Mobilising tacit knowledge to improve care for older patients with multi-morbidityRichard Lilford and Gill CombesTheme 4

15/04/2023

Background

65% of 65-84 year olds and 81.5% of 85+ year olds have multiple long-term conditions.(1)

Multi-morbid patients have higher mortality than expected from summing the effects of individual diseases. (2)

Good quality care for multi-morbid patients requires coordinated patient-centred care.

BackgroundCare is often sub-optimal:

- Patients report: repeated assessments and clinical tests; fragmented care; conflicting advice; polypharmacy; and difficulties navigating pathways.

- Many patients require multiple individuals to contribute to their care: hospital specialists, GPs, nurse practitioners, pharmacists, social workers and voluntary service workers.

- Professionals often work in silos or experience organisational barriers to multidisciplinary team working.

Background

Limited evidence base for treating multi-morbid patients (3)

Optimal treatment for patients with multiple conditions resists codification in guidelines.

Requires professionals to identify, elicit, integrate and communicate many types of knowledge – concept of the ‘bricoleur’. (4)

These types of knowledge can be defined as tacit knowledge (5) or sticky (6) knowledge.

Tacit knowledge can be surfaced and improved by structured group education which mirrors the delivery of care.

Possible curriculumCoolaCollaboration across service

and professional boundaries

Leadership and followership

skills

Communication with patients and carers

Knowing what each service does and the constraints they face

Knowing when and how to bring in services

Communicating with a range of other professionals

Negotiating on behalf of patients

Recognising the role of specialists in general care

Being able to challenge and alter specialist prescriptions

Specialists being willing to accept decisions made by generalists in patients’ interests

Eliciting patient preferences

Having an adaptable communication style

Communicating in ways which enhance patient empowerment

Prioritising when treatments are conflicting or over-burdensome

Recognising crucial treatments for different combinations of conditions

Integrating patient preferences with clinical judgement

Clinical skills

Developing an interventionIntervention could be a combination of:

1) Education

- team-based learning (hospital specialists, GPs, nurse specialists, pharmacists, social workers)- interactive, using scenarios/role play/simulation based on real patient

case studies- 3-4 half-day sessions.

2) Team and organisational development

- on-going support for implementing changes to care- facilitated team meetings every 4-6 weeks for 6 months- could include peer observation and feedback.

Evaluation

Programme Development Grant

1. Intervention development- curriculum development- case studies and scenarios- team and organisational element.

2. Pre-implementation evaluation- feasibility of implementation.

Evaluation

Programme Grant

1. Development of outcome measures- patient experience of care

- simulated quality of care

2. Pre-implementation piloting

3. Evaluation with teams from 6-8 GP practices

- 1 year intervention

- 12/18 months evaluation

Discussion questions

1. What theories are relevant to the acquisition of tacit knowledge?

2. Is the intervention powerful enough to impact on practice?

3. Is the intervention likely to be able to be implemented, given the constraints on the NHS?

4. Are there alternatives to the team and organisational development part of the intervention?

5. What observations might we use to test out if we are on the right track (in the Programme Development Grant phase)?

6. What might be suitable designs for the final study?

7. What sources of evidence should we seek to collect for which end-points?

References

(1) Barnett K., Mercer S., Norbury M. et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012; 380 (9836), 7–13 July: 37–43.

(2) Shiner A, Steel N, Howe A. Multimorbidity: what’s the problem? Quality in Primary Care. 2014; 22 (3):115-9.

(3) Rushton CA, Green J, Jaarsma T, Walsh P, Strömberg A, Kadam UT. The challenge of multimorbidity in nurse education: An international perspective. Nurse education today. 2015;35(1):288-92.

(4) Lévi-Strauss C. The Savage Mind. Chicago, IL: University of Chicago Press; 1966.

(5) Polyani M. The tacit dimension garden city. NY: Doubleday and co., 1966.

(6) Boisot