Creating a service system architecture for people living with multiple long-term conditions

Area of Science:

• Health Services Research
• Systems Engineering
• Patient-Centered Care

Background:

• Effective management of multiple long-term conditions (MLTCs) is a growing challenge in healthcare.
• Current care models often struggle to provide integrated and holistic support for patients with complex health needs.

Purpose of the Study:

• To identify barriers and opportunities for improving the management of care for individuals with MLTCs.
• To propose a novel service system architecture for integrated MLTC care.
• To achieve improved health outcomes for patients with multiple chronic conditions.

Main Methods:

• A systems engineering approach was employed to understand stakeholder needs.
• Multimorbidity case studies and abductive analysis informed system design principles.
• Co-design workshops, including LEGO® Serious Play®, involved patients and service providers.

Main Results:

• Stakeholder needs were identified through metaphors highlighting issues with current care.
• Six key principles for designing MLTC services were established, focusing on user needs, mental health, costs, and integration.
• A blueprint for a service system architecture for MLTC care pathways was developed.

Conclusions:

• The proposed system architecture promotes greater equality and equity in healthcare.
• It offers a framework for delivering holistic MLTC care across diverse clinical specialties and disciplines.
• This integrated approach is expected to enhance patient outcomes and system efficiency.