Supporting shared decision making for older people with multiple health and social care needs: a realist synthesis

Background: Health care systems are increasingly moving towards more integrated approaches. Shared decision making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; particularly for older people with complex needs. Objectives: Provide a context relevant understanding of how interventions to facilitate SDM might work for older people with multiple health and care needs, and how they might be applied in integrated care models. Design: Realist synthesis following RAMESES publication standards Participants: Twenty-four stakeholders took part in interviews Data sources: Electronic databases, Medline (PubMed), The Cochrane Library, Scopus, Google, Google Scholar, and lateral searches. All types of evidence were included. Review methods: Iterative stakeholder driven, three-stage approach, involving: 1) scoping literature and stakeholder interviews (n-13) to develop initial programme theory/ies, 2) systematic searches for evidence to test and develop the theories, and 3) validation of programme theory/ies with stakeholders (n=11). Results: We included 88 papers; 29 focused on older people or people with complex needs. We identified four theories (context-mechanism-outcome configurations) which together provide an account of what needs to be in place for SDM to work for older people with complex needs. This includes: • understanding and assessing patient and carer values and capacity to access and use care, • organising systems to support and prioritise SDM, • supporting and preparing patients and family carers to engage in SDM • a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that create trust between those involved, that allow service users to feel that they are respected and understood, and that engender confidence to engage in SDM. Limitations: There is a lack of evidence on interventions to promote SDM in older people with complex needs, or on interprofessional approaches to SDM. Conclusions: Models of SDM for older people with complex health and care needs should be conceptualised as a series of conversations that patients, and their family carers, may have with a variety of different health and care professionals. To embed SDM in practice requires a shift from a biomedical focus to a more person-centred ethos. Service providers are likely to need support, both in terms of the way services are organised and delivered and in terms of their own continuing professional development. Older people with complex needs may need support to engage in SDM. How this support is best provided needs further exploration, although face to face interactions and ongoing patient-professional relationships are key. Future work: This review suggests there is need for further work to establish how organisational structures can be better aligned to the needs of older people with complex needs. This includes a need to define and evaluate the contribution that different members of Health and care teams can make to SDM for older people with complex health and care needs. Study registration: This study is registered as PROSPERO CRD42016039013