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

多病是指一个患者长期存在多种精神、身体和认知障碍。这些疾病可能包括糖尿病、高血压、肺病、心脏病、中风、肾衰竭、肝脏问题或其他疾病。多种疾病可能有共同的病因和后果。在印度等低资源国家（低收入和中等收入国家- LMIC），多重发病率正在迅速上升。重要的是，多重发病导致生活质量下降、保健服务使用增加和预期寿命缩短。然而，在多病的管理中，它通常被认为是一系列不相关的疾病。因此，患有多种疾病的患者得到的护理少于最佳护理。卫生系统协同努力重新确定初级保健的提供方向，对于改善多种慢性病患者的生活质量非常重要。我们建议在印度喀拉拉邦的初级保健机构进行研究，将试图更好地理解劳动力优势、系统能力、人类行为、与社会资源的联系及其相互作用的复杂性，最恰当地从卫生系统的角度出发，开发一种创新的、以患者为中心的多病管理模式。我们将采取以下步骤：我们将使用不同的定性（讨论和观察）方法来调查我们的卫生机构目前为多病患者提供的服务。通过这种方式，我们将了解卫生系统管理者、卫生保健提供者和患者在为患有多种长期（慢性）疾病的患者提供护理的障碍和促进因素方面的看法。2. 我们将通过对现有文献的全面回顾，确定在其他环境中管理多病的成功干预模式。3. 我们将利用这篇文献综述和我们研究的数据来制定针对初级保健机构管理多病的具体干预措施。此外，我们将探索如何通过社区卫生工作者在社区内组织和整合对多种慢性病患者的护理。4. 然后，我们将使用方法来可视化系统中不同变量是如何相互关联的（因果循环模型），并确定一个变量的变化如何影响循环中的其他变量。5. 我们将确定改善获得社会资源的选择（例如：女性体育活动的可及性、康复服务等），以管理多重疾病，然后将其纳入步骤3和4中制定的干预模式。6. 此外，我们将确定可能对患者产生更直接影响的干预措施，对其进行优先排序，并在纳入步骤1中所有利益相关者的意见后最终确定它们。7. 最后，将为优先干预项目制定材料和方案。临床和卫生系统领导的最佳参与，包括患者在内的所有潜在利益相关者参与干预措施的制定是本项目所独有的。最后，将制定详细的计划，以便在未来的验证性研究中对已开发的干预措施进行正式评估。本项目的主要经验教训可能有助于将目前的卫生保健提供系统转变为以患者为中心的协调系统，以管理初级保健中的多种疾病。

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.