Exploring how multimorbidity care is managed and coordinated for an older Irish population within formal healthcare organisational structures and within informal networks: Preliminary results from an Irish study
Orla Caffrey | Trinity College Dublin | Ireland
Mandy Lee | Trinity College Dublin | Ireland
Keywords: Multimorbidity; Hospital Networks; MDTs; Integrated Care; Ageing Population
Multimorbidity is the presence of two or more chronic conditions within one individual. Continuity of care, effective communication and collaboration between different healthcare professionals are important factors in providing timely and appropriate care to patients with multimorbidity. Current evidence shows these patients can experience disorganised, inappropriate and/or delayed care as a consequence of a fragmented health system organised to deliver episodic care for single conditions (“disease silos”) that can result in adverse outcomes and preventable healthcare costs for this patient group. Additionally, self-management of chronic conditions is increasingly advocated for this patient cohort. Yet research to date tends to focus on formal healthcare organisational structures. This study aims to address the gap in evidence of how multimorbidity care is shaped not just by formal healthcare organisational interactions but also by informal intra-organisational networks. This is achieved by adopting a SNA study design that utilises a socio-centric analytical approach.
A socio-centric SNA is performed on a sample of hospital clinicians and support staff involved in managing patients with rheumatoid arthritis, COPD and a third condition that is identified by the respondent. The survey instrument compared professional interactions that were expected for these patient cohorts against what actually occurred in clinical practice. The expected interactions were derived from recommended care pathways for each included condition found in the literature. Professional support network captures the type and frequency of professional interactions with one another through a self-administered survey. Key services involved in coordinating care for these cohorts. Gaps that impinge on integrated care are revealed for both cohorts. The SNA instrument used for the professional socio-centric analysis took many iterations to overcome software issues, boundary issues, multiplicity of health services and professionals involved and time restrictions due to the busy participants targeted to complete the survey instrument.
Recommended care will be compared to interactions that occur in practice for the patient cohort of interest. Visualisations and interpretations of metrics for the clinical networks captured will be presented as preliminary results from the above study.
This study adds to our knowledge about the intra-organisational networks involved in managing complex multimorbid patients who are aged 50 or over living in the community. The second phase of this study will gather information from patients aged 50 or over with at least three chronic conditions that included rheumatoid arthritis and COPD using an egocentric approach to explore how multimorbidity care is managed from a patient’s perspective through their family, community & clinical support networks. To understand what enablers and barriers exist in accessing care for multimorbid patients, factors influencing their healthcare access care will also be explored through the egocentric analysis. There is scope to extend this research by investigating inter-organisational networks or applying the methods used here to other geographic areas or to another multimorbidity cohorts in order to inform future strategies to improve how multimorbidity care is organised and coordinated.
The Impact of Networking on Multi-Source Feedback Assessments for UK General Practitioners: A Social Network Analysis
Sebastian Stevens | Plymouth University | United Kingdom
Multisource feedback (MSF) is a method of workplace-based assessment in which ratees are evaluated by their colleagues on key performance behaviours. MSF has been widely adopted within medicine to assess and quality-assure clinical practice worldwide. In the United Kingdom (UK), MSF forms a core component of the medical re-certification process, created to increase patient safety and ensure that all doctors ‘up-to-date and fit-to-practise’ and known formally as medical revalidation. Throughout the medical education literature, MSF is widely reported as being a feasible, reliable and valid method of assessing medical performance. However, a number of threats to the validity of the assessment process have been highlighted, rater selection being one highlighted area of concern.
Currently, the majority of MSF assessments for medical revalidation in the UK require the doctor (ratee) to nominate colleagues (raters) in order to provide feedback; however, research exploring the selection of raters in MSF assessments has demonstrated significant differences in the feedback results of ratee vs. third party nominated raters. After controlling for factors previously believed to affect differences in feedback provided by colleagues, Archer and McAvoy (2010: 891) highlight that the ‘practice of choosing one’s own raters is likely to lead to more favourable results’. No evidence currently exists however to understand why this phenomena occurs. Addressing barriers to the validity of MSF assessments within medical revalidation is critical in terms of the safety and quality of patient care. Using General Practitioners (GP) as a sample group, the study looks to explore whether friendship networks within primary healthcare teams may be a factor influencing the rater selection choices made by doctors in MSF assessments for medical revalidation.
A cross sectional, mixed methods design is adopted to explore the research problem. Friendship networks are measured with an online survey using name generators, distributed within recruited GP practices in the South West region of the UK. Rater selection choices are measured with archival MSF data provided on behalf of the GP by CFEP UK Surveys, a private company providing administrative support for appraisal. Together, this data is combined to explore the degree to which friendship networks within a healthcare team impact the rater selection choices made by GP’s, and the likelihood of replying to feedback requests by nominated colleagues. Descriptive network measures including density, centrality, betweeness, and in/out degree will be analysed, with ERGM’s employed to explore the patterns underlying possible relationships between social closeness and rater selection.
Results and Conclusion
This paper will disseminate the results of regional network study in the South West UK to demonstrate the extent to which friendship networks may influence the rater selection process, and how this problem may translate into the quality and safety of patient care.
Physicians knowledge-sharing and Multidisciplinary Tumor Boards (MTB)
Natalia Zlotnik | Albert-Ludwigs-Universität Freiburg | Germany
According to WHO cancer is the leading cause of death worldwide. In Germany, a National Cancer Plan was introduced aiming to establish a cross-sectoral, integrated oncological health care. One accomplishment was the foundation of a network of Comprehensive Care Centres (CCC). The mission of these CCC is to provide diagnostic and therapy for patients based on latest medical insights and to bundle the expertise and knowledge of all professionals across Germany. The compulsory requirement for the CCCs according to DKG (German Cancer Society) are multidisciplinary tumor boards (MTB) or multidisciplinary tumor conferences. MTBs are crucial instruments for treatment recommendations and decisions unifying heterogeneous expertise and allowing to learn from the experience of others.
As state-of-the-art cancer treatment can only be accomplished by knowledge sharing of experts interacting on multiple organizational levels, the aim of this study is to draw the structural patterns of interpersonal and intraorganizational knowledge sharing mechanisms in a CCC. We focus on tie formation between physicians engaged in cancer treatment, their affiliation to multidisciplinary tumor boards as membership ties and knowledge flow across tumor boards by uncovering formal and informal relationships. The effects of experts’ formal embeddedness in tumor boards and their informal knowledge-sharing behavior lead to implications for knowledge management in health care.
Data was collected on interpersonal knowledge exchange. Applying exponential random graph models for multilevel networks, we illustrate the interrelationship of physicians’ informal ties and their formal membership in multidisciplinary tumor boards.
We hypothesize a tendency toward reciprocity in knowledge-sharing networks among physicians who share membership in tumor boards and a tendency in physicians’ popularity as experts with increasing tumor board membership. Our results are meaningful to the extent that insights could serve to identify key knowledge-actors in order to transfer expertise across CCC network’s members.
Keywords: Tumor Boards, exponential random graph models, health care networks, knowledge sharing, multilevel networks
Caregiving family networks and their impact on balancing caregiving for a home-dwelling relative with dementia and requirements of the family- and work-life: a planned mixed methods study
Lydia Neubert | University Medical Center Hamburg-Eppendorf | Germany
Background: Family caregivers of people with dementia are faced with personal burden due to the caregiving responsibilities which affect not only the primary caregivers but also the whole family. Additional (economic) burden arises if the caregivers are employed. When considering the affected family as a network, it is evident that it plays a substantial role in bearing not only caregiving- but also other family- and employment-related responsibilities. In Germany, studies have examined these reconciled requirements from an ego-centered (i.e. often the primary caregiver) view so far. A mixed methods study is planned to provide first indications about the structure and functioning of caregiving family networks in dementia and their impact on reconciling informal caregiving with requirements of family and employment.
Methods: We plan to interview at least five caregiving family networks of a demented relative living at home. Each network will comprise 2-4 family members with written permissions. A mixed methods design will be developed combining qualitative and quantitative methods (QUAL+quan). Episodic, guided interviews will be interpreted by „Documentary Method of Interpretation“ to obtain insights into the experiences and actions of family caregivers, which will also enable the development of a network typology. This qualitative analysis will be supported by MAXQDA. The MAXQDA-feature “Stats” and IBM SPSS Statistics will be used to statistically analyze short, self-completed questionnaires to quantify the impact of caregiving on caregivers' personal life. This questionnaire will comprise the German version of the CarerQol-7D/-VAS, selected items of the Zarit Burden Interview (ZBI), the German version of the EuroQol (EQ-5D), the NEO-Five-Factors-Inventory (NEO-FFI-30), the German short-form of the perceived self-efficacy scale (ASKU), and the German version of the Proactive Coping Inventory (PCI). Results of both data sources will also be combined at the level of interpretation.
Results: Qualitative findings will provide insights into family networks’ structure and function by describing the caregiving role of each network member and the ties between them. Family caregivers will value how informal caregiving modified their lives given the fact that requirements of family and employment are also demanding. Furthermore, types of family caregiving networks will emerge. Measured in a validated manner, quantitative findings will be based on variables to quantify caregiver strain, self-perceived health, self-efficacy, and coping skills. These data will allow examining the relationship between caregiving burden and personal traits or coping skills compared between single network members or the types of caregiving networks.
Conclusions: This planned study will provide an in-depth understanding of caregiving for a demented relative from a family-oriented view. By interviewing different family network members, barriers and facilitators regarding the potential of caregiving family networks will be identified. Implications to support families in caregiving for a demented relative will be drawn.