Assessment of older persons with multimorbidity in Norwegian primary care: a qualitative study of healthcare professionals' experiences and preferences in fostering continuity of care

Abstract

Background: As the population ages, more people live longer with multimorbidity. Older people with multimorbidity face diverse needs and medical conditions, increasing the risk of adverse health outcomes, and often experience fragmented healthcare. Research has called for better ways to reach, understand and care for this group to enhance care continuity. This study aimed to examine healthcare professionals' experiences and preferences as they relate to assessments' role in promoting care continuity for home-dwelling older patients with multimorbidity in community-based healthcare.

Methods: This qualitative study acquired qualitative data from 17 healthcare professionals from reablement teams, interdisciplinary teams, rehabilitation teams and home nursing in three Norwegian municipalities. Representing nursing, physiotherapy, occupational therapy and social work, all participants were experienced in assessing older home-dwelling patients with multimorbidity. Semi-structured focus group and individual interviews were conducted, then the interviews were transcribed and analysed using reflexive thematic analysis.

Results: The analysis elicited three themes: gaining insight beyond diagnoses to promote relational continuity, facilitating interaction to ensure informational continuity, and linking patient journeys to facilitate managerial continuity. The themes underscore the significance of evaluating patients beyond their medical conditions, emphasising assessment's collaborative nature across disciplines. Healthcare professionals use diverse assessment methods and facilitate interaction to understand patients' needs. Working together across different healthcare professions is key for care that includes the whole patient, but challenges such as underutilisation of assessments and poor documentation still exist. Furthermore, linking patient journeys remains difficult due to fragmented services and limited resources. Despite these challenges, assessments were viewed as crucial to care continuity.

Conclusions: In this qualitative study, healthcare professionals emphasised that assessment is a complex, continuous process due to the fluctuating health of individuals with multimorbidity. Effective instruments and diverse assessment methods are essential to understanding all aspects of patients' health and well-being to ensure care continuity across individual, service, and system levels. Our findings highlight the need for systematic and structured use of assessments to improve interdisciplinary collaboration and personalised care for older individuals with multimorbidity. Understanding the patient journey is crucial for achieving these goals, potentially benefiting healthcare professionals, policymakers, and primary care providers.

Keywords: Assessment; Care continuity; Holistic understanding; Interdisciplinary collaboration; Multimorbidity; Person-centred care; Primary care; Professional communication.