Meeting the health care needs of people with chronic conditions presents one of the greatest challenges for 21st century health care system renewal. Appropriate redesign of health care delivery with this complex patient population in mind requires information from many sources. Although much is known about the patient experience of chronic illness much less is understood about how patients navigate their health care delivery context. The purpose of this qualitative study was to examine the point of view of patients dealing with multi-morbidity. These people have a unique understanding of how health care delivery links across time, place, and settings because of the care they require for their multiple chronic conditions. An interpretive descriptive design was used to examine patient navigation from the perspective of 20 adult patients with chronic kidney disease, and co-existing diagnoses of diabetes mellitus and/or cardiovascular disease. The findings generated from iterative, constant comparative analysis add important patient perspectives about health care system navigation. From the consumer perspective health care navigation is challenging, requiring (a) ongoing discovery about the complex social structures that make up the health care system, and (b) learning how to strategically use this knowledge to manage the health care system. The findings highlight the disjunctures and misalignments in the health care delivery system, the cumulative health care-related burden of multiple chronic conditions for consumers, and consumer concerns about subtle inequities in the health care system. As health care renewal efforts gain momentum new knowledge from the perspective of consumers, such as that captured in this research, is important. The consumer perspective provides a valuable opportunity for stakeholders in health care policy- and decision-making to contextualize and make greater sense of the information used in making decisions about health care service delivery for vulnerable populations, like patients with multiple chronic conditions.

Meeting the health care needs of people with chronic conditions presents one of the greatest challenges for 21st century health care system renewal. Appropriate redesign of health care delivery with this complex patient population in mind requires information from many sources. Although much is known about the patient experience of chronic illness much less is understood about how patients navigate their health care delivery context. The purpose of this qualitative study was to examine the point of view of patients dealing with multi-morbidity. These people have a unique understanding of how health care delivery links across time, place, and settings because of the care they require for their multiple chronic conditions. An interpretive descriptive design was used to examine patient navigation from the perspective of 20 adult patients with chronic kidney disease, and co-existing diagnoses of diabetes mellitus and/or cardiovascular disease. The findings generated from iterative, constant comparative analysis add important patient perspectives about health care system navigation. From the consumer perspective health care navigation is challenging, requiring (a) ongoing discovery about the complex social structures that make up the health care system, and (b) learning how to strategically use this knowledge to manage the health care system. The findings highlight the disjunctures and misalignments in the health care delivery system, the cumulative health care-related burden of multiple chronic conditions for consumers, and consumer concerns about subtle inequities in the health care system. As health care renewal efforts gain momentum new knowledge from the perspective of consumers, such as that captured in this research, is important. The consumer perspective provides a valuable opportunity for stakeholders in health care policy- and decision-making to contextualize and make greater sense of the information used in making decisions about health care service delivery for vulnerable populations, like patients with multiple chronic conditions.

Meeting the health care needs of people with chronic conditions presents one of the greatest challenges for 21st century health care system renewal. Appropriate redesign of health care delivery with this complex patient population in mind requires information from many sources. Although much is known about the patient experience of chronic illness much less is understood about how patients navigate their health care delivery context. The purpose of this qualitative study was to examine the point of view of patients dealing with multi-morbidity. These people have a unique understanding of how health care delivery links across time, place, and settings because of the care they require for their multiple chronic conditions. An interpretive descriptive design was used to examine patient navigation from the perspective of 20 adult patients with chronic kidney disease, and co-existing diagnoses of diabetes mellitus and/or cardiovascular disease. The findings generated from iterative, constant comparative analysis add important patient perspectives about health care system navigation. From the consumer perspective health care navigation is challenging, requiring (a) ongoing discovery about the complex social structures that make up the health care system, and (b) learning how to strategically use this knowledge to manage the health care system. The findings highlight the disjunctures and misalignments in the health care delivery system, the cumulative health care-related burden of multiple chronic conditions for consumers, and consumer concerns about subtle inequities in the health care system. As health care renewal efforts gain momentum new knowledge from the perspective of consumers, such as that captured in this research, is important. The consumer perspective provides a valuable opportunity for stakeholders in health care policy- and decision-making to contextualize and make greater sense of the information used in making decisions about health care service delivery for vulnerable populations, like patients with multiple chronic conditions. / Applied Science, Faculty of / Nursing, School of / Graduate

BACKGROUND. Frailty is a syndrome characterized by a decreased resistance to stressors, leading to increased vulnerability to adverse outcomes, including mortality. Multi-morbidity refers to the presence of two or more chronic diseases, and is associated with increased risk of adverse health outcomes. Most of the literature in frailty is based on older people (65+ years) living in high income countries. OBJECTIVE. To compare the predictive ability of three frailty indices for all-cause and one-year mortality among high- (HIC), middle- (MIC), and low- income country (LIC) participants; and to assess the mortality risk associated with multi-morbidity. METHODS. Using data from the Prospective Urban and Rural Epidemiological (PURE) study, we developed three indices using different definitions of frailty (one phenotypic frailty index; two cumulative deficit indices). All indices were tested for predictive ability for mortality both individually and with multi-morbidity. RESULTS. Prevalence of phenotypic frailty was greatest in LIC (8%), intermediate in MIC (7%), and lowest in HIC (4%). Multi-morbidity was most prevalent in HIC (20%), intermediate in MIC (15%), and lowest in LIC (13%). Increased frailty was associated with greater mortality risk using all frailty indices (e.g. HR (95% CI) of 2.63 (2.35-2.95) for the phenotypically frail relative to the robust). At each frailty level, mortality risk was higher within one year of baseline measurement than afterwards, and increased if it was accompanied by concurrent multi-morbidity (e.g. HR of phenotypic frailty increases from 2.27 (1.96-2.62) to 5.08 (4.34-5.95) if accompanied by multi-morbidity). CONCLUSION. All frailty indices predicted mortality. This study is unique in evaluating the prognostic ability of frailty indices in middle-aged adults across HIC, MIC, and LICs. / Thesis / Master of Science (MSc)

Jakobsbergsgeriatriken och Stockholms Läns Sjukvårdsområde betonar vikten av värdeskapande insatser och arbetssätt. Med patientperspektiv skapas resultat av betydelse för patienten. Delaktighet anges som en viktig del. Återkommande patientenkäter  visar att det finns ett gap mellan målbild och arbetssätt på kliniken. Syftet med förbättringsarbetet var att öka patienternas delaktighet under hela vårdtillfället. Syftet med studien var att identifiera vilka erfarenheter som kunde knytas till förändrade arbetssätt. Med kvalitativ metod genom interaktiv forskningsansats för förbättringsarbetet arbetade medarbetarna fram förslag på arbetssätt och metoder som bättre kunde gynna patientdelaktighet, vilka testades genom upprepade PDSA-hjul. För att besvara frågeställningarna till studien av förbättringsarbetet användes mixed method. Semistrukturerad fokusgruppsintervju, enskilda djupintervjuer, två patientenkäter låg till grund för utvärdering av upplevelser av de förändrade arbetssätten.   Förbättringsarbetet resulterade i ett flertal förändrade arbetssätt från inskrivning till utskrivning, där patientens egna förväntningar, önskemål och behov blivit tydligare.  Exempel på förändringar;  Fokus på delaktighet från inskrivningssamtalet, avstämning halvvägs in i vårdtillfället för att fånga nya frågor och ytterligare identifierande behov/ förväntningar. Studiens resultat påvisar vikten av tydlig kommunikation/information inom teamet och med patienten som partner i beslutsfattande. Insikter om teamprocesser och aktiviteter som behöver anpassas ytterligare under vårdprocessen för att skapa bättre förutsättningar för ökad patientdelaktighet. / Jakobsberg Geriatric Clinic emphasizes the importance of value creation and working methods from a patient perspective that gives results of relevance to the patient, where participation is given as an essential part. Patient surveys have shown that there is a gap between the target and working processes, which does not promote participation sufficiently.   The purpose of the improvement work was to increase patient participation throughout the hospital stay. The purpose of the study was to identify experiences that could be linked to the changing working methods, through a patient’s as well as an employee’s perspective.  The Improvement work was performed with a quality design and an interactive research approach where care-staff drafted proposals on useful methods that would better favor patient participation. These methods were then tested by repeated PDSA-wheels.  To answer the questions to the study, mixed method was used. Semi-structured focused group interviews were conducted and participation observations occurred. Individual interviews were held and patient’s surveys were filled out to evaluate the experience of the changing working method.  The improvement work resulted in a number of changes, from admission to discharge, where the patient’s own expectations, wishes and needs, became more central. Examples of changes; an increased focus on patient participation, from the enrollment, as well a reconciliation offered midway through the care episode with the purpose to catch arising issues and to identify additional needs.  The findings in the study demonstrate the importance of clear communication / information within the team and with the patient as a partner in decision-making. Insights on team processes and activities that need to be further adapted during the care process to create better conditions for increased.

I takt med att andelen äldre ökar i samhället rapporteras om stigande läkemedelsanvändning. Normala åldersförändringar, ökad risk för multisjuklighet och kroniska sjukdomar i kombination med polyfarmaci och bristande följsamhet medför en ökad risk för läkemedelsrelaterad ohälsa hos äldre. Bristande följsamhet till läkemedelsbehandling är en stor och problematik hos äldre vilket kan medföra negativa konsekvenser för både patienten och samhället. Syftet med studien är att beskriva kunskapsläget avseende associerade faktorer till den äldres upplevelse av följsamhet och bristande följsamhet till läkemedelsbehandling. Studien är en integrativ litteraturstudie med sammanställning av totalt 11 vetenskapliga artiklar både kvalitativa och kvantitativa från databaserna CINHAL, PubMed, Web of Science och Nursing and Allied Health database. Efter granskning av artiklarna framträdde tre huvudteman; Kunskap och förståelse, Minne och vardagliga hinder, Stöd och strategier, utifrån dessa formades tio subteman. I resultatet framkom det att äldres upplevelse av bristande följsamhet till läkemedelsbehandling var associerade till flertal faktorer. Bakomliggande orsaker till äldres upplevelse av bristande följsamhet var således relaterade till bristande kunskap om sin läkemedelsbehandling, kognitiv svikt samt otillräckligt stöd och brist på strategier. Faktorer som hade positiv effekt på följsamhet till läkemedelsbehandling var kunskap och information om sina läkemedel, stöd från anhöriga, stöd och god relation med sin vårdgivare samt hitta rätt strategier. Studiens slutsats är att med hjälp av patientens egna strategier samt vårdgivarens stöd, information och undervisning kan äldres följsamhet till läkemedel främjas och osäker läkemedelsbehandling reduceras. / With the growing number of older people in society there is a report of increasing drug use. Normal age changes, increased risk of multiple morbidity and chronic diseases in combination with polypharmacy and lack of medication adherence entail an increased risk of drug-related illness in the elderly. Lack of medication adherence is a major problem in the elderly, which could have negative consequences for both the patient and society. The purpose of the study is therefore to describe the state of knowledge regarding factors associated with the elderly's experience of medication adherence and lack of medication adherence. The study is an integrative literature study with a compilation of a total of 11 peer reviewed articles both qualitative and quantitative from the databases CINHAL, PubMed, Web of Science and Nursing and Allied Health database. Through review of the articles, three main themes emerged; Knowledge and understanding, Memory and everyday obstacles, Support and strategies, based on these, ten sub-themes were formed. The result showed that the elderly's experience of lack of medication adherence was associated with several factors. The underlying causes of the elderly´s experience of lack of medication adherence were related to lack of knowledge about their drug treatment, cognitive impairment and insufficient support and lack of strategies. Factors that had a positive effect on medication adherence were knowledge and information about their drug treatment, support from relatives, support and a good relationship with their healthcare providers and finding the right strategies. The study concludes that with the help of the patient's own strategies and the support from the healthcare provider, information and education, the elderly's medication adherence can be promoted and unsafe medication treatment can be reduced

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This project aimed to enhance communication and collaboration among care providers in Stockholm Region and Stockholm Municipality by analyzing health data in various medical record systems and identifying the data that needs to be shared to support elderly individuals with multi-morbidity. Interviews with health experts, caregivers, and policymakers, as well as a literature review, were conducted to gather data. The findings indicated that caring for multi-morbid elderly individuals poses many challenges, including managing multiple chronic conditions, the risk of adverse drug interactions, physical and emotional burden, reduced functional ability, social isolation, and economic consequences. A holistic approach to care is needed, including coordinating care across multiple specialities, addressing social and psychological factors, and providing support for caregivers. Additionally, health data sharing could help with the challenges of ageing and multi-morbidity, but barriers to accessing relevant health data exist. The barriers include a lack of measurement values, different systems used in different healthcare facilities, outdated systems and a large amount of health data existing as free-text notes which make it difficult to extract useful information. Therefore, new HIE solutions are needed to improve patient safety and better integrate existing systems. Future work should focus on improving the accessibility and usability of health data, addressing security and privacy issues, and promoting standardization and interoperability. / Målet med detta projekt var att förbättra kommunikationen och samarbetet mellan vårdgivare i Stockholmsregionen och Stockholm kommun genom att analysera hälsodata i olika medicinska journalsystem och identifiera de data som behöver delas för att stödja multi-sjuka äldre. Intervjuer med hälsoexperter, vårdgivare och beslutsfattare samt en litteraturstudie genomfördes för att samla in data. Resultaten visade att vården för äldre personer med flera sjukdomar innebär många utmaningar, inklusive hantering av flera kroniska tillstånd, risken för biverkningar från läkemedel, fysisk och emotionell belastning, minskad funktionell förmåga, social isolering och ekonomiska konsekvenser. En helhetssyn på vården krävs, inklusive samordning av vården över olika specialiteter, beaktande av sociala och psykologiska faktorer och stöd till vårdgivare. Dessutom kan delning av hälsodata hjälpa till med utmaningarna med åldrande och flera sjukdomar, men det finns hinder för att få tillgång till relevant hälsodata. Hindren inkluderar brist på mätvärden, olika system som används i olika vårdinrättningar, föråldrade system och en stor mängd hälsodata som finns som anteckningar, vilket gör det svårt att extrahera användbar information. Därav, behövs nya lösningar för hälsodata-utbyte för att förbättra patientens säkerhet och bättre integrera befintliga system. Framtida arbete bör fokusera på att förbättra tillgängligheten och användbarheten hos hälsodata, hantera säkerhets- och integritetsfrågor och främja standardisering och interoperabilitet.