Systems thinking approach to developing an integrated and patient-centred intervention model for multimorbidity care in primary care settings in India

Multimorbidity is the existence of multiple long-term mental, physical, and cognitive disorders in one patient. These could include diabetes, hypertension, lung diseases, heart attacks, stroke, kidney failure, and liver problems or other conditions. Multimorbid conditions can share common disease causes and consequences. The rate of multimorbidity is rapidly increasing in low resource countries (low and middle-income countries - LMIC) such as India. Importantly, multimorbidity leads to reduction in quality of life, increase in use of health services and reduction in life expectancy. However, in management of multimorbidity, it is often considered as an assortment of disconnected diseases. Hence patients with multimorbidity receive less than optimal care. A concerted effort from the health system for re-orienting the delivery of primary care is important in improving the quality of life of people with multiple chronic conditions. Our proposed study in primary care settings of Kerala, India will try to better understand the complexity of workforce strengths, system capabilities, human behaviours, link to social resources and their interactions most aptly framed from a health system perspective in developing an innovative and patient centred model for management of multimorbidity. We will adopt the following steps:
1. We will use different qualitative (discussions and observations) methods to investigate what is currently happening in our health facilities with services that multimorbidity patients receive. In this way we will understand the perceptions of health system managers, health care providers and patients in terms of the barriers and facilitators of provision of care for patients with multiple long-term (chronic) conditions.
2. We will identify successful models of interventions for managing multimorbidity in other settings by conducting a comprehensive review of available literature.
3. We will use this literature review and data from our research to develop context specific interventions for managing multimorbidity in primary care settings. Additionally, we will explore ways in which the care for people with multiple chronic conditions can be organised and integrated within the community through community health workers.
4. We will then use methods to visualise how different variables in a system are interrelated (causal loop model) and identify how changes in one variable affects others in the loop.
5. We will identify options for improving access to social resources (eg: accessibility for physical activity for females, rehabilitation services etc.,) for managing multimorbidity, which can then be incorporated into the intervention models developed in step 3 and 4.
6. Further, we will identify interventions that potentially have a more direct impact on patients, prioritise them and finalise them after incorporating comments from all stakeholders as in step 1.
7. Finally, materials and protocols will be developed for prioritised intervention items.
Optimal involvement of clinical and health system leadership, engagement of all potential stakeholders including patients in the intervention development are unique to this project. Finally, a detailed plan will be developed for formal evaluation of the developed intervention in a confirmatory study in future. The key lessons from this project may help to transform the current health-care delivery system into a patient-centered and coordinated system for managing multimorbidity in primary care.

We will directly build on and expand findings from two recently funded studies (year 2019-2020) from our group to assess the pattern and distribution of multimorbidity in Kerala, India. Our current proposal will use a systems thinking approach and causal loop model to conceptualise how health systems manage patients with multi-morbidity in primary health care settings in India. Evidence will be sought from the literature by conducting an updated systematic review on benefits of existing interventions for patients with multi-morbidity in LMIC. An interdisciplinary research team of health system researchers, epidemiologists, and social scientists will conduct the study in two phases: (1) Identification of potential interventions for managing multimorbidity in primary care and (2) development of the final intervention tools for integrated management of multimorbidity evaluation in a future study. In the first phase, potential interventions will be identified and proposed to address gaps in the current system from patients, providers and health system perspectives. A causal loop modelling will be employed to identify feedback loops and evaluate impacts of the potential interventions at the level of patients and care providers. We will also look into ways in which the care for people with multiple chronic conditions can be organised and integrated within the community through community health workers. In the second phase the causal loop analysis results will be linked to decision making on intervention implementation and appropriate tools for the intervention will be developed. The interventions will be informed by our previous work in the area of clinical handover, evaluation methods for complex health system interventions, and primary care coordination for global risk reduction in primary care settings in India. The developed intervention package and the tools for implementation will be piloted and evaluated formally in a future study.

The System thinking Approach for Multimorbidity (SAM) proposal addresses an innovative approach for development of an integrated intervention model for management of multimorbidity in primary care settings with potential high impact and scalability. It will generate new knowledge in the form of peer-reviewed publications and academic presentations in the following areas; (a) understanding and contextualising factors that act as barriers and facilitators of extending integrated care for management of multimorbidity for purposes of decision making for policy makers and planners, (b) the capacity to revisit the conceptual frameworks for health systems change in management of multimorbidity, and health provider behaviour change for India as an example of a LMIC and (c) example of utility of systems-thinking approach for health-care organization in LMIC to holistically understand the impact of various components of their primary care system in managing chronic conditions. In India, UK and internationally, academic impact will be significant as new knowledge is shared in publications and presentations, setting a new agenda for research in LMIC, since multimorbidity assessment and interventions have seldom been explored in LMIC.
SAM study will have direct societal and economic impact as it engages with various stakeholders and involves them in research. For example, SAM study results will impact vital areas of society by; (a) harnessing existing partnerships with government (Government of Kerala), (b) training relevant sectors of the healthcare workforce in research models as they participate, building upon collaborations with local self-governments and patient advocacy groups, (c) involving policy makers and managers in developing a governance model for collaborative primary care delivery, (d) engaging current electronic health data technology partners in ensuring clinical hand over and patient centred care, (e) empowering patients to co-design self-management options and (f) identifying other opportunities to improve access to social resources for continuity of care. The management strategies guided by the use of appropriate technology and non-physician health worker coordinated patient-centered care, may result in better future health for participants. As they participate in this research, primary care providers will experience improved teamwork and ability to contribute to a quality service improvement design. Improved systems for patient information transfer/communication within the primary care will make patient management easier in future, and potentially reduce inappropriate outpatient visits. Other, collateral benefits will include greater awareness of global risk reduction, improved quality of care, better handover (linked to patient safety), continuity and integration of care, creating a stimulus for auditing and strengthening of local health services capacity for in-depth research.
The findings from the qualitative modelling and analysis will provide the health system leadership in Kerala with insights into gaps in care and a way forward for implementing and evaluating interventions more successfully and effectively. Results of the study will be shared with other stakeholders (policy makers, clinicians, primary care physicians, patient advisory group etc) so that they may jointly influence the care delivery in primary care settings for management of patients with multimorbidity.
Finally, a detailed plan will be developed for formal evaluation of the developed intervention in a confirmatory follow-on evaluation study. If found useful in the confirmatory study, it may influence policy strategies in other state in India and it will become eligible to be adapted for incorporation into the ongoing National Programme for prevention and control of Cancer, Diabetes Cardiovascular diseases and Stroke (NPCDCS) in India. The model thus developed may be applied to even other low resource settings in LMIC.