Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management.
To explore processes underpinning the implementation of CKD management in primary care.
Design and setting
Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester.
Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data.
A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions.
Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity.
doctor–patient relations; kidney disease; chronic; normalisation process theory; primary care
While injuries are a leading health concern for Aboriginal populations, injury rates and types vary substantially across bands. The uniqueness of Aboriginal communities highlights the importance of collecting community-level injury surveillance data to assist with identifying local injury patterns, setting priorities for action and evaluating programs. Secwepemc First Nations communities in British Columbia, Canada, implemented the Injury Surveillance Project using the Aboriginal Community-Centered Injury Surveillance System. This paper presents findings from a community-based participatory process evaluation of the Injury Surveillance Project. Qualitative data collection methods were informed by OCAP (Ownership, Control, Access, and Possession) principles and included focus groups, interviews and document review. Results focused on lessons learned through the planning, implementation and management of the Injury Surveillance Project identifying lessons related to: project leadership and staff, training, project funding, initial project outcomes, and community readiness. Key findings included the central importance of a community-based and paced approach guided by OCAP principles, the key role of leadership and project champions, and the strongly collaborative relationships between the project communities. Findings may assist with successful implementation of community-based health surveillance in other settings and with other health issues and illustrate another path to self-determination for Aboriginal communities. The evaluation methods represent an example of a collaborative community-driven approach guided by OCAP principles necessary for work with Aboriginal communities.
First Nations; Community-driven; Participatory evaluation; OCAP; Community readiness
The Chronic Care Model (CCM) achieved widespread acceptance and reflects the core elements of patient-centred care in chronic diseases such as CVD and COPD. Our aim is to assess the extent to which current care for CVD and COPD patients aligns with the CCM in Dutch healthcare practices in the early stages of implementing disease-management programmes, thereby revealing possible predictors that tell us whether certain patients are more likely to receive CCM-compliant care than others.
We use a cross-sectional study, addressing CVD or COPD patients from 106 primary care practices in the Netherlands. Our response rate was 53%; i.e., 2,487 of 4,681 questionnaires were returned. The Patient Assessment of Chronic Illness Care (PACIC) was used to assess compliance with CCM. Quality of life was assessed with the Short-Form 36 Health Survey (SF-36) and we used the Hospital Anxiety and Depression Scale (HADS) to assess depressive symptoms. Multilevel regression models were performed to reveal predictors of high CCM compliance.
With a mean (SD) of 2.77 (0.86) in CVD patients and 2.89 (0.89) in COPD patients (p = 0.002), the PACIC sum score was lower than in previous studies conducted in HMOs in the US, but similar to a European primary care setting study. The PACIC score was associated with age and depressive symptoms in both patient groups.
Younger and less depressed patients report higher PACIC scores, indicating that their care better aligns to the CCM.
Disease management; Chronic care model; Chronic illness care; Quality; Primary care
Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council’s model for complex interventions and the Chronic Care Model.
We used the Medical Research Council’s five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model.
The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council’s model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere).
The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council’s model added transparency to the design phase which further facilitated the process of implementing the program.
Trial registration: http://www.clinicaltrials.gov/(NCT01228708).
implementation; disease management; Denmark; Chronic Care Model; Breakthrough Series; PaTPlot
Site visits were conducted for the evaluation of the national Healthy Start program to gain an understanding of how projects design and implement five service components (outreach, case management, health education, depression screening and interconceptional care) and four system components (consortium, coordination/collaboration, local health system action plan and sustainability) as well as program staff’s perceptions of these components’ influence on intermediate outcomes. Interviews with project directors, case managers, local evaluators, clinicians, consortium members, outreach/lay workers and other stakeholders were conducted during 3-day in-depth site visits with eight Healthy Start grantees. Grantees reported that both services and systems components were related to self-reported service achievements (e.g. earlier entry into prenatal care) and systems achievements (e.g. consumer involvement). Outreach, case management, and health education were perceived as the service components that contributed most to their achievements while consortia was perceived as the most influential systems component in reaching their goals. Furthermore, cultural competence and community voice were overarching project components that addressed racial/ethnic disparities. Finally, there was great variability across sites regarding the challenges they faced, with poor service availability and limited funding the two most frequently reported. Service provision and systems development are both critical for successful Healthy Start projects to achieve intermediate program outcomes. Unique contextual and community issues influence Healthy Start project design, implementation and reported accomplishments. All eight projects implement the required program components yet outreach, case management, and health education are cited most frequently for contributing to their perceived achievements.
Infant mortality; Health disparities; Consumer voice; Cultural competence; Systems development; Case management; Outreach; Health education; Consortium
As a major public health issue in China and worldwide, late-life depression is associated with physical limitations, greater functional impairment, increased utilization and cost of health care, and suicide. Like other chronic diseases in elders such as hypertension and diabetes, depression is a chronic disease that the new National Health Policy of China indicates should be managed in primary care settings. Collaborative care, linking primary and mental health specialty care, has been shown to be effective for the treatment of late-life depression in primary care settings in Western countries. The primary aim of this project is to implement a depression care management (DCM) intervention, and examine its effectiveness on the depressive symptoms of older patients in Chinese primary care settings.
The trial is a multi-site, primary clinic based randomized controlled trial design in Hangzhou, China. Sixteen primary care clinics will be enrolled in and randomly assigned to deliver either DCM or care as usual (CAU) (8 clinics each) to 320 patients (aged ≥ 60 years) with major depression (20/clinic; n = 160 in each treatment condition). In the DCM arm, primary care physicians (PCPs) will prescribe 16 weeks of antidepressant medication according to the treatment guideline protocol. Care managers monitor the progress of treatment and side effects, educate patients/family, and facilitate communication between providers; psychiatrists will provide weekly group psychiatric consultation and CM supervision. Patients in both DCM and CAU arms will be assessed by clinical research coordinators at baseline, 4, 8, 12, 18, and 24 months. Depressive symptoms, functional status, treatment stigma and clients' satisfaction will be used to assess patients' outcomes; and clinic practices, attitudes/knowledge, and satisfaction will be providers' outcomes.
This will be the first trial of the effectiveness of a collaborative care intervention aiming to the management of late-life depression in China primary care. If effective, its finding will have relevance to policy makers who wish to scale up DCM treatments for late-life depression in national wide primary care across China.
The DCM project is registered through the National Institutes of Health sponsored by clinical trials registry and has been assigned the identifier: NCT01287494
Cardiovascular risk management (CVRM) received by patients shows large variation across countries. In this study we explored the aspects of primary care organisation associated with key components of CVRM in coronary heart disease (CHD) patients.
273 primary care practices in Austria, Belgium, England, Finland, France, Germany, The Netherlands, Slovenia, Switzerland and Spain.
A random sample of 4563 CHD patients identified by coded diagnoses in eight countries, based on prescription lists and while visiting the practice in one country each.
Main outcome measure
We performed an audit in primary care practices in 10 European countries. We used six indicators to measure key components of CVRM: risk factor recording, antiplatelet therapy, influenza vaccination, blood pressure levels (systolic <140 and diastolic <90 mm Hg), and low-density lipoprotein cholesterol <2.5 mmol/l. Data from structured questionnaires were used to construct an overall measure and six domain measures of practice organisation based on 39 items. Using multilevel regression analyses we explored the effects of practice organisation on CVRM, controlling for patient characteristics.
Better overall organisation of a primary care practice was associated with higher scores on three indicators: risk factor registration (B=0.0307, p<0.0001), antiplatelet therapy (OR 1.05, p=0.0245) and influenza vaccination (OR 1.12, p<0.0001). Overall practice organisation was not found to be related with recorded blood pressure or cholesterol levels. Only the organisational domains ‘self-management support’ and ‘use of clinical information systems’ were linked to three CVRM indicators.
A better organisation of a primary care practice was associated with better scores on process indicators of CVRM in CHD patients, but not on intermediate patient outcome measures. Direct support for patients and clinicians seemed most influential.
Primary Care; Cardiology; Coronary heart disease; Health Services Administration & Management
Recommendations on best practices typically are drawn from unique settings; these practices are challenging to implement in programs already in operation. We describe an evaluation that identifies best practices in implementing lifestyle interventions in the Center for Disease Control and Prevention's WISEWOMAN program and discuss our lessons learned in using the approach.
We used a mixed-methods evaluation that integrated quantitative and qualitative inquiry. Five state or tribal WISEWOMAN projects were included in the study. The projects were selected on the basis of availability of quantitative program performance data, which were used to identify two high-performing and one low-performing site within each project. We collected qualitative data through interviews, observation, and focus groups so we could understand the practices and strategies used to select and implement the interventions. Data were analyzed in a multistep process that included summarization, identification of themes and practices of interest, and application of an algorithm.
Pilot testing data collection methods allowed for critical revisions. Conducting preliminary interviews allowed for more in-depth interviews while on site. Observing the lifestyle intervention being administered was key to understanding the program. Conducting focus groups with participants helped to validate information from other sources and offered a more complete picture of the program.
Using a mixed-methods evaluation minimized the weaknesses inherent in each method and improved the completeness and quality of data collected. A mixed-methods evaluation permits triangulation of data and is a promising strategy for identifying best practices.
The objectives of this study were to characterize survivorship models of care across eight LIVESTRONG Survivorship Center of Excellence (COE) Network sites and to identify barriers and facilitators influencing survivorship care.
Using the framework of the Chronic Care Model (CCM), quantitative and qualitative methods of inquiry were conducted with the COEs. Methods included document reviews, key informant telephone interviews with 39 participants, online Assessment of Chronic Illness Care (ACIC) surveys with 40 participants, and three site visits.
Several overarching themes emerged in qualitative interviews and were substantiated by quantitative methods. Health system factors supporting survivorship care include organization and leadership commitment and program champions at various levels of the health care team. System barriers include reimbursement issues, lack of space, and the need for leadership commitment to support changes in clinical practices as well as having program “champions” among clinical staff. Multiple models of care include separate survivorship clinics and integrated models as well as consultative models. COEs' scores on the ACIC survey showed overall “reasonable support” for survivorship care; however, the clinical information system domain was least developed. Although the ACIC findings indicated “reasonable support” for self-management, the qualitative analysis revealed that self-management support was largely limited to health promotion provided in clinic-based education and counseling sessions, with few COEs providing patients with self-management tools and interventions.
The CCM framework captured experiences and challenges of these COEs and provided insight into the current state of survivorship care in the context of National Cancer Institute-designated comprehensive cancer centers. Findings showed that cancer patients and providers could benefit from clinical information systems that would better identify candidates for survivorship care and provide timely information. In addition, a crucial area for development is self-management support outside of clinical care.
Implications for cancer survivors
Cancer survivors may benefit from learning about the experience and challenges faced by the eight LIVESTRONG Centers of Excellence in developing programs and models for cancer survivorship care, and these findings may inform patient and caregiver efforts to seek, evaluate, and advocate for quality survivorship programs designed to meet their needs.
Cancer; Cancer survivorship; Chronic care model; Health care
We investigated the effects on collaborative work within the UK National Health Service (NHS) of an intervention for service quality improvement: informal, structured, reciprocated, multidisciplinary peer review with feedback and action plans. The setting was care for chronic obstructive pulmonary disease (COPD).
Theory and methods
We analysed semi-structured interviews with 43 hospital respiratory consultants, nurses and general managers at 24 intervention and 11 control sites, as part of a UK randomised controlled study, the National COPD Resources and Outcomes Project (NCROP), using Scott's conceptual framework for action (inter-organisational, intra-organisational, inter-professional and inter-individual). Three areas of care targeted by NCROP involved collaboration across primary and secondary care.
Hospital respiratory department collaborations with commissioners and hospital managers varied. Analysis suggested that this is related to team responses to barriers. Clinicians in unsuccessful collaborations told ‘atrocity stories’ of organisational, structural and professional barriers to service improvement. The others removed barriers by working with government and commissioner agendas to ensure continued involvement in patients' care. Multidisciplinary peer review facilitated collaboration between participants, enabling them to meet, reconcile differences and exchange ideas across boundaries.
The data come from the first randomised controlled trial of organisational peer review, adding to research into UK health service collaborative work, which has had a more restricted focus on inter-professional relations. NCROP peer review may only modestly improve collaboration but these data suggest it might be more effective than top-down exhortations to change when collaboration both across and within organisations is required.
collaboration; inter-organizational; inter-professional; quality improvement; respiratory disease
The identification of patients most likely to benefit from care management programs case finding – is a crucial determinant of their effectiveness regarding improved health outcomes and reduced costs. Until now, research has mainly focused on claims data-based case finding. This study aimed to explore how primary care physicians (PCPs) select patients for practice-based care management and how risk prediction may complement their case finding.
We performed 12 semi-structured interviews with PCPs from 10 small- to middle-sized primary care practices in Germany. The interviews focused on their criteria for selecting patients as potential participants of an on-site care management program and how PCPs evaluate claims data-based risk prediction as a case finding tool. All interviews were transcribed verbatim. We performed qualitative content analysis using the ATLAS.ti software.
Three major categories emerged from the physicians interviewed: 1) the physicians’ interpretation of the program’s eligibility criteria, 2) physician-related criteria and 3) patient-related criteria. The physician-related criteria included “sympathy/aversion” and “knowing the patient”. Patient-related criteria concerned care sensitivity in terms of “willingness to participate”, “ability to participate” (e.g. sufficient language skills, cognitive status) and “manageable care needs”. PCPs believed that their case finding can be supported by additional information from claims-data based risk prediction.
Case finding for care management programs in primary care may benefit from a structured approach combining clinical judgement by PCPs and claims-data based risk modelling. However, further research is needed to identify the optimal case finding strategy for practice-based care management.
Care management; case management; primary health care; case finding; care sensitivity
Improving quality of life and quality and management of care of clients with a schizophrenic disorder by the use of a comprehensive internet based disease management (DM) platform. Presenting factors influencing the implementation of an internet based DM platform for clients with schizophrenia.
The project started in December 2008. Two mental health care institutions in the south of the Netherlands participate in the implementation of the digital instrument (the DM platform).
The implementation of the DM platform will be followed by a process and an effect evaluation.
Measurement instruments: In the effect evaluation, quality of life, number of symptoms of schizophrenia, quality of care, social functioning, self management, and insight in schizophrenia and its treatment will be measured. Process evaluation: Semi-structured interviews will be held with different (formal primary and secondary, and informal) caregivers, managers and clients of each institute. These interviews will be conducted before the implementation of the platform and one, two and three years later.
In the digital platform the guideline for people with schizophrenia will be implemented and also information for clients and their home caregivers. When the platform is ready clients will be able to communicate digital with their caregivers in the mental health institute and with their home caregivers and GPs. They also get information and feed-back about their illness and psycho education.
The effect evaluation starts in September 2009, the process evaluation has started in May 2009. We will have the first results in June 2009; they will be used to adjust the implementation and the development of the DM platform. In the meantime we can report about the building of the DM platform and what the expectations from the future users are.
– What are the factors that influence the process of implementation of a digital tool that provides help and care on a distance?
– In what way does the digital tool (care from a distance) stimulate people who need chronically care to be more self-supporting?
– In what way does the digital tool support professionals to be able to stimulate people with schizophrenia to be more self-supporting?
mental health; self management; schizophrenia
Most research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered.
Process evaluation of an action research project (2003–2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process.
The overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding.
Guided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure. The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers. Currently primary care providers lack the opportunities to take up full responsibility for chronic care.
Trial registration number
ClinicalTrials.gov Identifier: NCT00824499
Stroke services are a form of integrated care which have been introduced in many countries, including the Netherlands, to improve health outcomes and processes of care by connecting the acute, rehabilitative, and chronic phases of stroke care. Limited research exists on the effects of payment systems on the functioning of integrated care services from the perspectives of those involved in providing, planning and contracting the care. This qualitative study identified stakeholder views on i) challenges in integrated stroke care associated with fee-for-service systems; ii) other possible financing models for stroke care, and iii) challenges in the implementation of an integrated financing mechanism for stroke care.
Twenty-four participants were interviewed using face-to-face audio-recorded semi-structured interviews. Respondents were purposively selected from five stakeholder groups; care providers, health care managers, health insurers, experts and patient representatives. Transcribed data were coded and analysed to generate themes relating to the study aims.
Respondents mentioned the following challenges associated with the current fee-for-service system; inappropriate incentives for cooperation, efficiency and improving quality and the inability to exert steering power at the level of the stroke service. In addition, care is not patient-centred and the financing system is inflexible.
The respondents mentioned several solutions for the challenges, but there was no consensus amongst them. Regarding the implementation of integrated financing, respondents mentioned the following general challenges; a) the foundations of the financing system are incompatible with integrated financing, b) co-morbidity and c) the lack of evidence on the effect of integrated financing. Stroke-specific challenges were; a) the diverse patient population, b) a non-uniform care trajectory, c) unclear division of responsibility for the overall care and d) different stages of development among stroke services.
This study provides new knowledge on stakeholder perception of the effect of payment systems and financial incentives on cooperation processes, quality of care and cost-containment in integrated stroke care. The results show that fee-for-service does not provide the right incentives for the integration of stroke care. We recommend to perform financial experiments for integrated stroke care.
Integrated care; Stroke; Payment system; Incentive; Fee-for-service; Cooperation
The assumption underlying tailoring is that implementation interventions are most helpful if these effectively address the most important determinants of practice for improvement in the targeted setting. The aim of the Tailored Implementation For Chronic Diseases (TICD) project is to develop valid and efficient methods of tailoring implementation interventions to determinants of practice for knowledge implementation in chronic illness care.
The TICD project has organized the planned empirical research in three work packages that follow the three main steps of tailoring: identification of determinants of healthcare practice, matching implementation interventions to identified determinants of practice, and applying and assessing the tailored implementation interventions. These three key steps of tailored implementation will be applied to targeted chronic conditions in five different healthcare systems: cardiovascular disease in the Netherlands, obesity in England, depression in Norway, chronic obstructive pulmonary disease in Poland, and multimorbidity in Germany. The design and interpretation of empirical research will be informed by systematic reviews of previous research on tailoring implementation interventions.
The TICD project will provide much needed evidence on the advantages and disadvantages of different methods of identifying important determinants of practice and selecting implementation strategies that take account of those. It will also provide five rigorous evaluations of tailored implementation interventions for five different chronic conditions.
Disease management programmes are heterogeneous in nature and often lack a theoretical basis. An evaluation model has been developed in which theoretically driven inquiries link disease management interventions to outcomes. The aim of this study is to methodically evaluate the impact of a disease management programme for patients with chronic obstructive pulmonary disease (COPD) on process, intermediate and final outcomes of care in a general practice setting.
A quasi-experimental research was performed with 12-months follow-up of 189 COPD patients in primary care in the Netherlands. The programme included patient education, protocolised assessment and treatment of COPD, structural follow-up and coordination by practice nurses at 3, 6 and 12 months. Data on intermediate outcomes (knowledge, psychosocial mediators, self-efficacy and behaviour) and final outcomes (dyspnoea, quality of life, measured by the CRQ and CCQ, and patient experiences) were obtained from questionnaires and electronic registries.
Implementation of the programme was associated with significant improvements in dyspnoea (p < 0.001) and patient experiences (p < 0.001). No significant improvement was found in mean quality of life scores. Improvements were found in several intermediate outcomes, including investment beliefs (p < 0.05), disease-specific knowledge (p < 0.01; p < 0.001) and medication compliance (p < 0.01). Overall, process improvement was established. The model showed associations between significantly improved intermediate outcomes and improvements in quality of life and dyspnoea.
The application of a theory-driven model enhances the design and evaluation of disease management programmes aimed at improving health outcomes. This study supports the notion that a theoretical approach strengthens the evaluation designs of complex interventions. Moreover, it provides prudent evidence that the implementation of COPD disease management programmes can positively influence outcomes of care.
Nearly 50% of Canadians are overweight and their number is increasing rapidly. The majority of obese subjects are treated by primary care physicians (PCPs) who often feel uncomfortable with the management of obesity. The current research proposal is aimed at the development and implementation of an innovative, integrated, interdisciplinary obesity care management system involving both primary and secondary care professionals.
We will use both action and evaluative research in order to achieve the following specific objectives. The first one is to develop and implement a preceptorship-based continuing medical education (CME) program complemented by a web site for physicians and nurses working in Family Medicine Groups (FMGs). This CME will be based on needs assessment and will be validated by one FMG using questionnaires and semi structured interviews. Also, references and teaching tools will be available for participants on the web site. Our second objective is to establish a collaborative intra and inter-regional interdisciplinary network to enable on-going expertise update and networking for FMG teams. This tool consists of a discussion forum and monthly virtual meetings of all participants. Our third objective is to evaluate the implementation of our program for its ability to train 8 FMGs per year, the access and utilization of electronic tools and the participants' satisfaction. This will be measured with questionnaires, web logging tools and group interviews. Our fourth objective is to determine the impact for the participants regarding knowledge and expertise, attitudes and perceptions, self-efficacy for the management of obesity, and changes in FMG organization for obesity management. Questionnaires and interviews will be used for this purpose. Our fifth objective is to deliver transferable knowledge for health professionals and decision-makers. Strategies and pitfalls of setting up this program will also be identified.
This project is relevant to health system's decision-makers who are confronted with an important increase in the prevalence of obesity. It is therefore critical to develop strategies allowing the management of obesity in the 1st line setting. Results of this research project could therefore influence health care organization in the field of obesity but also eventually for other chronic diseases.
Primary care for chronic illness varies across European healthcare systems. In patients suffering from coronary heart disease (CHD), factors associated with patients’ experiences of receiving structured chronic care and counselling at the patient and practice level were investigated.
In an observational study comprising 140 general practices from five European countries (Austria, Germany, the Netherlands, Switzerland and the United Kingdom), 30 patients with Coronary Heart Disease (CHD) per practice were chosen at random to partake in this research. Patients were provided with a questionnaire and the Patient Assessment of Chronic Illness Care (PACIC-5A) - instrument. Practice characteristics were assessed through a practice questionnaire and face to face interviews. Data were aggregated to obtain two practice scores representing quality management and CHD care, respectively. A hierarchical multilevel analysis was performed to examine the impact of patient and practice characteristics on PACIC scores.
The final sample included 1745 CHD-patients from 131 general practices with a mean age of 67.8 (SD 9.9) years. The overall PACIC score was 2.84 (95%CI: 2.79; 2.89) and the 5A score reflecting structured lifestyle counselling was 2.75 (95% CI: 2.69; 2.79). At the patient level, male gender, more frequent practice contact and fewer related or unrelated conditions were associated with higher PACIC scores. At the practice level, performance scores reflecting quality management (p = 0.013) and CHD care (p = 0.009) were associated with improved assessment of the structured chronic care and counselling received.
Patients’ perceived quality of care varies. However, good practice management and organisation of care were positively reflected in patients’ assessments of receiving structured chronic illness care. This highlights the importance of integrating patient experiences into quality measurements to provide feedback to health care professionals.
To plan for a community case management (CCM) program after the implementation of the Free Health Care Initiative (FHCI), we assessed health care seeking for children with diarrhoea, malaria and pneumonia in 4 poor rural districts in Sierra Leone.
In July 2010 we undertook a cross-sectional household cluster survey and qualitative research. Caregivers of children under five years of age were interviewed about healthcare seeking. We evaluated the association of various factors with not seeking health care by obtaining adjusted odds ratios and 95% confidence limits using a multivariable logistic regression model. Focus groups and in-depth interviews of young mothers, fathers and older caregivers in 12 villages explored household recognition and response to child morbidity.
The response rate was 93% (n=5951). Over 85% of children were brought for care for all conditions. However, 10.8% of those with diarrhoea, 36.5% of those with presumed pneumonia and 41.0% of those with fever did not receive recommended treatment. In the multivariable models, use of traditional treatments was significantly associated with not seeking outside care for all three conditions. Qualitative data showed that traditional treatments were used due to preferences for locally available treatments and barriers to facility care that remain even after FHCI.
We found high healthcare seeking rates soon after the FHCI; however, many children do not receive recommended treatment, and some are given traditional treatment instead of seeking outside care. Facility care needs to be improved and the CCM program should target those few children still not accessing care.
While the Chronic Care Model (CCM) has been shown to improve the care of patients with chronic illnesses, primary care physicians have been unprepared in its use, and residencies have encountered challenges in introducing it into the academic environment.
Our residency program has implemented a diabetes management program modeled on the CCM to evaluate its impact on health outcomes of diabetic patients and educational outcomes of residents.
University-affiliated, community-based family medicine residency program.
Six residents, two faculty clinicians, and clinic staff formed a diabetes management team. We redesigned the outpatient experience for diabetic patients by incorporating elements of the CCM: multidisciplinary team care through planned and group visits; creation of a diabetes registry; use of guidelines-based flow sheets; and incorporation of self-management goal-setting. Residents received extensive instruction in diabetes management, quality improvement, and patient self-management.
We achieved overall improvement in all metabolic and process measures for patients, with the percentage achieving HbA1c, LDL, and BP goals simultaneously increasing from 5.7% to 17.1%. Educational outcomes for residents, as measured by compliance with review of provider performance reports and self-management goal-setting with patients, also significantly improved.
Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.
chronic care model; learning collaborative; diabetes; residency education
Self-management (SM) programs are effective for some chronic conditions, however the evidence for arthritis SM is inconclusive. The aim of this case series project was to determine whether a newly developed specific self-management program for people with osteoarthritis of the knee (OAK), implemented by health professionals could achieve and maintain clinically meaningful improvements.
Participants: 79 participants enrolled; mean age 66, with established osteoarthritis of the knee. People with coexisting inflammatory joint disease or serious co-morbidities were excluded.
Intervention: 6-week disease (OA) and site (knee) specific self-management education program that included disease education, exercise advice, information on healthy lifestyle and relevant information within the constructs of self-management. This program was conducted in a community health care setting and was delivered by health professionals thereby utilising their knowledge and expertise.
Measurements: Pain, physical function and mental health scales were assessed at baseline, 8 weeks, 6 and 12 months using WOMAC and SF-36 questionnaires. Changes in pain during the 8-week intervention phase were monitored with VAS.
Pain improved during the intervention phase: mean (95% CI) change 15 (8 to 22) mm. Improvements (0.3 to 0.5 standard deviation units) in indices of pain, mental health and physical functioning, assessed by SF-36 and WOMAC questionnaires were demonstrated from baseline to 12 months.
This disease and site-specific self-management education program improved health status of people with osteoarthritis of the knee in the short and medium term.
The Chronic Care Model (CCM) was developed to improve chronic disease care, but may also inform other types of preventive care delivery. Using hierarchical analyses of service delivery to patients, we explore associations of CCM implementation with diabetes care and counseling for diet or weight loss and physical activity in community-based primary care offices.
Secondary analysis focused on baseline data from 25 practices (with an average of four physicians per practice) participating in an intervention trial targeting improved colorectal cancer screening rates. This intervention made no reference to the CCM. CCM implementation (measured through staff and clinical management surveys) and was associated with patient care indicators (chart audits and patient questionnaires).
Overall, practices had low levels of CCM implementation. However, higher levels of CCM implementation were associated with better diabetes assessment and treatment of patients (p=0.009, 0.015), particularly in practices open to “innovation”. Physical activity counseling for obese and particularly overweight patients was strongly associated with CCM implementation (p=0.0017), particularly among practices open to “innovation”; however, this association did not hold for overweight and obese patients with diabetes.
Very modest levels of CCM implementation in unsupported primary care practices are associated with improved care for patients with diabetes and higher rates of behavioral counseling. Incremental incorporation of CCM components is an option, especially for resource stretched community practices with cultures of “innovativeness.”
care delivery system; chronic care; health promotion; obesity; organizational design; primary care
In many Western countries, including the Netherlands, disease management programs are increasingly being implemented to enhance quality and continuity of care for patients with chronic conditions. Fragmentary funding of these programs, however, hampered the establishment of long-term programs. In 2007, the Dutch minister of health therefore approved the introduction of a bundled-payment approach to stimulate the implementation of disease management. This was initially on an experimental basis for single-disease programs including programs for diabetes patients. In 2010, the bundled-payment concept was approved for nationwide implementation for diabetes, COPD and vascular risk management.
Under this system, insurers pay a single fee to cover a full range of chronic care services for a fixed period. One of the key questions regarding this bundled payment approach is how to deal with patients with multimorbidity. Participation of these patients in multiple single-disease oriented programs may again lead to fragmented care.
The workshop comprises three presentations. The first presentation will provide an overview of disease management initiatives and evidence for their effects on quality of care and health care costs. During this presentation also payment reforms regarding disease management, among which pay-for-performance and bundled payments, will be discussed.
During the second presentation the basic premises of the Dutch bundled payment model for diabetes care will discussed in-depth. Further, the results of a three-year follow-up study evaluating the experiences with bundled payment will be presented. Data from electronic health records, extensive interviews with stakeholders, and patient questionnaires distributed in a random sample of diabetic patients were used to assess the satisfaction of all stakeholders and the quality of delivered care. The third presentation focuses on care programs for patients with multimorbidity. During this presentation the results of a systematic review on care programs for this target group will be summarized. After the presentations a discussion will be held on how to bridge the gap between multimorbidity and the single-disease management approaches funded by bundled payments.
Integrated care; financing; multimorbidity; bundled payment
One-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilities are obese and, therefore, at higher risk for developing multiple chronic diseases. To address this problem, the VHA designed and nationally disseminated an evidence-based weight-management program (MOVE!). The objective of this study was to examine the organizational factors that aided or inhibited the implementation of MOVE! in 10 VHA medical facilities.
Using a multiple, holistic case study design, we conducted 68 interviews with medical center program coordinators, physicians formally appointed as program champions, managers directly responsible for overseeing the program, clinicians from the program's multidisciplinary team, and primary care physicians identified by program coordinators as local opinion leaders. Qualitative data analysis involved coding, memorandum writing, and construction of data displays.
Organizational readiness for change and having an innovation champion were most consistently the 2 factors associated with MOVE! implementation. Other organizational factors, such as management support and resource availability, were barriers to implementation or exerted mixed effects on implementation. Barriers did not prevent facilities from implementing MOVE! However, they were obstacles that had to be overcome, worked around, or accepted as limits on the program's scope or scale.
Policy-directed implementation of clinical weight-management programs in health care facilities is challenging, especially when no new resources are available. Instituting powerful, mutually reinforcing organizational policies and practices may be necessary for consistent, high-quality implementation.
Oral anticoagulant therapy (OAT) involves many health care disciplines. Even though collaboration between care professionals is assumed to improve the quality of OAT, very little research has been done into the practice of OAT management to arrange and manage the collaboration. This study aims to identify the problems in collaboration experienced by the care professionals involved, the solutions they proposed to improve collaboration, and the barriers they encountered to the implementation of these solutions.
In the Netherlands, intensive follow-up of OAT is provided by specialized anticoagulant clinics (ACs). Sixty-eight semi-structured face-to-face interviews were conducted with 103 professionals working at an AC. These semi-structured interviews were transcribed verbatim and analysed inductively. Wagner's chronic care model (CCM) and Cabana's framework for improvement were used to categorize the results.
AC professionals experienced three main bottlenecks in collaboration: lack of knowledge (mostly of other professionals), lack of consensus on OAT, and limited information exchange between professionals. They mentioned several solutions to improve collaboration, especially solutions of CCM's decision support component (i.e. education, regular meetings, and agreements and protocols). Education is considered a prerequisite for the successful implementation of other proposed solutions such as developing a multidisciplinary protocol and changing the allocation of tasks. The potential of the health care organization to improve collaboration seemed to be underestimated by professionals. They experienced several barriers to the successful implementation of the proposed solutions. Most important barriers were the lack motivation of non-AC professionals and lack of time to establish collaboration.
This study revealed that the collaboration in OAT is limited by a lack of knowledge, a lack of consensus, and a limited information exchange. Education was identified as the best way to improve collaboration and considered a prerequisite for a successful implementation of other proposed solutions. Hence, the implementation sequence is of importance in order to improve the collaboration successfully. First step is to establish alignment regarding collaboration with all involved professionals to encounter the lack of motivation of non-AC professionals and lack of time.