Joint medical appointments: a sustainable way of optimising care for adults with multimorbidity?

Asuka Leslie's picture

Welcome to my first blog as one of the Royal College of Psychiatrists’ Sustainability Scholars of 2016-17! In this post I’ll be focusing on joint medical appointments as a sustainable way to optimise care for adults with multimorbidity.

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Introduction
Multimorbidity is defined as “the presence of two or more long-term health conditions, which can include:
• defined physical and mental health conditions such as diabetes or schizophrenia
• ongoing conditions such as learning disability
• symptom complexes such as frailty or chronic pain
• sensory impairment such as sight or hearing loss
• alcohol and substance misuse” (1).

Management approaches have traditionally been single-condition-focused, but this approach no longer meets the needs of the population that we serve, as reflected in the findings of a large, representative cross-sectional survey using data from 314 Scottish medical practices where 54·9% had multimorbidity and 19·8% had physical and mental health comorbidity (2).

NICE published guidelines last month to help clinicians better assess and manage multimorbidity, looking mainly at reducing treatment burden, in the form of polypharmacy and multiple appointments, and unplanned care (1). Discussions around how clinical services and practice could be adapted to reduce treatment burden represents an opportunity to think sustainably.

Joint medical appointments
NICE recommends the prioritising of appointments but goes further in their BMJ article summarising the new guidance, suggesting that in putting the guidelines into practice the “combining [of] appointments that may previously have been conducted separately” is considered (3).

So let’s think about an actual example. According to the above study, among patients with depression, 23% have hypertension and 27% have a painful condition (2). If this patient was under the care of secondary psychiatric services and had a care co-coordinator, they would see a psychiatrist at least twice a year. If they were receiving specialist input into their hypertension and painful condition, then they would see their relevant specialist at least once a year, making a total of at least 4 appointments year.

Sustainability
The combining of appointments aligns with the principles of sustainable clinical practice, particularly lean systems and low carbon alternatives. By having one joint appointment a year and cutting the total number of appointments by half we could reduce the:

1. Number of journeys made by the patient
2. Number of journeys made by administrative and nursing staff
3. Amount of electricity and gas used to light and heat the clinic space

I foresee other benefits. Joint appointments would trigger discussions around interactions between different medications and rationalising of medication. Both patient and clinician could gain a better understanding of how the patient’s comorbid conditions impact on each other. In being able to have a dialogue with one another with the patient present, we would reduce duplication and foster cross-specialty learning.

I envision this leading to both increased patient and clinician satisfaction. Thinking specifically about the population I work with, joint appointments with my medical and surgical colleagues could help to reduce stigma around mental health and improve the physical healthcare of patients with mental health conditions.

In a 2013 systematic review and synthesis of qualitative research, general practitioners identified disorganisation and fragmentation of care and barriers to shared decision-making as two of the four key areas whey the encounter difficulties manging patients with multimorbidity (4). Joint appointments in secondary care could go some way to ameliorate this.

References
1. National Institute for Health and Care Excellence. Multimorbidity: clinical assessment and management. London: NICE; 2016. p. 13.
2. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet. 2012; 380:37-43.
3. Farmer C, Fenu E, O’Flynn N, Guthrie B. Clinical assessment and management of multimorbidity: summary of NICE guidance British Medical Journal. 2016; 354:i4843.
4. Sinnott C, Mc Hugh S, John Browne J, Colin Bradley GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. British Medical Journal. 2013;3:9.

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In my next blog post, I’ll be feeding back from the ‘Transforming Mental Health and Dementia Provision with the Natural Environment’ conference on 10th November 2016, hosted by Natural England and organised by The Centre for Sustainable Healthcare.Tickets are still available here:
https://www.eventbrite.co.uk/e/transforming-mental-health-and-dementia-provision-with-the-natural-environment-tickets-26751465353

Comments

Hi Asuka, very interesting

David Gregory's picture

Hi Asuka, very interesting post. They all seem to be realistic benefits too, and may even cut down on DNA rates if peoples community care is simplified - which again would increase efficiency of the whole system.

 By 'joint appointment' do they mean between primary and secondary care, or also between two separate secondary care specialties if needed? I imagine the latter may have more logistical problems but still feasible.

There is really good evidence for joint working between primary and secondary care. The Connecting Care 4 Children programme www.cc4c.imperial.nhs.uk is well worth a look.

Also here in Brighton primary mental health services we have a number of new services being developed based along a consultation-liaison or collaborative care design - both of which bring secondary care expertise into GP practices. The recent Cochrane reviews support these models, particularly for depressive and anxiety disorders.

http://www.cochrane.org/CD007193/EPOC_consultation-liaison-primary-care-appears-improve-mental-health-practice-and-outcomes-people-mental

http://www.cochrane.org/CD006525/DEPRESSN_collaborative-care-for-people-with-depression-and-anxiety

Looking forward to hearing about the natural environment conference!

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