Background.

Patients living with multiple chronic conditions, or multimorbidity, represent a growing portion of the adult population. One in four adult Americans, three in four over the age of 65, live with multimorbidity. This population experiences unique challenges, many of which are driven by the way healthcare is delivered. Specifically, patients must cope with the work of being a patient. For patients with a single condition to follow recommended guidelines, the work amounts to approximately two hours per day. However, with multiple chronic conditions, this can quickly become a part- or full-time job for patients and their families. The ability to cope with this work rests on patients' capacity, which is a result of their interactions with their biography, resources, environment, patient and life work, and social network. When this capacity is overwhelmed by the work of being a patient, problems accessing and using healthcare and enacting self-care arise, which if unaddressed can have negative impacts on patients' health outcomes and quality of life. Minimally Disruptive Medicine (MDM) is a philosophy of care, supported by a conceptual model and multiple theoretical frameworks, that seeks to address and remedy problems of patient workload-capacity imbalance. To date, chronic care remains unexamined in light of the principles of MDM, and MDM remains untested.

Aims.

Therefore, the aims of this dissertation were to: 1) Conduct a systematic review and synthesis of recent interventions using the Chronic Care Model to examine the extent to which MDM had been adopted within those interventions; 2) Evaluate the implementation process of a six-month pilot of an MDM-driven intervention, Capacity Coaching, in primary care using focused ethnographic observations and in-depth interviews; and 3) Propose a detailed protocol to implement and test MDM using a proven culture-change curriculum.

Methods.

We conducted a systematic review and qualitative thematic synthesis of reports of Chronic Care Model (CCM) implementations published from 2011 -- 2016, a focused ethnographic study, which included the synthesis of written artifacts, nine hours of clinic observation, and nine interviews with ten key stakeholders, and propose a mixed-methods, cluster-randomized trial to test MDM using a culture-change approach.

Results.

CCM implementations examined were mostly aligned with the healthcare system's goals, condition-specific, and targeted disease-specific outcomes or healthcare utilization. No CCM implementation addressed patient work. Few reduced treatment workload without adding additional tasks. Implementations supported patient capacity by offering information, but rarely offered practical resources (e.g., financial assistance, transportation), helped patients reframe their biography with chronic illness, or assisted them in engaging with a supportive social network. Capacity Coaching's implementation, however, addressed most of these shortcomings of past chronic care interventions, including being available to patients living with any chronic condition(s), acknowledging and seeking to reduce patient work, and supporting patient capacity holistically across all constructs described in the Theory of Patient Capacity. Its implementation was successful in getting many individuals on the healthcare team to understand the purpose of the program and the ways in which it was distinguishable from other programs and in getting a small group of dedicated champions to drive implementation of the program forward. However, implementation struggled to get a broader group of individuals across the clinic involved in the program and to build in evaluation of the program's success. These challenges are ones specifically addressed in the Leadership Saves Lives culture-change curriculum.

Conclusion.

MDM offers a unique lens to meet the needs of the growing population living with multimorbidity. However, recent chronic care interventions have not implemented most MDM principles. Capacity Coaching is a novel intervention that uses MDM principles and when implemented showed promise in overcoming past chronic care shortcomings. Its pilot implementation highlighted challenges in enrolling the full healthcare team to drive MDM forward. The LSL program offers promise to overcome these challenges, but deserves large-scale testing.