How can skill-mix innovations support the implementation of integrated care for people with chronic conditions and multimorbidity?

Abstract

Many countries in Europe have started to reorganize the delivery of health and social care services in response to the increasing numbers of patients with chronic conditions and multimorbidity, recognizing the importance of moving away from a fragmented and disease-centred approach to a holistic, patient-centred one. The emerging integrated and coordinated care models often require changes to the skills, competencies, roles or tasks within and across health professionals, subsumed under “skill-mix changes”. These skill-mix changes aim to better meet the increasing and changing demands of patients with complex needs and improve coordination and collaboration between various professionals within the health sector but also across the health and social care sectors. The COVID-19 pandemic has further highlighted the importance of flexibility in the health workforce and the necessity of reskilling and distributing tasks and roles differently. This experience has shown the potential of skill-mix innovations to surge capacities of health systems, and that these are fundamental for implementing new ways of health services provision Our research aimed to analyse which skill-mix innovations can improve integrated delivery of care for individuals with chronic conditions and multimorbidity. We conducted an evidence synthesis of 78 systematic reviews on the impact of skill-mix interventions for patients with chronic conditions and multimorbidity on individual health outcomes and health system-related outcomes. This was complemented by a cross-country analysis of trends and in skill-mix interventions in Europe. We identified six skill-mix interventions as most promising to tackle current and emerging challenges in primary and ambulatory care and in improving the integration of care of patients with chronic conditions and multimorbidity: shifting tasks and roles, relocation of care to other settings, introduction of care coordination roles, empowering patients and caregivers, new dedicated prevention roles and establishment of teamwork and collaboration in multi-professional teams. Evidence from the systematic reviews show that skill-mix innovations for patients with single chronic conditions and multimorbidity have overall positive impact or at least equivalent results on patient outcomes compared to routine care. Many systematic reviews on advanced practice roles of nurses and pharmacists reported improved medication adherence, blood glucose levels and blood pressure control. Evidence on care coordinators, peer educators, community health workers and patient navigators indicate that these roles are associated with an improvement in physical health, adherence to screenings, and patient engagement in treatment and social relationships, although results for patients with mental illness were mixed. Teamwork and collaboration appear to have a moderate impact on physical health but collaborative care in mental health is associated with a positive impact on depressive symptoms and patient satisfaction.