Multimorbidity, which is the co-occurrence of several diseases in one person, has become a challenge in our western societies and even more health professionals are looking for innovative solutions to better address patients' needs through a "patient-centered" approach which takes into account the person in his/her complexity and context, rather than focusing on single diseases in the current "silo" manner. The Potku project, in Finland, is a pilot experience which has tested new ways of addressing chronic diseases, and in particular multimorbidity. Could you explain the most innovative elements of this initiative?
Erja Oksman, project manager Potku: What I myself consider most innovative of the Potku project, is that we developed not just one intervention, but a comprehensive set of interventions to make changes in different aspects of the way chronic illness care is provided at a regional level in Finland. From our previous experiences, we had learned that it is not enough to make changes in just one or two aspects, but that real improvements could only be achieved, if we organised chronic illness care in a totally different way. What was very helpful in this respect, is that we could build on a strong conceptual model to guide the development of new care processes and the supportive tools. This was the Finnish Health Gain model, which has been adapted from the well-known Chronic Care Model developed in the USA. Based on this model, developmental groups consisting of care professionals from different disciplines together with patient representatives developed a new model to provide chronic illness care with teams of primary care doctors and nurses being together responsible for the care and support provided to individual patients. Together with the patient, a Health and Care Plan was developed based on the comprehensive needs of the patient and his or her preferences and (self-management) competencies. In this way we made sure that the care provided by the health centers was really patient-centered and tailored to the needs of each individual patient.
Mieke Rijken: As part of the EU-funded ICARE4EU-project (Innovating care for people with multiple chronic conditions in Europe; www.icare4eu.org), I was part of a team that made a site visit to Finland to study the Potku-project and talk with the management, primary care physicians, nurses and a representative of a patient family organisation involved in the project. What I personally consider the greatest strength of Potku is its so-called whole system'-approach: all interventions that have been developed are related and together form a strong basis to deliver better chronic illness care in a primary care setting. Potku was not designed to focus on multi-morbidity in particular, but given its emphasis on patients' individual preferences and priorities to guide decision-making regarding the care process and the comprehensiveness of the care and support provided, I believe that this project may respond very well to the needs of people with multi-morbidity.
What are the successes encountered by patients and health professionals?
Erja Oksman: The use of Health and Care Plans (HCPs) appears to be very effective: chronic disease patients whom had an HCP developed together with their nurse and doctor experienced a better quality of care than similar patients without such a plan. In the project such HCPs were developed for about 16,000 patients. Also the primary care providers involved in the project reported that the care improved in many ways. And although the Potku-project was not primarily aimed to reduce healthcare utilisation or costs, it seems very likely that it has achieved such aims as well. At least for the use of primary care services, we have seen significant reductions in the number of (both planned and unplanned) visits to physicians and nurses, and the largest decreases were seen among the heavy users. What did increase were the number of phone calls to the nurses, but this may reflect a substitution to less expensive care.
Mieke Rijken: A key lesson that I learned from the Potku-project is that improving patient-centeredness does not necessarily imply that physicians or nurses spend more time on chronic disease patients. Initially it might take more time to develop an HCP with a patient, but this investment will often be compensated by less (unplanned) visits to the health centre at a later stage.
What are the limits and aspects that should deserve higher attention to improve the project?
Erja Oksman: Potku has finished as a project in 2014. The fact that it had been entirely embedded in regular' primary care increases the likelihood that also after the financing of the project has stopped primary care teams will continue to work according to the new approach. Nevertheless we see that the extent to which the health centers continue to work in this way varies depending on the leadership of a health center's management. Some health centers have structurally changed their delivery process, whereas this is less the case in centers where the management did not actively support such changes. We also see that the collaboration between the health centers has become less intensive, now that the project financing has stopped. Other innovations have however continued, such as the collaboration between health centers and local patient associations.
Mieke Rijken: Looking at the project from outside, I think that the collaboration between primary care and specialised (hospital) care needs further attention. In the Potku-project a more integrated provision of primary care and hospital services was incidentally realised, based on the efforts of individuals. For a subgroup of the total population of multi-morbidity patients, the people with the most complex needs, further integration of primary care and specialised care, but also collaboration with social care services is needed.
Erja Oksman: That is why we started a new project this year, called Parempi Arki (Better everyday life). This project specifically focuses on the people who are in need of both healthcare and social care. The idea is to better identify these people at a local level and to develop an integrated Health and Social Care Plan (HSCP) with these people, starting from their comprehensive needs for care and support and involving all care services and sectors that provide services tailored to these needs.
Which advices would you give to other European contexts and health professionals willing to take inspiration from your experience?
Erja Oksman: I could mention so many things, but may be the most important message I could give is to start from a solid conceptual framework, when developing patient-centered care for people with chronic conditions or other complex needs. From a management point of view, you can always lean on such a framework or model, when developing innovations or to motivate participants in this process. And when I talk about participants, I mean all stakeholders: managers of health centers or other care organizations, care providers and patients or their representatives. Developing together and using a PDCA cycle, with continuous evaluation of the processes, also helps very much to decide on the next steps in such complex processes together with all participants.