Enacting person‐centredness in integrated care: A qualitative study of practice and perspectives within multidisciplinary groups in the care of older people

Abstract Background Person‐centredness is important in delivering care for long‐term conditions. New models of care aim to co‐ordinate care through integration of health and social care which require new ways of working, often remotely from the patient. Objective To describe how person‐centred care is enacted within multidisciplinary groups (MDGs) created as part of a new service, integrating health and social care for older people. Methods We followed the implementation of eight neighbourhood MDGs, observing and interviewing staff from three MDGs at different phases of programme implementation using semi‐structured topic guides. Results Thirty‐four MDG meetings were observed and 32 staff interviewed. Three core themes were identified which impacted on enactment of person‐centred care: the structural context of MDGs enabling person‐centred care; interaction of staff and knowledge sharing during the MDG meetings; and direct staff involvement of the person outside the MDG discussion. Conclusions This study provides new insights into attempts to enact person‐centred care within a new model of service delivery. Teams did what they could to enact person‐centred care in the absence of the “real” patient within MDG meetings. They were successful in delivering and co‐ordinating some aspects of care (eg prompting medication reviews, referring to social worker, health improvement and arranging further multidisciplinary team meetings for complex cases). This “absence of patients” and time pressures within the MDGs led to reliance on the “virtual” record, enhanced by additional “soft” knowledge provided by staff, rather than ensuring the patient's voice was included.

ature review and evidence synthesis identified three core themes of patient-centred care: patient participation and involvement; the relationship between the patient and the health-care professional, and the context where their care is delivered (including access, organizational systems and the therapeutic environment). 15 Ideally, patients are presented with all potential options around their management and then participate in shared decision making with professionals.
Although there is a link between integrated and person-centred care, achieving both is not without challenge. Core features of person-centred care include detailed knowledge of the patient and an effective "therapeutic relationship," which may be more difficult to achieve in team-based care, as a patient seeing a variety of professionals may feel less able to build up a rapport. 16 There may also be tensions between the aims of integrated and person-centred care. The latter is designed to ensure that care is "closely congruent with, and responsive to patients" wants, needs and preferences, 17 whereas a major impetus behind the promotion of integrated care is to reduce hospital admissions and costs, and to do so across a defined populations of "at-risk" patients which may involve significant numbers of individuals. Greenfield et al explored patient narratives in integrated care and describe a continuum of experience between having "space" to be heard and seen vs feeling "translucent," "unseen," and "unheard." 18 They highlighted that person-centredness based on relationship dyads may not correspond to the reality of working in integrated care settings and suggested that patient experience of compassion was often absent.
There has been little research into how person-centred care is achieved in integrated MDTs using case management. Previous ethnographic studies have offered valuable insights into how contradictory organizational pressures are managed within MDTs. 19 In the context of care pathways, Allen found that redesign reduced personcentredness with a tendency for people to be "ushered" down a particular route often with little consultation. We adopted a similar methodology to Allen, 19 using qualitative interviews and detailed observations to reflect critically on the possibility of enabling person-centred care in the context of multidisciplinary case discussions and team-based decision making when the person is presented as a "case," but is not present.

| Context of the study-the Integrated Care Programme
The Integrated Care Programme (ICP) was a large-scale transformation of services for patients over 65 years of age, including significant integration across organizations and services in an area in the north-west of England. 20 Budgets for older people were pooled in order to drive the implementation of ICP.
Public engagement during the development phase of the ICP included public governors, patient organizations, and older peoples' forums and reference groups. Real data were used to create a fictitious character Sally Ford, helping staff focus on improving the experience of older people similar to "Mrs Smith," who illustrated older people's issues in Torbay. 21 As part of the ICP, 22 the population was stratified into levels of need. Multidisciplinary groups (MDGs) were set up to provide integrated case management for the 3100 people identified receiving 3 or more visits per week from district nursing and/or social care.
Neighbourhood MDGs operated fortnightly and included a project manager supported by an administrator. Each MDG included a GP and/or practice nurse from between 4 and 10 local GP practices.
Nursing and social care practitioners cochaired meetings which were also attended by a geriatrician, mental health advance practitioner and health improvement officer. A shared care record (SCR) was created which was populated with data from existing primary care databases, with additional data being input prior to meetings.
The SCR was displayed at MDG meetings during patient discussions and updated with outcomes and actions agreed. These actions included referrals to social care, mental health or health improvement with additional meetings held for some of the most complex cases.
The professional best known to the patient was usually assigned the role of care co-ordinator within the SCR.

| Data collection
Our study used multiple qualitative methods including observations and interviews to research the work conducted and to explore perspectives of MDG team members. This provided insights into staff expectations, how MDGs worked in practice, and staff perceptions of being able to deliver person-centred care. Other meetings outside the MDGs were observed to understand underlying processes, for example social care and nursing pre-MDG meetings, demonstrations of SCR creation and data population, cochair meetings to ensure co-linearity across the neighbourhoods.
ICP documentation was used to compare the operational aspirations of the MDGs with emergent findings.
Semi-structured interviews were conducted with 27 staff attending MDGs, covering all roles (Table 1), plus 5 others whose work supported the MDGs. Interviews were conducted by a research fellow (LR) trained in qualitative methods and averaged 59 (range 34-96) minutes. The topic guide covered roles and responsibilities, patient interaction and project progress. Since this article focuses on how MDG staff enacted person-centeredness, interviews with patients and carers are reported elsewhere. 22 Participants provided written consent and interviews were digitally audiotaped and transcribed. Interview transcripts were verified against the audio file, anonymized and re-read ahead of initial coding. Transcripts, field notes and supporting documents were organized using NVivo v10. 23 A thematic analysis was conducted, drawing upon some techniques of a grounded theory approach, including a constant comparative technique whereby iterative analysis informed adaptation of the topic guides and further sampling. Initial coding treated interviews and observation notes independently, with memos enabling deeper insights as the project progressed. The qualitative project team met monthly to review emerging themes and to agree themes and subthemes. Observations and interviews, however, revealed that patients and/or carers were not invited to participate in MDG meetings and very few were routinely involved in discussions beforehand. Despite the absence of the patient at the MDG meetings, staff attempted to deliver person-centred care in a variety of ways.

| RE SULTS
We have therefore structured the results into three core themes concerning the enactment of person-centred care, representing a continuum of increasing levels of patient involvement. Table 1 shows a summary of these themes, differentiated by the various staff involved in the MDG meetings, and we provide direct interview extracts below.

| Roles and records: MDG structures supporting person-centred care
Integration in the ICP was mirrored in MDGs, with nursing and social care leads cochairing meetings. Input from general practice was usually by a nominated GP, sometimes accompanied by or represented by a practice nurse. Acute or community geriatricians also attended. Mental health was represented by an advanced practitioner, and in two neighbourhoods, a consultant psychiatrist. Health improvement officers helped link older people into activities in their communities such as befriending schemes and exercise classes.
GPs felt the multidisciplinary approach increased the solutions available, but emphasized patient choice was important in meeting their needs.

| MDG meetings: enabling sharing "soft" knowledge
In addition to MDG professionals being able to optimize patient care by conducting medication reviews, making referrals etc., less concrete interactions also occurred. This second theme reflects how staff viewed the MDG meetings as an opportunity to share "soft" knowledge, that is knowledge extending beyond the "usual" medical diagnoses or treatments captured by the SCR as "data." This "soft" knowledge is generally unspoken and unwritten but may provide meaning and context to existing routine data. 24   Towards the end of the MDG observation period, a "Summary of existing risks and issues" was introduced to the SCR. This more proactive approach to care planning, when combined with direct patient consultation, led to positive outcomes for a small number of patients.

| Summary of main findings
This article illustrates how new MDGs set up to integrate primary and secondary health and social care were able to enact some degree of person-centredness, despite patients being absent from MDG discussions.
Integrated Care Programme documentation 20 described a named care co-ordinator consenting patients before discussion at MDG meetings and incorporating their needs and preferences into care planning. Some GPs and practice nurses reported speaking with patients beforehand, and feeding back the outcome of MDG meetings to patients during routine appointments, but workload and service pressures meant there was little time to contact patients ahead of MDG discussions. Whilst care co-ordinators were nominated, many viewed their roles more as co-ordinating care between services rather than providing liaison between the patient and the MDG.

| Strengths and limitations
Qualitative interviews with MDG staff provided an insight into how they expected person-centredness to be achieved within the ICP, and this combined with the observations during MDG meetings helped to identify the processes through which it was enacted.
Interviews with patients and/or their carers are unlikely to have yielded this level of detail given how few appreciated the changes in how their health and social care was now being delivered.
There were a disproportionate number of interviews with nursing and GPs attending the MDG meetings compared to social care staff, and we were unable to interview the consultant psychiatrist.
This reflects the caseload pressures and also the mechanisms by which staff from social care and mental health were involved in the MDGs. One

| Relationship of the findings to the wider literature
Our findings echo those from the North-West London Integrated Care Pilot for patients aged 75 years or more or with a diagnosis of diabetes, 27 where MDG staff reported team meetings were more provider-than patient-oriented. In-depth analysis of utterances in these multidisciplinary meetings found relatively low levels of "integrative intensity" (defined as communication that is solution oriented, reflexive and oriented towards systems), 28  Greenfield found a gap between the goals of integrated care initiatives, and the experience of many patients. 18 Our work identified some of the ways in which practitioners could enact patientcentredness in situations where the patient was not present, through sharing of information about the patient in meetings and capturing that information in the care records. Nevertheless, we did not identify many occurrences when knowledge about patient "wants, needs and preferences" was explicit in these discussions, meaning that the "patient as person" was generally filtered through the perspectives of professionals.
Harris found that discussions in MDTs often did not translate into actions. 28 Our work suggests that when actions were suggested from meetings, there was still uncertainty as to whether the solutions would be acceptable to patients. One alternative observed in cancer MDT meetings shows decision making occurs "backstage," with a consensus opinion or best treatment recommendations presented to patients "frontstage" in an MDT clinic. 26 This provides an opportunity, albeit late, to be involved in decisions around their care. In work by O'Driscoll, patients with physical health problems seemed on the whole happy to defer decision making to "professionals" but liked having the opportunity to be involved if they wished. 29