究还包括使用远程医疗支持自我管理的经验。
采用混合定性方法探讨常规自我管理支持和远程医疗作为支持自我管理的工具。共有 42 名参与者（20 名医生、3 名注册护士、12 名患者和 7 名家庭照顾者）接受了焦点小组访谈（PHC 专业人员）、配对访谈（患者和家庭照顾者）和单独访谈（注册护士、患者和家庭照顾者）。研究于 2018 年 4 月至 2019 年 10 月在瑞典中部城市和南部农村地区进行。使用内容分析法对数据进行分析。
出现的主要主题是“站在共同立场上实现个性化支持”。为了实现这种支持，专业人员需要了解自己对谁承担患者自我管理的主要责任的看法，以及患者的自我管理能力、需求和观点。个人连续性和信任关系促进了这种理解。研究结果还表明，专业人员应该为患有多种疾病的患者提供便利，充当知识翻译（帮助患者了解自己的症状以及症状与疾病的相关性），并协调各级护理之间的关系。远程医疗支持持续监测并促进患者与 PHC 专业人员的联系。
通过个人连续性和以患者为中心的咨询，专业人员可以与患者合作，实现自我管理支持的个性化。对一些患者来说，这意味着 PHC 专业人员可以控制和监测症状。对其他患者来说，PHC 专业人员的控制作用较小，增强了患者的自我管理能力。为患有多种疾病的患者开发和改进电子健康工具应侧重于提高设定共同目标的能力，增强患者的内在动机，并纳入多个照顾者，以加强信息共享和护理协调。
