Primary Healthcare Competencies Needed in the Management of Integrated and Person-centred Care for Chronic Illness and Multimorbidity


 Background: Chronic disease management is important in primary care. Disease management programs focus primarily on the disease. The occurrence of multimorbidity and social problems is addressed to a limited extent. Person-centred integrated care as an alternative approach empowers patients to become active participants. In this scoping review we explore necessary competencies for healthcare professionals working in collaborative teams where the main focus lies within the concept of person-centred integrated careMethods: Six literature databases and grey literature were searched for guidelines and peer-reviewed articles. A thematic synthesis was carried out to highlight healthcare professionals competencies that are needed to deliver person-centred integrated care.Results: Four guidelines and 21 studies were included to identified four themes; interprofessional communication, interprofessional collaborative teamwork, leadership and patient-centred communication. Included papers lack a description of competencies core concepts, such as healthcare professionals knowledge, skills and attitudes necessary for a person-centred integrated care approach or details on how these competencies can be acquired.Conclusion: This review provides an integrative view on competencies necessary to provide person-centred integrated care within primary care. Details on core concepts of these competencies are lacking. More research is needed, on competencies and educational programs to ensure healthcare professionals in primary care are better equipped to deliver person-centred integrated care for chronic ill patients.


Background
Chronic diseases such as cardiovascular-and pulmonary disease and diabetes mellitus type 2 are the leading causes of death and disability worldwide. According to the World Health Organization these diseases kill 41 million people each year, equivalent to 71% of all deaths globally (1). Approximately one in three adults suffer from multiple chronic diseases (2,3). Patients with multimorbidity are at higher risk of safety issues for instance due to polypharmacy, more frequent and complex medication interactions and the involvement of different healthcare professionals resulting in competing priorities and lack of coordination of care (4). Chronic diseases and multimorbidity are also associated with considerable economic burden due to higher healthcare costs (5). Many developed countries designed disease management programs or clinical practice guidelines for prevalent chronic diseases. These programs, often implemented in primary healthcare settings, improve quality of care and patient outcomes in chronic disease (6). Studies have shown that good primary care may lead to fewer avoidable hospitalizations, but also that inadequate primary care can deteriorate illnesses leading to unnecessary hospitalizations (3).
The management of chronic diseases, in particular multimorbidity, is complex and the challenge is widely recognized. The focus of disease management programs is predominantly on the medical aspects of individual chronic disease and much less on multimorbidity and social problems (7). A broader perspective on the management of chronic disease seems necessary, including other domains of life as well, to meet the speci c needs of individuals (8). A PC-IC approach seems more appropriate to achieve this (9). PC-IC standards share a common ground: they place the patient's needs in the centre and tailored care to these needs is offered (10). The goal of PC-IC is to empower patients to become active participants in their care. This approach of giving patients more choice and control in their lives is particularly suitable in primary care where general practitioners often have a life-long relationship with patients (11).
Shifting from regular disease management towards PC-IC also means a shift in professional competencies due to the holistic approach that underlies it, which considers the different domains of the patients' life. Considering the complexity of care for patients with one or more chronic diseases their care needs often cannot be met by one single professional as different areas of expertise are necessary to optimize care for this large group of patients (7). Involved healthcare professionals should be equipped to be a part of a collaborative team where the main focus lies within the concept of person-centred care. This team consist of different professionals such as general practitioners, nurses, physical therapists, psychologists and dieticians who work side by side and rely on each other's expertise. Where necessary this primary care team collaborates with professionals from other sectors, for instance hospitals and social welfare organizations.
There is variation in the terminology used to describe this team collaboration; terms include 'multidisciplinary', 'interdisciplinary', 'interprofessional' and 'multiprofessional'. The term interprofessional applies when two or more professions learn or practice together to improve health outcomes in patients whereas multiprofessional applies when professions practice together but not necessarily on shared goals (12). The PC-IC approach is based on interprofessional collaboration, also including the patient as partner. It requires a speci c skillset for team members. Being a member of such a collaborative team means working together but also setting common goals while taking the needs and preferences of the patient into account. However, it is unclear which competencies and core concepts (i.e. knowledge, skills and attitudes) these professionals should have or obtain in order to be able to deliver PC-IC.
In this scoping review our primary objectives were to provide an overview of (i) the current knowledge regarding the competencies healthcare professionals who provide PC-IC to patients with a single chronic disease or multimorbidity should have, and (ii) the core concepts underlying these competencies. Our second aim was to get insight into how these competencies can be acquired.

Study design
We performed a scoping review guided by the methodological framework proposed by Arksey and O'Malley (13); (I) identifying the research question, (II) identifying relevant studies, (III) selection of eligible studies, (IV) charting the data, and (V) collating, summarizing and reporting the results. Quality appraisal of the methodology of empirical studies was not done as we included all types of study designs. Nonetheless, whenever possible we took the level of the available evidence into consideration to guide the narrative syntheses of our results.

I. Identifying the research question
Our primary research question for the literature review was: Which interprofessional competencies do primary care professionals need to offer person-centred integrated care for patients with one or more chronic diseases? Our secondary research question was: How can these competencies be acquired?

II. Identifying relevant studies
We developed a comprehensive search strategy with the assistance of a librarian (TP) of the HAN University of Applied Sciences. The search was conducted from onset of the respective literature databases till September 2020. First we searched for guidelines and chronic disease management programs in the Trip medical database (https://www.tripdatabase.com) with the following terms including their linguistic variations; a) primary care, b) integrated care, c) chronic illness, d) multimorbidity, e) shared decision making and f) competencies (Appendix 1). For this search no lters were applied. Next, using the same keywords, we searched for peer-reviewed articles in the following scienti c literature databases: Cinahl, Embase, PubMed, Medline, and Web of Science (Appendix 1). Grey literature was hand-searched through websites of relevant national and international journals, scanning reference lists and through Google and Google Scholar by the main researcher (LM). We searched only for articles in English or Dutch. Search records were downloaded, combined and de-duplicated using EndNote bibliographic software (Clarivate Analytics, Philadelphia, PA, U.S.A.). Afterwards, we exported our search records to Rayyan QCRI (14) which facilitates process of blind screening.

III. Study selection
All titles, abstracts and full texts were reviewed against inclusion and exclusion criteria. The titles and abstracts of both the guidelines and peer-reviewed articles were screened blind by pairs of two out of four researchers (LM, AT, EB, ML) of which the main researcher (LM) screened all identi ed guidelines and peer-reviewed articles.

Inclusion criteria:
Practice guidelines and disease management program for chronic disease(s) All types of empirical studies and literature reviews on integrated care of chronic care Primary healthcare setting involving the care for either pulmonary disease; Cardiovascular disease; Obesity; and Palliative or end-of-life care for these chronic diseases All papers reporting on chronic diseases or multimorbidity or comorbidity, without reporting a speci c diagnosis Exclusion criteria: All other settings, not being primary healthcare Papers that only focus on diagnostic and/or pharmacology for chronic illnesses Papers focused on integrated care for cancer, terminal care, and mental illnesses Concerning pediatric care or papers focused on chronic care for children

Conference abstracts or posters
First the titles and abstracts were screened for relevance. Publications considered relevant only by one of the two reviewers were discussed until consensus was reached. Secondly the full text publications were retrieved and synthesized when they met the inclusion criteria.
IV. Charting the data Two reviewers (LM, ML) jointly developed a data charting form in Excel to describe relevant information.
The extracted data included the following elds: Organization/1st author and year of publication Country Aim/objective Study design and level of evidence Competencies This form was used to chart data for all included guidelines and peer-reviewed papers. The main researcher (LM) lled in the data forms, which were subsequently checked by one of the other authors (ML or EB). The authors frequently met to discuss the charting of the data.

V. Collating, summarizing and reporting the results
In this nal step a narrative report was produced to summarize the extracted data. We did not put emphasis on the "weight of evidence" nor on evaluating the quality of evidence. Study design was used as an analytic framework to guide the narrative account of the results.

Results
The searches identi ed 327 guidelines and 1,810 articles; after removing duplicates, posters and conference abstracts a total of 325 guidelines and 952 articles were screened for inclusion ( gure 1).
There was disagreement between two authors regarding the eligibility of a guideline/article in 4.4% of all documents. These disagreements were solved in discussion between the two authors and it was not necessary to include a third author as referee. The screening resulted in 17 guidelines and 89 articles to be obtained in full text. After reading full text papers, a total of 4 guidelines and 21 articles met the inclusion criteria and were included in the data synthesis. Table 1 reports the study characteristics. The four guidelines included were from United States (n=2), Australia (n=1) and Switzerland (n=1). Publication dates ranged between 2014 and 2021. The guidelines covered different patient populations, one was on COPD (chronic obstructive pulmonary disease) (14), one on elderly people (15), one on Palliative and End of Life care in stroke patients (16), and one on primary prevention of chronic disease in the general practice setting (17). The 21 included peer-reviewed papers used quantitative, qualitative and mixed research methods. The designs varied -ranked by level of evidence from one randomized controlled trial (15), four literature reviews (16)(17)(18)(19), two expert opinions (20,21), and two studies were mixed methods studies (22,23). The remaining twelve studies were qualitative studies (24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35). The included studies were performed in the United States (n=9), the Netherlands (n=5), Australia (n=2) and one study in each of the following countries: Belgium, Canada, Ireland, New Zealand and the United Kingdom. Publication dates ranged between 2006 and 2020.

Identi ed competencies
All competencies concerning PC-IC as described in the included documents were extracted. The data synthesis identi ed four main themes: 1* interprofessional communication; 2* collaborative teamwork 3* Leadership and 4* patient-centred communication ( Table 2).  (39,40) and 15 articles described communication to be an important competency when offering PC-IC (17-19, 21, 23, 25-32, 34, 35, 41). According to the authors communication requires open, responsive and regular communication between professionals, in team meetings as well as in bilateral conversations. Decision-making, problem-solving and goal-setting are important issues to be discussed with each other (15,17,25,30,35,39,42). Also, this should be an interdisciplinary team effort (26,30,32,34). It is essential that the collaborating healthcare professionals are able to discover shared patient goals during team meetings (18, 26, 30-32, 39, 43). Each healthcare professional should have the ability to communicate with colleagues and other disciplines in a bidirectional manner (30,34). This means that each party is aware of the other's professional backgrounds, strengths and boundaries and points in which professionals can reinforce each other. Team consensus is reached by dialoguing and discussing issues with all team members on an equal level. In the communication own professional perspectives and expertise are highly valued and contribute to the quality of PC-IC plans (26). Good communication skills are not only necessary within the primary care team, but it is equally important that these healthcare professionals show good communication skills towards external organizations such as other healthcare services or community agencies (32,39,44).

Collaborative teamwork
Three guidelines (39,42,45) and 15 articles (16-18, 20, 22-24, 26, 28-30, 32-35) described interprofessional teamwork or team collaboration skills. Healthcare professionals should have the ability and attitude to work collaboratively with others and share pertinent information (28,32,34,37). Another critical competency is the intrinsic motivation of professionals to collaborate with others (30). This is essential as interprofessional collaboration is often considered to be time consuming, while time is scares. Sharing knowledge of each other's involvement in patient care is another competency when sharing the same goals for their patients (21,25,31,34). Interpersonal factors may also cause barriers to collaboration and therefore it is important to de ne a shared language and discuss the diversity of personal perspectives (30). Healthcare professionals should know who else is on the team and there should be a clear understanding of the professionals own roles as well as a clear understanding of the other professions roles and competencies (26,29,31,37,39). It could be helpful if the professionals within the collaborative team invest in getting to know each other. Research has shown that professionals knowing each other well are better able to take advantage of each other's discipline-speci c competencies (30). Knowing each other also contributes to an atmosphere of mutual trust and respect which creates an open and safe environment in which the professionals involved dare to think and act broader than their own discipline (23,30,39).

Leadership
One guideline (39) and ve articles (16,18,20,27,30) mark good leadership as an important competency for sustainable and effective collaboration in interprofessional teams. Leadership characteristics include modeling and advocating of interprofessional teamwork, providing resources and infrastructure, and promoting shared team leadership, goals and decision making (30). Leadership skills are also required for bringing the interprofessional team together and to support professionals to adopt the shift in values and attitudes towards collaborative working (16,18,30,39). Leadership skills are also necessary for attaining e cient and successful team meetings (i.e., planning, agenda setting, structuring, chairing).
Although all team members should have leadership skills, within the collaborative team one team member should take the role as leader or coordinator and monitor the team's shared goals and objectives (16,30,39). Professionals with strong leadership competencies show to be patient advocates; they ensure that the team discusses patients' goals and needs and that patients are put in the center of care (27,30). also necessary. Most articles considered education to be a major facilitating factor to ensure that (future) professionals are equipped to provide care for patients with chronic illness and multimorbidity.
Professional education to develop knowledge and skills should be incorporated in undergraduate programs as well as in postgraduate programs and be part of on the job training (26,32,33). In interprofessional education two or more professions learn with, about, and from each other to enable effective collaboration and improve health outcomes in patients (16,39,45,46). Learning together with other healthcare professionals will also improve the understanding of each other's roles (20,32). Two papers speci ed the training needs. Van der Pol et al. (35) and Helitzer et al. (15) reported that professionals need speci c training on communication. In particular professionals need more skills in asking open ended questions. Rocker et al. (19) emphasized that during medical training, by effective mentorship and observation, medical students should obtain in depth skills on how to discover patients' needs.

Discussion
This scoping review showed that interprofessional competencies as well as patient-centred competencies are important when professionals aim to provide PC-IC in primary care. The overall ndings contained limited data about speci c quali cations and competencies. Nonetheless, we were able to derive some general competencies from the ndings. Communication, collaborative teamwork and leadership seem to be essential competencies that healthcare professionals in primary care should either have or make sure to acquire when delivering PC-IC.
The communication competencies that would be expected from healthcare professionals apply to interprofessional communication as well as to patient-centred communication, and both should be based on equality and respect for the interlocutor(s). This is also con rmed by a recent literature review on competencies to promote collaboration between primary and secondary care physicians (48). This particular review also showed, similar to our ndings, that team members should be open minded and willing to look beyond one's own position (48). Perceived hierarchy is the main conceptual barrier hindering collaboration between professionals. A new approach leads to a shift from subordination to complementarity in order to meet patients' needs (49). Patient-centred care requires physicians and other healthcare professionals to have communication skills to elicit patients' true wishes and to recognize and respond to both their needs and emotional concerns (50). Our ndings show that asking open ended questions, listening, recognizing nonverbal signs and the ability to adjust to the level of understanding of the patient are the most important communication skills needed to accomplish this.
We also found that leadership skills are needed to facilitate interprofessional collaboration in more than one way. Leadership skills are needed by professionals within the primary care setting, but also in relation to collaboration with professionals from external organizations. Jansen et al. (48)  In the included articles the factor 'time' is important to facilitate interprofessional collaboration and the execution of PC-IC. Time is important during consultation in order to build a relationship with the patient and meet their needs (21,30,31,(33)(34)(35)39). The lack of time and the large number of patients to see daily are important barriers when dealing with patients with multimorbidity. Other research also shows that seeing more than 3 or 4 patients per hour may lead to suboptimal content of consultations, lower patient satisfaction, increased patient turnover, or inappropriate prescribing (51). This points to the direction that, besides competencies, also a different way of practice organization (in particular extra consultation time) is necessary for successful execution of PC-IC (30,31,34,35). Besides time for patient consultations, the current payment systems may hinder collaboration between healthcare professionals as interprofessional meetings are often not reimbursed (30).
In preparing health care professionals to take on this task, establishing standards for training in PC-IC is important. The prevalence of chronic illness is growing worldwide, and management is increasingly undertaken by interprofessional teams, yet education is still generally provided monodisciplinary (25). Educational training of both undergraduate as well as graduated healthcare professionals is needed to better prepare healthcare professionals to meet the needs of ageing patients with multiple chronic conditions in a way that is person-centred, effective and sustainable (52). Interprofessional education has an important role to play in professionals developing the competencies required to collaborate successfully (50). Future research on education should guide professionals in acquiring different quali cations and competencies.

Strengths And Limitations
To our knowledge this is the rst review to provide an overview of competencies that healthcare professionals should possess to deliver PC-IC in primary care. Another strength of our review is that we used various and broad search terms, allowing inclusion of all types of literature, both scienti c and grey.
The aim of this study is to provide an comprehensive list of competencies. We deliberately chose to include all types of study designs and guidelines without limitations in order to capture relevant guidelines as well as scienti c articles.
This study was also subject to some limitations. We excluded studies in languages other than English and Dutch. Although we might have missed some studies, most studies are likely to be published in English. While performing this review, we noted rather heterogenous terminology describing the concept of the PC-IC approach as well as for interprofessional collaboration. Therefore, to optimize our search strategy we thoroughly explored different de nitions and concepts before nalizing the search strategy. We chose a sensitive search strategy rather than a speci c strategy, to ensure we would not miss relevant guidelines or peer-reviewed papers of our interest. The comprehensive search included an extensive search string using Boolean operators and truncations to combine all relevant keywords and we checked the results of our search strategy against key publications. Nonetheless we may have missed relevant studies that report PC-IC related competencies due to the use of different terminology.
The fact that we did not undertake a methodology quality assessment of the included articles might be considered another limitation. We deliberately chose to include all types of study designs and guidelines without limitations in order to capture all required competencies. We gave equal weight to all included guidelines and articles, regardless of the robustness of the underlying methodology. We consider this justi ed given the purpose of the scoping study, i.e. providing a narrative account of competencies for executing PC-IC and how these can be acquired.

Conclusion
Primary healthcare organizations are redesigning care pathways to better meet the needs of patients with chronic illness and multimorbidity. We identi ed interprofessional as well as patient care-related competencies to be relevant for the execution of person-centred integrated primary healthcare. Nonetheless, guidelines and articles lack a detailed description of the competencies in terms of knowledge, skills and attitudes and how these can be acquired. Further research in which the core concepts of the required competencies are clearly described is still necessary to properly prepare primary healthcare professionals to offer high value care to patients with chronic diseases and multimorbidity.
Educational programs, both undergraduate and postgraduate, should take these competencies into account. A shift towards interprofessional education is necessary to acquire these competencies. The author team would like to thank Thomas Pelgrim for the development of the search strategy and the execution of the searches. We would like to thank Ans Tordoir who assisted us in the screening of title and abstracts.

Abbreviations
Ethics approval and consent to participate: Not applicable.

Consent for publication:
Not applicable. Flow chart describing the process of the review of clinical guidelines and scienti c peer-reviewed articles