We evaluated the implementation of the ZWIP with a mixed methods study, consisting of (1) a quantitative evaluation by means of a survey and data collected during the implementation and use of the ZWIP, followed by (2) a qualitative evaluation by means of semi-structured interviews with purposively selected participants. The local ethics committee, the Committee on Research involving Human Subjects Arnhem-Nijmegen, reviewed the study and stated that no formal approval was required.
Participants of the study were community-dwelling frail older people, who were patients of participating general practices in the province of Gelderland or Noord-Brabant, the Netherlands; their informal caregivers; and healthcare and welfare professionals involved in their care. They participated in the ZWIP during its implementation phase, which started in September 2010 and ended on the first of July 2011. We monitored the use of the ZWIP and its implementation strategies for both frail older people and professionals. Further, professionals were surveyed and interviewed. We chose not to survey or interview frail older people and informal caregivers as the project had already been time-consuming for them, and they would be surveyed and interviewed as part of the project’s future effect evaluation as well.
Intervention: the Health and Welfare Information Portal
The ZWIP was developed by means of Intervention Mapping [14
], a method for the systematic development of evidence-informed interventions. Throughout this development, future users, i.e. primary care professionals and geriatricians (n
15), as well as (frail) older people and informal caregivers (n
14), were involved extensively trough their participation in working groups. These working groups started with participants specifying which problems related to interprofessional collaboration and self-management by frail older people should be solved by the ZWIP, for example not knowing which professionals are involved in the care of a particular frail older person and professionals not being able to contact each other. Then, theories matching the identified determinants of these problems were used to support the development of the intervention. These included Social Cognitive Theory[15
], Goal Setting Theory [16
] and elements of organizational change theories [17
]. The involvement of the target populations continued during the iterative development process of the ZWIP.
The ZWIP can be considered a combination of an Electronic Health Record accessible to the frail older person, informal caregiver and all professionals involved, with a tool for interprofessional and patient-professional communication. The ZWIP consists of (1) information about the frail older person’s health, functioning and social situation, contact information about professionals involved in their care, and care-related goals formulated by or with the frail older person, (2) a secure messaging system for communication between the frail older person and one or more professionals or between professionals, and (3) tailored educational materials for the frail older person and informal caregiver. The frail older persons hold the key to the ZWIP, as they decide which professionals are granted access to their personal ZWIP. The ZWIP can be entered by logging on to a website which conforms to Dutch security regulations. This website, which runs in Dutch, can be accessed from any computer. Frail older persons and their informal caregivers can log on by means of a shared user name and password, while professionals need a security token for logging on. Additional file 1
presents a movie which demonstrates the use of the ZWIP by a frail older person and her informal caregiver.
Implementation of the Health and Welfare Information Portal
The ZWIP implementation team consisted of the project manager, physicians, a nurse, a nurse scientist experienced with implementation, and research assistants working for the department of Geriatric Medicine of the Radboud University Nijmegen Medical Centre. They implemented the ZWIP using tailored implementation strategies for each target population, i.e. frail older people and informal caregivers, professionals and the employing organizations of professionals. An overview of the implementation strategies used is provided in Table .
Implementation strategies as planned for each target population
We invited general practices affiliated with this University Hospital or involved in the program’s development to participate in the ZWIP, which was made available to them at no charge for the duration of the study. The participating practices invited local primary care professionals from all relevant disciplines involved in the care of frail older people, such as physiotherapists, district nurses and social workers, to take part in the programs’ interprofessional educational program. This program, for which continuing medical education credits were available, addressed screening for frailty, self-management support, interprofessional collaboration, and use of the ZWIP during three three-hour workshop meetings. In addition, professionals received coaching in specific components of the program, and were supported by a telephonic helpdesk. Further, financial compensation was provided for the time invested in the program.
The general practices screened their populations of ≥70
years for frailty using a two-step screening questionnaire (Easycare-TOS). In the first step, the general practitioner (GP) selected patients which were considered (possibly) frail. In the second step, the thus selected patients were screened for frailty on the physical, psychological and social domain during a home visit by a nurse or gerontological social worker. During a second home visit, all people who were frail were invited to participate in the ZWIP. If they gave informed consent, a ZWIP was installed for them.
We supported frail older people and informal caregivers in using the ZWIP by a number of strategies, such as offering a visit by a volunteer who could demonstrate the ZWIP, having a telephonic helpdesk available, and making the ZWIP available in print when this was preferred.
The quantitative evaluation of the implementation of the ZWIP consisted of a survey for professionals, and an evaluation of the data collected about the use of the implementation strategies and the data from the ZWIP itself. Data collected included the numbers of older people screened, the number of participants, the number of messages sent, the number of professionals participating in a frail older person’s ZWIP, the number of participants who logged on to the ZWIP, the number of calls to the telephonic helpdesk and the number of visits to frail older people by volunteers.
The survey for professionals was sent out at the beginning of July 2011. The survey was developed building on existing questionnaires used previously to evaluate the implementation of complex interventions and on previous experience of the authors. The survey included questions concerning demographics, time spent on using the ZWIP, perceived value of the implementation strategies, and barriers and facilitators for the use of the ZWIP. We used separate questionnaires for GPs, for nurses and gerontological social workers conducting the screening, and for other professionals. Participants were asked to fill out the survey online, those who did not respond were sent a paper version.
The qualitative evaluation consisted of semi-structured interviews about experiences with the implementation process and perceived barriers and facilitators for the use of the ZWIP. A topic list for these interviews was developed by members of the research group and was adjusted until consensus was reached. We conducted these interviews with 12 purposively selected professionals, who had a variety of experiences with the implementation process of the ZWIP. This was arranged by selecting professionals from several disciplines and with different roles in the implementation process, who came from three general practices with varying levels of adoption of the ZWIP. In addition, we interviewed members of the implementation team, who were not involved in conducting its evaluation. Interviews were conducted by members of the research group (LvN, MP, SR) and were transcribed verbatim by a research assistant.
We used descriptive statistics to describe baseline characteristics of participants, data collected about the implementation and the actual use of the ZWIP, and data derived from the survey for professionals. The qualitative data gathered in the semi-structured interviews were analyzed by two members of the research group (MP, SR) using content analysis [18
]. Interviews were conducted in parallel with data analysis, using Atlas.ti to support this. We conducted interviews until theoretical saturation was achieved.