From Medscape Medical News http://www.medscape.com/viewarticle/718095?src=smo_tw_BUSI

New Model Addresses Caring for Patients With Multiple Chronic Conditions

Laurie Barclay, MD

March 8, 2010 — A new primary care practice model addresses the challenges of caring for patients with multiple chronic illnesses, according to a report in the March/April issue of the Annals of Family Medicine.
"These patients typically consult multiple clinicians, use multiple medications, and compared with patients with a single chronic illness, have higher psychological distress, longer hospital stays, increased use of emergency facilities, and higher rates of mortality," write Hassan Soubhi, MD, PhD, from the University of Sherbrooke in Chicoutimi, Quebec, Canada, and colleagues.
"Clinicians who care for them face competing demands, complexities of polypharmacy, difficulties in applying practice guidelines, and increased potential for errors. Clinicians also face increased diagnostic and treatment challenges as different combinations of conditions can interact in unpredictable ways."
Because of these challenges, primary care for patients with multiple comorbid conditions requires flexibility and ongoing coordination to ensure patient-specific care tailored to individual circumstances. The authors propose that communities of practice could facilitate delivery of complex yet flexible care, provided that the clinicians within these communities are willing to take the following steps:

Learn from their shared experience of success and failure.
Help one another accomplish their goals.
Promote ongoing learning within the community.

The study authors describe primary care in these communities as a complex adaptive process in which member clinicians learn to improve care through repetition. Specific strategies would include the following:

Defining common goals.
Creating care plans jointly.
Participating in reflective, case-based learning.

"As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions," the study authors write. "Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients."
Redesigning primary care practices based on a community of practice model would require optimizing the allocation of clinical responsibility in accordance with clinicians' knowledge base and training, support by senior leaders of community development and iterative change, and willingness to experiment with different payment models.
"Some of these changes are already underway in many practices, with the increasing incorporation of midlevel clinicians and use of small cycles of practice change," the study authors conclude. "To accelerate collective learning and the evolution of practices, there is a need for appropriate feedback mechanisms related to different payment modalities, eg, pay for performance, payment for complex patients' visits, care-coordination fees, and various incentives for knowledge production and sharing within and between primary care practices....Testing the added value of communities of practice in primary care remains an empirical issue worth exploring in future research."
Ann Fam Med. 2010;8:170-177.