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R E S E A R C H A R T I C L E Open Access
Coordination of care for multimorbid
patients from the perspective of general
practitioners –a qualitative study
Judith Stumm
1*
, Cornelia Thierbach
1
, Lisa Peter
1
, Susanne Schnitzer
2
, Lorena Dini
1
, Christoph Heintze
1
and
Susanne Döpfmer
1
Abstract
Background: In Germany, a decreasing number of general practitioners (GPs) face a growing number of patients
with multimorbidity. Whilst care for patients with multimorbidity involves various healthcare providers, the
coordination of this care is one of the many responsibilities of GPs. The aims of this study are to identify the
barriers to the successful coordination of multimorbid patient care and these patients’complex needs, and to
explore the support needed by GPs in the care of multimorbid patients. Interviewees were asked for their opinion
on concepts which involve the support by additional employees within the practice or, alternatively, external health
care professionals, providing patient navigation.
Methods: Thirty-two semi-structured, qualitative interviews were conducted with 16 GPs and 16 medical practice
assistants (MPAs) from 16 different practices in Berlin. A MPA is a qualified non-physician practice employee. He or she
undergoes a three years vocational training which qualifies him or her to provide administrative and clinical support.
The interviews were digitally recorded, transcribed and analysed using the framework analysis methodology.
Results: The results of this paper predominantly focus on GPs’perspectives of coordination within and external to
general practice. Coordination in the context of care for multimorbid patients consists of a wide range of different
tasks. Organisational and administrative obstacles under the regulatory framework of the German healthcare system,
and insufficient communication with other healthcare providers constitute barriers described by the interviewed GPs
and MPAs. In order to ensure optimal care for patients with multimorbidity, GPs may have to delegate responsibilities
associated with coordinating tasks. GPs consider the deployment of an additional specifically qualified employee inside
the general practice to take on coordinative and social and legal duties to be a viable option.
Conclusions: The cross-sectoral cooperation between all involved key players working within the healthcare system, as
well as the coordination of the whole care process, is seemingly challenging for GPs within the complex care system of
multimorbid patients. GPs are generally open to the assignment of a person to support them in coordination tasks,
preferably situated within the practice team.
Keywords: Primary health care, Multimorbidity - coordination of care - general practitioner, Medical practice assistant -
navigator - qualitative research
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: judith.stumm@charite.de
1
Institute of General Practice, Charité –Universitaetsmedizin Berlin,
Charitéplatz 1, 10117 Berlin, Germany
Full list of author information is available at the end of the article
Stumm et al. BMC Family Practice (2019) 20:160
https://doi.org/10.1186/s12875-019-1048-y
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Background
Due to a recent demographic change in Germany, GPs are
faced with a growing number of patients with multimor-
bidity. The care of these patients with complex needs is
often provided by multiple doctors and a range of other
healthcare professionals, and the coordination of their care
is challenging for both GPs and patients [1]. Coordination
of care for multimorbid patients means a functioning
trans-sectoral care that interlocks all involved healthcare
providers. The coordination of care especially includes
work beyond the direct patient contact. The elements that
define coordination are difficult to specify, because coord-
ination tasks are not detached from other care tasks [2].
Research findings suggest that coordination of care in gen-
eral practice as well as care provided by multidisciplinary
teams can enhance the continuity of care of patient with
multimorbidity [2–4].
Primary health care (−teams) play a decisive role in
the coordination and therefore the continuity of care of
multimorbid patients [2]. GPs provide comprehensive
long-term care for patients with multimorbidity, playing
the central role in patients’care, which implies a sense
of affiliation [5]. Often, they have to assume a mediating
role between specialists and patients in order to find a
compromise between the specialist’s recommendations
and the patient’s needs, views and wishes [2–6].
At the same time, the decline in the number of GPs in
Germany means that new concepts have to be developed
to support them, particularly in the coordination of care
for patients with complex needs [7].
Possible concepts include the integration of general
practice into a cross-sectoral model of care [8], or the de-
ployment of additional healthcare professionals to coord-
inate the care of patients with multimorbidity in general
practice. The deployment of non-medical professions for
coordination tasks and specific clinical duties could relieve
the GPs and raise consultation times [2,8,9]. Further-
more, medical settings, in which physicians and non-
medical healthcare professions work together in teams
demonstrate improved patient outcomes [10]. A shared
definition of goals, cooperative tasks and responsibilities
help to enhance patient care [11].
In Germany, general practices are mostly small units
with one or two GPs and two to four MPAs [9]. Currently,
single-handed practices are the most strongly represented
in Germany [12]. In general practices, the “qualified med-
ical practice assistant”(“Medizinische Fachangestellte”,
MPA), the primary mid-level healthcare professional, is an
important member of German GPs’practice teams. MPAs
complete a three-year training programme which qualifies
them for office management/clerical administration (such
as scheduling appointments and updating patients’files)
and a broad range of nursing-based clinical duties (such as
taking medical histories, explaining treatment procedures,
performing diagnostic procedures like ECG and blood
pressure measurements, taking blood samples, and pro-
viding home visits). Two thirds of the training programme
take place in the practice and one third in vocational
school [13]. Even though GPs have to provide medical
treatments personally, they are allowed to delegate certain
tasks. These tasks are defined in the “Agreement on the
delegation of medical services to non-medical staff in
ambulatory healthcare”by the Federal Medical Associ-
ation [14]. Studies have shown that care management
interventions are feasible and effective if they are delivered
by MPAs [15,16]. The involvement of MPAs can also im-
prove patient care, and lead to a reduction of GPs’work-
loads [17]. GPs and MPAs work in close collaboration,
and MPAs enjoy a high level of acceptance on the side of
patients [18].
In other countries, the involvement of additional health
professionals in primary care, such as physician assistants,
nurses and nurse practitioners in anglo-american countries
or “praktijkondersteuner”in the Netherlands is common.
A multidisciplinary primary care team might contribute to
more comprehensive patient care and improve the coord-
ination of care in comparison to a physician working in a
solo practice (Bellagio-Model) [19].
Another model for the improvement in the care of pa-
tients with complex needs is based on navigation. Patient
navigation is an umbrella term based upon models of
care and case management that include support and
guidance for patients accessing the care system [20].
Patient navigation does not address a single point in care
but follows patients proactively throughout the entire
process of ambulatory and inpatient healthcare. Naviga-
tion programs differ in types of navigator roles; common
tasks are the provision of information, guidance, advo-
cacy, emotional and practical support, as well as educa-
tion and empowerment [20,21]. A central aim of patient
navigation is to serve vulnerable populations [20].
The research consortium “NAVICARE –Patient-centred
health services research”(https://navicare.berlin/de/),
funded by the Federal Ministry of Education and Re-
search (“Bundesministerium für Bildung und Forschung”,
BMBF), aims to acquire knowledge about the barriers
which keep patients from receiving optimal care, and to
study effective, patient-oriented ways to overcome these
barriers, such as navigation, by exploring different perspec-
tives in two subprojects, see Additional file 1:FigureS1.
The subproject COMPASS (https://navicare.berlin/de/
forschung/navicare-forschung/) focuses on the perspec-
tive of the GP practice and patients in the long term
ambulatory care. This article concentrates on the find-
ings of the first stage of the mixed-methods approach
within COMPASS, the interviews with GPs and MPAs.
The aims of the interviews were 1.) to explore the views
of GPs’and MPAs’on requirements and barriers for the
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successful coordination of care for patients with multi-
morbidity and complex needs, 2.) to identify the need
for support, and 3.) to investigate opinions on two differ-
ent models of support: support from within the practice,
by delegation and/or expansion of the practice team, or
support from external health care professionals, providing
navigation.
Methods
We conducted semi-structured interviews with 16 GPs
who are statutory health insurance registered (“KV-
Ärzte”) in Berlin, as well as one of their MPAs (n= 16).
The participants were purposively sampled from the
practice-based research network “ANCHOR”of the In-
stitute of General Practice, Charité - Universitaetsmedi-
zin Berlin. They were approached via e-mail and
telephone. The selection of GPs was carried out in order
to represent the Berlin GP population in terms of gender
as well as the maximum spread of practice locations
over different city districts of Berlin. The GPs then des-
ignated one MPA from their practice as the other inter-
view partner, meaning that from each recruited practice,
one GP and one MPA were interviewed individually.
The interviews took place in the respective GP practices.
Interviews were audio-recorded and transcribed verba-
tim. Any identifying details were removed and partici-
pants were assigned pseudonyms. Written informed
consent was obtained from all participants.
The study was approved by the research ethics com-
mittee of the Charité - Universitaetsmedizin Berlin
(EA4/034/17).”
The interview guideline was developed based on stud-
ies from the previous literature as well as the experience
of the researcher. It was discussed in a multidisciplinary
working group and adjusted until a consensus was
reached. The same interview guideline was applied to
GPs and MPAs. The interview guideline included a
number of open questions regarding the theme’s coord-
ination, delegation, optimal care and community care in
general practice (see Table 1).
Face-to-face interviews were chosen as the data collection
method for the first stage of the COMPASS project. This
was in order to ensure in-depth discussions of this complex
topic. The issues raised in the interviews were then used to
develop a questionnaire that was sent to all GPs in Berlin
who are statutory healthcare registered. The aim was to
supplement the qualitative study results by obtaining a
broader perspective of a large number of GPs. In this paper
we report the results of the interviews with the GPs, com-
plemented by the views of the interviewed MPAs.
Data analysis
By using the framework analysis [22] as a systematic ap-
proach to manage and analyse qualitative data, seven
Table 1 Topic guide with exemplary questions from the
interview guideline
Theme: Coordination
Topic Examples of questions
1. Problems/Barriers in health
care coordination
Can you recall a multimorbid
patient of yours with complex
care needs?
2. Patient groups with need
for coordination
Are there any other patient
groups that you think are
particularly affected by
coordination difficulties?
3. Achievements in the
coordination of health care
Can you think of an example
where coordination went well?
4. Improvements in the
coordination of health care
You mentioned some problems
and achievements, do you have
additional suggestions on what
you would like to improve in
coordination?
5. Coordination within
your practice
Could you imagine that one or
more people in your practice
take on coordinative tasks?
6. Coordination offers outside
the general practice
There are concepts and projects
that introduce so-called extern
navigators - these are additional
people who are supposed to take
on specific coordinative tasks but
are not permanently located in
the GP practice.
Do you have any experience
with this?
Theme: Delegation
7. Delegation of medical
services from doctor to
medical practice assistant
in the practice
Which additional tasks would you
hand over to your medical practice
assistant?
8. Recognition of the
professional group of the
medical practice assistant
What could be an appropriate
appreciation/compensation for
the additional services and
responsibilities of the medical
practice assistant?
9. Team collaboration How do you exchange information
about patients in your team?
10. Multidisciplinary
collaboration
Could you imagine having an
employee in your practice who
is neither a medical doctor nor
a medical assistant, but belongs
to a new professional group and
takes on tasks of care and
coordination?
Theme: Optimal Care
11. Definition of optimal
patient care from a
primary care perspective
and viewpoint of the MPA
What would optimal care mean
for your sample patient from
the question in the beginning?
Theme: Community Care
12. Use of social and medical
support services in the
region
What are your experiences regarding
medical and social support services?
Which ones do your patients use?
Topic guide with exemplary questions. Complete interview guideline is
available from the authors upon request. Questions could be individually
adapted to the conversation flow of the respective interviews
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steps have been implemented: (1) transcription of the in-
terviews; (2) familiarisation with the interviews; (3) cod-
ing; (4) developing a working analytical framework; (5)
applying the analytical framework; (6) charting data into
the framework matrix; and (7) interpreting the data. The in-
terviews were analysed by a research team that included re-
searchers from different professional disciplines, such as
GPs, health services researchers, a sociologist and a public
health scientist. By applying these different perspectives, re-
searcher (investigator-) triangulation was achieved. Two re-
searchers (CT, JS) coded the interviews independently.
Subsequently, both researchers compared, discussed and, if
necessary, adjusted the coding. A combined deductive and
inductive approach was used for the coding procedure. Con-
sensus on the interpretation was established in the group of
researchers after a thorough discussion of the data.
All interviews were analysed with the support of the
qualitative analysis software program MAXQDA® 18
(VERBI software GmbH, Germany).
Results
We interviewed 16 GPs from nine different city districts
and, independently, 16 MPAs from the same practices (for
details, see Table 2). Each interview lasted 45 to 60 min.
Coordination from the perspective of the GPs
Initially, we wanted to know what the term “coordin-
ation”means to GPs in the context of care for patients
with multimorbidity. The interviewed GPs had various
opinions on what coordination consists of.
“Well everything I do here is actually coordination, I
bring the various support possibilities and healthcare
services together, yes. I do little else except coordinate.
Apart from prescribing tablets. [ …]and so we actually
do very little. We are more a sort of dispatcher; we
connect where and when it makes sense.”(GP_10).
“[…]Coordination means: one learns from the
other …and one informs the other, like hospitals
and GPs. [ …]”(GP_11).
“Determining the medication regime; ensuring home
care; referrals, also for physiotherapy, logotherapy etc.;
avoiding hospitalisations; and the quality of life of the
patient and the psychosocial context are also
important.”(GP_15).
The coordination role of the GP starts with being the
primary contact for the patient, assessing the needs of
the patient and their relatives and organising further
help structures.
The general practice constitutes a social and medical
contact point and simultaneously provides immediate
and sustained medical care. It can act as an advisory
point for medical matters but also for social and legal
problems, relating to questions relevant to family as well
as local community relationships, and questions relevant
to social legislation like gaining access to social benefits
and socio-medical services.
“[…]The general practitioner is the person who is
always in charge.”(GP_7).
GPs perceive themselves as the appropriate person to
coordinate patients’care. They take on a coordinating role
by law (Book V of the Social Law § 73), but also see them-
selves as the authority to manage the patient’sentirecare
process. The role of the coordinator includes organisa-
tional and administrative matters, as well as coordinating
care involving other medical and non-medical profes-
sionals, such as other medical specialists, home care ser-
vices, physiotherapists, psychologists or health insurance.
GPs cite examples of successful coordination, such as
the involvement of patients’relatives, the implementa-
tion of the standardised national medication plan, the
introduction of disease management programs (DMP),
as well as quality assurance measures.
In summary, from the GPs’perspective, good
coordination:
requires defining what is best for the patients and
acting in the interests of the patients;
in general practice, is based on reliability as well as
trust in the practice staff;
requires that all medical and non-medical key
players engaged in the patient’s care have knowledge
of and communicate with each other.
Barriers to successful coordination
Frequently reported problems in the coordination of pa-
tients’care were constraints resulting from administra-
tive and organisational issues, the regulatory framework
for GPs in Germany, and the communication with other
health professionals and specialists.
Table 2 Characteristics of interviewees by group (n= 32)
Characteristics of interviewees
GPs (n = 16) MPAs (n = 16)
Gender Male: 10 Male: 2
Female: 6 Female: 14
Age (years) Median: 54.5
(Range: 39–69)
Median: 44
(Range: 21–63)
Practice type Single handed: 7
Group: 9
Number of employees
in the practice
Median: 5.5 (Range: 3–19)
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Organisation and administration
Many of the patients’needs are not of a medical na-
ture. Some of the interviewed GPs feel that there is a
need to delegate services that do not fall within their
responsibilities to other professionals. These needs are
not of a medical nature and rather relate to social
and legal issues.
“[…]There is a need for services that essentially don’t
fall into the responsibility of the GPs because they are
not of a medical nature. They could be delegated to a
person who is qualified in social matters, for example,
social services.”(GP_16).
Many interviewed GPs feel burdened by the lack of time
in the care of patients with complex needs. The scheduled
time for consultation does not provide enough time to
deal with the multiple issues of the patient.
“Lack of time is the biggest problem. The patients have
too many issues …and after the consultation, they
don’t know any more what has been discussed. I try to
write it down for them, but I only have the time for
very short notes. [ …]”(GP_8).
The burden of administrative and organisational re-
quirements seems to be particularly high when caring
for patients with multimorbidity.
According to the interviewed GPs, organisational and
administrative tasks include accounting, arranging ap-
pointments with specialists and other healthcare pro-
viders, filling out and signing forms (such as assessment
forms for nursing care), organising home care services,
and organising the transfer of immobilised patients to
hospitals or other health specialists.
“Let me put it this way. We have an 85-year-old
male patient; we have to arrange appointments for
him, organise transport and even have to print out
his medical report and make sure he takes it with
him.”(GP_5).
Some GPs feel that certain organisational duties could
be assigned to a trusted MPA, but most GPs want to re-
tain ultimate responsibility. Others would appreciate an
additional employee to take responsibility for all future
organisational and administrative tasks.
“I would wish that all these forms […]could be signed
by a nurse, e.g. for home care, ergotherapy, even the
repeat prescriptions. Why not? This would be a relief
for me because for this you don’t need to be a doctor
[…]But this isn’t possible with the existing
bureaucratic regulations. “(GP_1).
Regulatory framework for GPs in Germany
Individual elements of the general framework of the Ger-
man health system seem to cause a barrier to patient care.
The interviewed GPs reported that they need to justify
necessary care beyond the basic level of services, which
causes extra administrative work.
In this context, a frequently mentioned problem is the
insufficient renumeration for the care of patients with
complex and frequent needs. GPs describe that they are
often in conflict in terms of whether to act in line with
economic considerations or to offer optimal care for this
patient group by investing a considerable amount of
time and financial resources.
“[…]The lump sum payment per patient per three
months only covers two visits per patient. Patients who
are chronically ill and have to come more often are
not sufficiently covered. [ …]If I wanted to work
economically, I could only see the patients twice every
three months. But even if the patient is not here, I still
have to react to diagnostic reports and have to
organise things like transports to other doctors or
arranging appointments [ …]If I want to care for the
patients at the highest possible level, I have to do that
for free.”(GP_5).
In Germany, every patient has to be personally seen by
the doctor, even for minor ailments. Some interviewees
believe that an employee with an additional qualification
in certain fields could relieve the GP and provide more
room for the care of patients with complex care needs.
“This would indeed be a relief for us, but it would also
turn our system on its head (laughs). We are a doctor-
dominated system and every patient with a bug, such
as a cold, has to visit a GP. Of course, it would make
more sense if not every patient with minor ailments
was obliged to visit a GP; why should I as a doctor see
every patient with a cold? It’s completely absurd. Eco-
nomically, of course, it makes sense: financially it is at-
tractive to see healthy patients.”(GP_12).
In Germany, GPs don’t have a gatekeeping function.
Therefore, some patients don’tevenhaveaGP.Most
of the interviewed GPs perceived that multimorbid
patients with insufficient social support from a stable
social environment who are not in contact with a
general practice, are in danger of slipping through the
net of the German healthcare system. On the other
hand, patients with complex needs may make exten-
sive use of the system. For both patient groups, it
would be helpful if someone led them through the
“jungle”of manifold available healthcare resources
and coordinated their care.
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“This is a structural problem: someone rambles
through the health care system without any
coordination, then suddenly hits the GP practice with
a completely unclear situation. Then it is impossible to
reconstruct the story because reports were not collected
anywhere”(GP_12).
Communication with external healthcare providers
The interviewed GPs reported a lack of sufficient com-
munication structures with other caregivers such as spe-
cialist physicians, home care nurses or physiotherapists.
Much time has to be invested into trying to contact
other healthcare providers in order to coordinate the
next steps in the care of the patient. In Germany, patient
data is not exchanged electronically between healthcare
professionals. External patient documents such as dis-
charge letters and findings are usually sent by post.
Often medical reports are only sent to GPs after re-
peated reminders. As a result, the coordination of care
becomes difficult when important information is missing
or is difficult and time-consuming to obtain.
“Iactuallydon’t spend most of my time treating patients
and writing prescriptions; I spend most of my time
talking, listening, calling someone, not being able to
reach someone and then having to call someone else.
This makes some situations very difficult.”(GP_14).
The GPs reasoned that better cooperative treatment
with the possibility of easily accessible, specialised
counselling for patient-related issues would lead to
better patient care.
In the interviews, they often emphasised the difficulty
that patients have obtaining appointments with special-
ists, as well as the lack of opportunities for professional
exchange with other doctors.
“To obtain an appointment with a specialist
sometimes is really difficult for the patient. Principally,
it is an option that we as GPs try to arrange for an
appointment, but we also have to phone several times
before we reach somebody, and this is extremely time-
consuming and often unsuccessful. […]So, you have to
send the patient home and try it again after office
hours, and finally you have to ask the patient to come
again to your practice to explain everything. All this
requires considerable effort …“(GP_3).
Discharge from hospital
Another frequently mentioned problem is the uncoordin-
ated management of discharge from hospital. Often the
patient gets discharged from hospital without ensuring the
further continuation of treatment. The GPs don’treceive
information about the patient’s discharge in advance to
prepare further care. Often discharge takes place just be-
fore the weekend and without sufficient medication.
“I believe that patients are getting pushed out of
clinics. From a GP’s perspective, we are being
presented with a fait accompli without being
consulted. And even as GPs, we can’t organise home
care on a Friday evening. The cooperation just doesn’t
work.”(GP_2).
Through premature and/or uncoordinated discharge
from the hospital, aftercare is shifted from the hospital
to the general practice.
Concepts for task shifting to an additional healthcare
professional inside or outside the general practice
During the interviews, the GPs identified some tasks and
responsibilities that, in principle, could be shifted to other
professional groups inside or outside general practice (see
Table 3). From the perspective of the GPs, it is an essential
prerequisite for task shifting that the patients are open to
a new person becoming involved in their care. The pa-
tients need a person whom they can trust.
During the course of the interview, the GPs were asked
for their views on two different concepts to support the
general practice in the coordination of care: the deploy-
ment of an external navigator who is not affiliated with
the general practice; or, alternatively, the employment of a
further healthcare professional within the practice.
Deployment of an external navigator
The interviewer explained the definition of an external
navigator as a person who is not employed by the prac-
tice but is affiliated to another institution that partici-
pates in the collaborative care of the patient.
Only very few of the interviewed GPs had ever heard
or read about the possible role of a “navigator”, and
most of them were sceptical. Initially, they could not im-
agine which professional group had to the skills and
abilities to work as an external navigator. For GPs, a
Table 3 Possible areas of responsibilities for an additional
health care professional
Arrangement of appointments with specialists
Organisation of the patient transfer
Providing advice relating to social and legal services
Undertaking home visits
Coordination of patients with dementia or multimorbidity
Contact and communication with other health care
professionals involved in the care
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well-coordinated team is crucial. An external person,
who does not know the team members and the work
structure of the practice, could be a disruptive factor.
The GPs feared needing to invest even more time and
energy into the integration of yet another person who
does not know the work processes of the practice.
“(…)No, I haven’t had any experience with it at all. I
think it’s a waste of time and energy. I can’t see how
this cooperation can work out; it would be like Chinese
Whispers. There will be yet another person between me
and the patient. I’d prefer to deal directly with the
patient or ask my MPA to sort things out. I think it
will just cause further mistakes and I don’t have the
time. When it comes to time management, I can’t see
how it would improve anything either.”(GP_14).
Table 4gives an overview of the reasons GPs are scep-
tical about both task shifting concepts or why they re-
fuse to work with an external navigator or an additional
employee inside the general practice.
A few GPs still felt attracted by the idea of an external
navigator, although they remained sceptical at the same
time.
“Yes, for the moment, as an interim solution, this
might be a good idea. But I think in the long run,
another institution can’t replace what should actually
happen in the practices. [ …]And there are too many
multimorbid patients. So, this would only work in
lighthouse projects but could not be applied
comprehensively. [ …]”(GP_12).
Deployment of other healthcare professionals inside the
practice
The idea of the employment of a further healthcare pro-
fessional within the practice was accepted more openly
than the idea of an external navigator. From the perspec-
tive of some of the interviewed GPs, shifting tasks and
responsibilities to an MPA could be a possible solution,
either with an MPA who already is a member of the
team or to an additional MPA.
“The point is that the medical practice assistants know
the patients, and this, of course, gives them an enormous
advantage over external professionals.”(GP_13).
The idea of assigning a person who works within the
practice and who is familiar with social and legal matters
was mentioned frequently by the GPs.
“Anyone medical, social, possibly social AND medical,
so that they can take part in the process. In an ideal
world it would be a medical practice assistant or a
nurse or even better, a medical practice assistant who
has had further training.”(GP_11).
Most of the interviewees felt that an additional per-
son involved in the care of multimorbid patients in-
side the practice could reduce the burden of the GPs
as well as MPAs, given that the effort required to in-
volve this person is low.
Social worker/ person who is familiar with social and legal
matters
GPs are highly aware of the patients’unmet needs with
regards to social and legal issues, especially in the context
of multimorbidity. Upon asking the GPs which profes-
sional group would be the most appropriate to meet these
needs, the majority of GPs mentioned the need for a quali-
fied person to take care of all social and legal demands.
“Well I would like it if I had someone who could take
over the social issues, a kind of social worker. There
are lots of problems which older patients have and
can’t deal with any more, such as writing applications
and filling out forms. I would like it if there was
someone here who could explain how to draw up a
living will. I just don’t have the time and neither do
my MPAs, so I can’t delegate it to them.”(GP_9).
“Idon’t know how other doctors manage, but I
think they face the same difficulties. I have
problems with all this social legislation, I never
really got to grips with. This gets more and more
complicated. [ …]How is a physician sitting in his
practice all day long supposed to understand this?
Ifthiscouldbedonebysomeoneelse…”(GP_1).
Several possible ideas for assigning social and legal
matters to an additional member of the care team were
discussed. These consisted of:
A social worker who is employed within the general
practice, belonging to the established practice team.
A social worker who is not directly affiliated with
the general practice, but to another institution.
Table 4 Arguments against a task shifting concept
Limited financial resources
Requires a large amount of time
MPAs take over most of the tasks already
MPAs are familiar with the patients
Deployment location only possible outside the practice,
for example, in home care
Patients need a person they know
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A social worker who is shared by several general
practices in the district and who could be deployed
to different practices on an hourly basis.
Qualifying the existing MPA with training or
specialisation in social and legal affairs. However, to
ensure financing, additional services must be
covered by the public health insurance scheme.
The role of the social worker is primarily to be the
first contact person for patients, relatives, GPs and other
relevant parties with regards to social and legal issues.
Perspective of the MPAs
MPAs perceived similar problems to GPs in the co-
ordination of care of multimorbid patients. Organisa-
tional and administrative issues appeared to be a
major concern and require additional time for MPAs
as well as for GPs.
The MPAs described themselves as the principally re-
sponsible person for administrative and organisational
tasks. Phone calls, arranging appointments and filling in
forms are typical administrative and organisational tasks
for MPAs.
“It is really time-consuming to arrange appointments
and organise the transport of immobile patients. [ …]”
(MPA_7).
By assigning the full responsibility for these matters to
MPAs, in their view, double structures in administrative
procedures could be avoided.
„[…]As soon as the request for nursing care is
received it is processed by us. Then the doctor checks it
back; he determines whether everything is filled in
correctly. Finally, he signs it and gives it back to us to
send the formula back to the patient or nursing care.”
(MPA_15).
In contrast to the GPs, the MPAs tended to focus
more on the coordination within the general practice
and the cooperation of everyone involved. For example,
the issues of priority were the communication with the
patient and their relatives as well as the regular schedul-
ing of patients’appointments.
“Important is the cooperation between my boss and us,
and with the relatives; only if we all have the same
goal can things work out”. (MPA_9).
The interviewed MPAs were highly motivated and
willing to extend their knowledge by undergoing further
training. Nevertheless, a lack of time was considered to
be a barrier to acquiring additional qualifications.
“Very often you would like to do more, but you simply
don‘t have the time. This really is a shame in this
profession: we go through our day like a hamster on a
wheel and we can only touch the surface. But when
you do this very thoroughly you also are more
satisfied.”(MPA_16).
MPAs seem to be persons of trust to whom patients
can talk to on their own level. In contrast, GPs are seen
as authority figures. Accordingly, patients entrust MPAs
with more intimate information. MPAs hereby under-
take the important task of distinguishing between per-
sonal and health-related information and decide what to
communicate to the GP.
“For example, when you are alone with a patient
while taking a blood sample, they take the
opportunity to tell me things they wouldn’twantto
report to the doctor.”(MPA_6).
“The doctor is seen almost as a god by some patients.
So, we are rather on the same level and they rather
share their worries with me.”(MPA_16).
In line with the perspectives of the GPs, the MPAs were
concerned that an additional coordinator or navigator
from outside the practice might disturb the workflow.
“Well, I think if we were better organised, we would be
able to manage everything from within. Somebody
from the outside would really need time to understand
the processes, and probably every practice is a bit
different.”(MPA_16).
Discussion
This paper explores the perspective of GPs, complemented
by the views of MPAs of the same practices, of require-
ments and barriers for the coordination of care of patients
with complex needs, such as multimorbid patients.
While the responsibility of the GPs for the coordin-
ation of patient care is embodied in German social law,
in the interviews we found very heterogeneous views on
what coordination entails, especially in the context of
complex care for multimorbid patients.
A study from Krug H. demonstrates the necessity of add-
itional expenditure for the care of elderly, multimorbid pa-
tients. New financial concepts should be adopted to prevent
negligence occurring in the patients’medical care [23].
Our results confirm the problem of the lack of ad-
equate compensation for coordination tasks, which may
hinder the GPs from giving optimal care to their pa-
tients. GPs have to consider their resources while trying
to provide optimal care to their patients [24,25].
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A barrier discussed by many of the interviewed GPs and
MPAs is the insufficient cooperation and communication
between different players in the healthcare system, espe-
cially across the sectoral borders. Successful cooperation
requires a full and timely flow of information.
The interviews show that the importance of cooper-
ation across the sectors is particularly reflected in the
problems regarding the discharge of the patient from
hospital. Treatment reports and discharge letters were
reported as often not reaching the GPs in time. Medica-
tion regimes as recommended by the hospital are often
not fully understood by the patients at the time of
discharge.
This is in line with previous research. An international
health policy survey with primary care physicians from
2006 shows that more than 50% of primary care physi-
cians wait over 14 days before receiving the patients’full
report from the hospital after their discharge. 70% of the
responding GPs stated the importance of better integrat-
ing information systems between office-based physicians
and hospitals [6]. Other studies confirm that discontinu-
ation of care happens at the interface between the in-
patient and outpatient sectors [23,26–29]. Also Gulliford
et al. confirm that problems with management continuity
of care are highly associated with hospital utilisation [3].
The focus still is on acute medical care and specialist care.
Too little emphasis has been given to life-long support for
chronically ill patients in primary care [2]; life-long sup-
port measures are implemented in the general practice. A
coordinated care in general practice including a good
relationship between doctors and patients and the collab-
oration between different professions in different settings
goes hand in hand with continuity of care [3].
Furthermore, statutory regulations require substantial
time and effort for administrative and organisational mat-
ters. The documentation of work, filling in forms and ad-
ministrative tasks are part of the doctors’responsibilities.
The interviews with GPs confirm that these tasks are a
major part of the coordination of care in general prac-
tice. The interviewed GPs burdened by assuming organ-
isational and administrative tasks while providing
medical care. Assigning responsibility for these tasks to
someone else, such as an additional MPA, could allow
them to focus on the medical care of the patients. The
findings from our interviews are in line with the findings
of a study from Margolius et al.; at times of primary care
physician shortage, it may help to improve patients’care
by reorganising practices to expand the capacity for staff
members to engage in different tasks [30].
While expressing a need for support and identifying
possible tasks that could be delegated, GPs mostly seem
to favour support by an additional healthcare profes-
sional who works within the general practice while
retaining ultimate responsibility.
The findings from our interviews with MPAs confirm
that they are highly motivated to undergo further train-
ing to take over more responsibilities and to relieve GPs.
Previous studies also show that MPAs are interested in
gaining supplementary qualifications. Further training of
MPAs can strengthen the role of the MPA in the prac-
tice team and improve the quality of patients’care as
well as the satisfaction of patients [31,32]. However, the
expansion of roles in general practice will only be feas-
ible if GPs do not feel threatened by the shift of territory
and responsibility [15,17].
As for coordination tasks, which were the focus of our
study, the question arises as to whether one single, uni-
form concept for the support of the GPs would fit the
setting of each individual general practice. The expert
report from the ‘Advisory Council on the Assessment of
Developments in the Healthcare System’[2] underlined
the need for further structural development in primary
healthcare in Germany, involving a restructured distribu-
tion of work and competencies, in which non-medical
professionals will take over more tasks and responsibil-
ity. The advisory council stressed the need for research
on the significance of organisational features such as
leadership and practice culture in Germany, as well as
internal resources for changes on health outcomes in
general practice [2].
GPs are highly aware of multimorbid patients’un-
met social needs and they do not feel sufficiently
equipped and qualified to respond to questions con-
cerning the social and legal sector. Another profes-
sional group –such as social workers or MPAs with
further training in social and legal fields, in cooper-
ation with other local institutions –could address so-
cial and legal issues without interfering with GPs’
responsibility. These findings are in line with previous
studies. Social workers can provide comprehensive
care, which goes hand in hand with a broad range of
roles, such as, helping patients to cope with their
complex chronic illness providing counselling, or sup-
porting patients and families in their daily routines
[33]. McGregor et al. found that patients with com-
plex needs may obtain measurable health benefits
from the deployment of social workers in primary
care settings [34]. According to Zimmermann et al.,
cooperative and “low-threshold”solutions to employ
non-medical support measures in the general practice
are required [35].
Strengths and limitations
Certain limitations should be taken into account when
interpreting the findings of the study.
Recruiting GPs from a practice-based research net-
work assures sufficient participation rates but might
introduce sampling effects and bias by selecting GPs
Stumm et al. BMC Family Practice (2019) 20:160 Page 9 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
who are interested in research and therefore more com-
mitted than others [36]. However, the non-random se-
lection of participants by applying a purposive sampling
strategy is the adequate choice when aiming at under-
standing the opinion of individuals who are already in-
formed or interested in the topic of the study [37].
We believe that by performing a comprehensive
survey as the next step in the project, on the basis of
the results of the qualitative interviews, a broader
perspective of a large number of GPs will be inte-
grated with the deeper insights of a selected group.
By using the framework approach to analyse the data,
we could benefit from multidisciplinary teamwork.
This approach may also add different perspectives
and provide more depth to the data.
The patient perspective will be evaluated in further
subprojects: an ongoing interview study explores the
view of chronically ill patients on the quality of care and
unmet needs. Furthermore, as part of a regular nation-
wide survey members of the public are asked for their
view on delegation of tasks to medical practice assis-
tants. The results will complement the perspective of
GPs and MPAs presented here.
There may also be limitations concerning the transfer-
ability of the results to other countries. The German
healthcare system neither has a gatekeeping system nor
rules for committing patients to specific practices. Our
findings reflect the characteristics of German settings.
Nonetheless, we discussed and underpinned our findings
with several studies from the international literature, in
which new models of coordination in general practice
have already been developed.
Conclusions
Coordination is a primary component in patient care
in general practice. The term “coordination”includes
awiderangeoftasks,whichvarydependingonthe
structure of the practice. The GP, as the coordinator
of the whole process of care, has the main responsi-
bility. Therefore, they also take responsibility for tasks
which aren’t exclusively medical and are not remuner-
ated. The support of patients with multimorbidity, in
particular, is comprehensive and involves players
across different sectors. In order to ensure optimal
care for this patient group, the general practice needs
to obtain coordinative support. The findings from the
interviews in this study show that GPs and MPAs
hold diverse opinions about possible solutions. Both
GPs and MPAs are generally interested in implement-
ing new concepts, but they are also still sceptical
about the practicability. GPs are nevertheless more
open to the deployment of an additional healthcare
professional within the practice rather than from
outside.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12875-019-1048-y.
Additional file 1: Figure S1. NAVICARE network. Authors own figure of
NAVICARE project structure
Abbreviations
DMP: Disease management programs; GP: General Practitioner; MPA: Medical
practice assistant
Acknowledgements
The authors would like to thank all interviewees for participating in this
study and sharing their ideas, knowledge and experiences with the
coordination of multimorbid patients.
Furthermore, we would like to thank all of the researchers for participating in
the interviews as well as supporting the NAVICARE research consortium
team and the funding of the German Ministry of Education and Research.
Authors’contributions
All authors qualify as an author according to the ICMJE guidelines. They have
read the final draft of the manuscript and have revised it for important
intellectual content. In the following, we highlight the particular
commitment of individual authors in certain areas: J.S., S.D., L.P. and C.H.
developed the research questions. J.S., L.P. and S.D. conducted the
interviews. J.S. and C.T. predominantly performed the qualitative analysis. S.D.
and C.T. monitored the data collection for the entire study. As part of the
analysis, S.D., C.T. and C.H. regularly discussed the results of the coding
process with J.S. to ensure a high-quality analysis. S.Schn. substantially con-
tributed to the results section and discussion of this paper by integrating the
patient perspective into the interpretation of this study by providing results
from the patient survey. L.D. substantially supported the study as well as the
writing process with her professional expertise in the field of delegation and
task shifting in primary care. J.S. wrote and revised the first draft of the
manuscript and all authors contributed to editing the article. S.D., C.T., C.H.,
S.Schn. and L.D. contributed significantly to subsequent manuscript revisions.
All authors have read and approved to the final version of the manuscript.
Funding
COMPASS is part of the research consortium “NAVICARE –Patient-centred
health service research”and is funded by the German Ministry of Education
and Research (BMBF- grant no. 01GY1601).
The funding body had no role in the design and conduct of the study, data
collection, analysis, and interpretation of the data; nor in the preparation,
review and approval of the manuscript.
The publication is supported by the Open Access Publication Fund, provided
by the Charité-Universitaetsmedizin Berlin, and the German Research
Foundation (DFG).
Availability of data and materials
The data in this paper is based on the transcripts of 16 audio-recorded inter-
views with GPs and their MPAs. Data supporting the findings of this study
can be found in the translated quotes in the results section of this article.
However, to protect the participants’identities, the full data from this study
(transcripts and audio files) will not be made available to the public.
Ethics approval and consent to participate
The study protocol for this qualitative study was approved by the ethical
review committee of the Charité - Universitaetsmedizin Berlin (reference
EA4/034/17). All participants gave written informed consent to participate in
the study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Stumm et al. BMC Family Practice (2019) 20:160 Page 10 of 11
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Author details
1
Institute of General Practice, Charité –Universitaetsmedizin Berlin,
Charitéplatz 1, 10117 Berlin, Germany.
2
Institute of Medical Sociology and
Rehabilitation Science, Charité - Universitaetsmedizin Berlin, Charitéplatz 1,
10117 Berlin, Germany.
Received: 10 July 2019 Accepted: 7 November 2019
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