Responding to vulnerable patients with multimorbidity: an interprofessional team approach

Area of Science:

• Healthcare delivery research
• Primary care innovation
• Patient-centered care

Background:

• Multimorbidity affects vulnerable populations, necessitating specialized care.
• Social determinants of health significantly impact individuals with multiple health conditions.
• Interprofessional primary healthcare (PHC) teams offer tailored approaches for complex patient needs.

Purpose of the Study:

• To describe how interprofessional PHC teams identify and care for vulnerable patients with multimorbidity.
• To explore innovative consultation models for addressing complex patient needs.
• To understand the role of PHC teams in managing patients facing healthcare system challenges.

Main Methods:

• Descriptive qualitative study design.
• Conducted 48 interviews with allied health professionals, physicians, and decision-makers.
• Utilized iterative thematic analysis for data interpretation.

Main Results:

• Vulnerable patients with multimorbidity face significant healthcare access and navigation barriers.
• Mental health issues and social determinants of health are key factors in patient vulnerability.
• Team collaboration fostered innovative recommendations tailored to individual patient needs.

Conclusions:

• The one-time consultation provided a psycho-social-contextual understanding of vulnerability.
• This approach extends beyond multimorbidity assessment to address holistic patient needs.
• Findings have implications for clinical practice and policy to support vulnerable patients.