Strengthening continuity of care for multiple long-term conditions in India through integrated referral and follow-up systems (SYNC-RF): A mixed-methods study protocol

Introduction Multiple long-term conditions (MLTC) or multimorbidity are becoming increasingly common in low- and middle-income countries, such as India, placing demands on constrained primary healthcare systems that are still predominantly organised around acute care and single-condition management. Weak referral, counter-referral, and follow-up processes contribute to fragmented care and poor continuity for people living with MLTC. This programme of work aims to develop an integrated referral and follow-up model for people with MLTC who seek care in the primary healthcare system in India. Methods This sequential, multistage mixed-methods research programme will be conducted in three interlinked phases. First, a systematic review of global literature will be conducted, which will synthesise evidence on referral and follow-up models or systems for providing MLTC care. Second, a convergent mixed-methods assessment will be undertaken in Jodhpur district, Rajasthan, including facility assessments of Primary Health Centres and linked referral facilities, a cross-sectional survey of adults with MLTC, and in-depth interviews with patients, caregivers, healthcare providers, and policymakers. Quantitative data will be analysed using descriptive and inferential statistics, while qualitative data will be analysed using reflexive thematic analysis. Third, an integrated referral and follow-up model, SYNC-RF (SYstem for Navigation, Coordination, Referral, and Follow-up), will be developed based on the triangulated evidence and refined through expert consultation to ensure feasibility and contextual relevance. Conclusion The study will generate context-specific evidence on gaps, barriers, and enabling factors affecting referral and follow-up for MLTC care. The integrated model developed through this research is expected to strengthen continuity of care, improve coordination across various levels of the health system, and improve health outcomes for those living with MLTC.