Table 1 The eight dimensions of patient-centred care in the primary care setting for patients with multimorbidity

1) Patients’ preferences

Patients with multimorbidity have indicated that they need to be seen as a whole person instead of a sum of certain diseases. It is, for example, not sufficient to complete a standard template of a care plan for a patient with COPD and another template for the same patient’s diabetes. Whole-person care is a concept requiring professionals’ understanding of each patient as a whole by taking the time to really get to know the patient and his/her values and preferences, thereby improving the patient’s well-being. To enhance PCC, health care professionals should involve chronically ill and multimorbidity patients in decisions about their care and support them in setting and achieving their own treatment and life goals. Preference-sensitive decisions include therapy that may improve one condition but make another worse (e.g., corticosteroids for chronic obstructive pulmonary disease may exacerbate osteoporosis); therapy that may confer long-term benefits but cause short-term harm (e.g., preventive agents, such as statins, frequently have adverse effects); and multiple medications, each with benefits and harms that must be balanced. Finally, preferences may change over time and should be re-examined, particularly with a change in health status.

2) Information and education

The provision of complete information to patients about all aspects of their care is necessary. Patients should have access to their care records (e.g. via e-health applications) and be in charge of their care. Open communication between patients and health care professionals, which requires professionals to possess high-quality communication skills, is also necessary. Although healthcare professionals may often feel that some adverse effects are less important than expected benefits, patients with multimorbidity often consider them to be highly significant given that they often use multiple medicines and treatments. Multimorbidity disproportionally affects those from lower socio-economic groups, which calls for information suitable for patients from all educational levels.

3) Access to care

Access to care refers to waiting times (to schedule an appointment as well as waiting time during the visit), an accessible building (including those with physical limitations and mobility problems) as well as medicine access (patients can easily request a repeat recipe). Research unfortunately shows older patients with (multiple) chronic diseases experience many difficulties when it comes to access to care and find it difficult to make an appointment with their general practitioner and specialist. Obstacles include overloaded telephone lines and the inability to schedule an appointment less than several months in advance. Furthermore, special attention is needed for (im)migrant and illiterate patients.

4) Emotional support

Multimorbidity patients often experience anxiety about the impact of their multiple illnesses on their lives as a whole not just their physical health outcomes. Being in constant pain and feeling tired also limits the ability to invest in social relationships and to keep your job, which may cause a lot of worries and anxieties. Proper support is needed to help patients with multimorbidity in their abilities to achieve social and mental well-being, which is currently a major challenge in the primary care setting.

5) Family and friends

In the case of chronical diseases and especially multimorbidity (depending on the seriousness of the conditions), these illnesses not only affect the patient, but also his/her family and friends. In such cases, PCC may be improved by the involvement of relatives in decisions about the patient’s care, and attention to the role and needs of informal caregivers. Furthermore, optimal care of older adults with multimorbidity is best achieved by a collaborative effort that involves patients, family members, and health care providers. Family members, especially spouses, often play a leading role in sharing responsibility for some of the care. A person-centred approach begins by gathering specific information about a person’s preferences in light of health circumstances, with input from family members and other caregivers if the person wishes. Added to a comprehensive health and functional assessment within the patient preferences dimension, this information is used to help a person shape and articulate his or her health and life goals. These goals are driven first and foremost by how a person wants to function and what he or she envisions for future well-being.

6) Continuity and transition

Continuity and secure transition between health care settings have been identified as important aspects of PCC for patients with multimorbidity. Smooth transitions require the transfer of all relevant patient information; ensuring that patients are well informed about where they are going, what care they will receive, and who their contact person will be; and the provision of skilled advice about care and support at home after discharge from a hospital for example. Involvement of various healthcare professionals, numerous treatments and taking multiple medications is known to have adverse effects. A complex regimen is associated with non-adherence, adverse drug events, economic burden, and informal caregiver stress. These risks can worsen with impairments in cognitive and physical function. Thus, it is recommended to periodically evaluate the patient’s capability to manage medications. Continuity and smooth transition can help simplifying the regimen as well as carefully monitoring the patient with feedback if needed. Older patients with more complex health and psychosocial issues indeed are known to benefit from comprehensive evaluation by geriatricians, psychiatrists, social workers, and home care providers, who continuously work well together.

7) Physical comfort

Multimorbidity patients’ physical comfort should be supported effectively in order to support their ability to achieve physical well-being. Pain should be managed effectively, patients have to sleep well and healthcare professionals should take patients’ needs about support and their daily living needs into account. Not just physical comfort in the daily life of patients matters, but they should also be provided with comfort during their visit to the healthcare professional; areas should for example be clean and comfortable and patients’ privacy must be respected.

8) Coordination of care

Patient care should be well coordinated among professionals (teamwork in care delivery). Health care professionals should be well informed so that patients do not have to repeat their stories over and over again. Given the involvement of multiple professionals in the case of patients with multimorbidity, this becomes increasingly important.