Quality of Chronic Care Predicts Productive Interaction · existence of high-quality interactions...

For peer review only

Quality of Chronic Care Predicts Productive Interaction between Patients and Health Care Professionals

Journal: BMJ Open

Manuscript ID: bmjopen-2014-005914

Article Type: Research

Date Submitted by the Author: 13-Jun-2014

Complete List of Authors: Cramm, Jane; Erasmus University Medical center, Health Policy and Management Nieboer, Anna; Erasmus University Medical center, Health Policy and Management

<b>Primary Subject Heading</b>:

Health services research

Secondary Subject Heading: General practice / Family practice

Keywords:

PRIMARY CARE, Quality in health care < HEALTH SERVICES

ADMINISTRATION & MANAGEMENT, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Quality of Chronic Care Predicts Productive Interaction between Patients

and Health Care Professionals

JANE MURRAY CRAMM1* and ANNA PETRA NIEBOER1

1Erasmus University Rotterdam, Department of Health Policy & Management (iBMG),

Rotterdam, The Netherlands

*Corresponding author at: Erasmus University (iBMG), Burgemeester Oudlaan 50, 3062 PA

Rotterdam, The Netherlands. Tel.: +31-10-408 9701; fax: +31-10-408 9094; e-mail:

[email protected]

Keywords: Chronic disease, disease management, interaction, patient-centered care, quality

of care

Word count main text= 2646

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Abstract

Context: This study aims to identify the predictive nature of quality of chronic care delivery

on productive interactions between patients and (teams of) healthcare professionals within

disease management programs.

Methods: This longitudinal study included patients participating in 18 DMPs. At baseline

(T0) a questionnaire was sent to all 5076 patients, of which 2676 responded (53%). One year

later (T1), 4693 patients still participating in the DMPs received a questionnaire, which was

filled in by 2191 respondents (47%). Two years later (in 2012; T2) 1722 patients responded

(out of 4350; 40% response).

Findings: After controlling for age, marital status, educational level and gender these results

clearly show that quality of chronic care (T0), first-year changes in quality of chronic care

(T1 – T0) and second-year changes in quality of chronic care (T2 – T1) predicted productive

interactions between patients and (teams of) healthcare professionals at T2 (all at p ≤ 0.001).

Furthermore, we found a negative relationship between lower educational level and

productive interactions between patients and healthcare professionals two years later.

Conclusions: We can conclude that successfully dealing with the consequences of chronic

illnesses requires proactive patients who are able to make productive decisions together with

their health care providers. Since patients and health care professionals share responsibility

for management of the chronic illness, they must also share control of interactions and

decisions. The importance of patient-centeredness is growing and this study reports a first

example of how quality of chronic care stimulates productive interactions between patients

and healthcare professionals.

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Strengths and limitations of this study

• Strength of this study is that we investigated 18 disease management programs

targeting patients with cardiovascular diseases (n = 9), chronic obstructive pulmonary

disease (n = 4), heart failure (n = 1), comorbidity (n = 1), and diabetes (n = 3).

• This study investigated long term (two-year changes) effects of quality of care on

productive interactions between patients and (teams of) healthcare professionals.

• The importance of patient-centeredness is growing and this study reports a first

example of how quality of chronic care stimulates productive interactions between

patients and healthcare professionals.

• Limitation of this study is that we did not have a control group for each disease

management program.

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Introduction

Chronic diseases, such as cardiovascular diseases, chronic obstructive pulmonary disease,

and diabetes, are major causes of death and disability worldwide, and their prevalence

continues to increase.1 Current care, however, is often driven by the treatment of acute

conditions, despite evidence that chronically ill patients benefit from a structured and

proactive approach tailored to their individual needs.2

The chronic care model (CCM) is an increasingly used approach to improving the quality

of chronic care.3–7 In the Netherlands, many disease management programs (DMPs), which

employ coordinated disease management interventions to improve quality of chronic care, are

based on this model.8–10 The CCM provides a framework guiding the shift from acute and

reactive care delivery to the provision of chronic and proactive care that is organized,

structured, and planned. This transition can be achieved through the development of effective

multidisciplinary teams in combination with planned interactions with chronically ill

patients.5 The model of high-quality chronic care delivery seeks to promote a fuller

understanding of each patient’s life and preferences, tailoring care to his or her needs and

empowering him or her as a proactive participant in care delivery.11,12 These concepts are

often associated with the term “patient-centered care.”13

The essential element of good chronic illness care is productive interaction between

patients and (teams of) health care professionals, as opposed to interactions that tend to be

frustrating when coordination among professionals and with patients is not prioritized. DMPs

based on the CCM are expected to achieve such interaction, thereby improving patient

centeredness and health outcomes. Productive interaction means that the work of evidence-

based chronic disease care gets done systematically and meets patients' needs.14 While

modern medical care is sometimes influenced by the two separate paradigms of “evidence-

based medicine” (i.e., decision making about care based on research-supported risk estimates

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and clinical expertise) and “patient-centered medicine,”15 the CCM provides a framework of

care delivery that brings these separate worlds together.13 Productive interaction requires that

patients are informed (i.e., have sufficient information based on evidence-based medicine to

make wise decisions related to their illness) and activated (i.e., understand the importance of

their role in managing the illness). These objectives may be difficult to achieve for patients

with low educational levels or different ethnic or cultural backgrounds. Besides informed and

activated patients, high-quality care requires teams of care providers that are organized,

trained, and equipped to conduct productive interaction. Productive interactions between

professionals may be recognized by accurate, frequent, and problem-solving communication

that is supported by relationships based on shared goals and mutual respect, which enables

health care organizations to better achieve their desired outcomes. Jody Hoffer Gittell16,17 has

demonstrated that this concept, known as “relational coordination,” is an important predictor

of a team’s ability to achieve its performance objectives. Relational coordination is concerned

with the quality of interactions and productive collaboration. An instrument for the

measurement of this concept was originally developed for the airline industry,18 but has been

applied in hospital,19,20 primary care,9,10 and community care21 settings to assess relational

coordination among health care professionals. However, relational coordination has not been

investigated previously in the context of the coproduction of care, which refers to the

existence of high-quality interactions and productive collaboration between patients and

health care professionals.

The CCM framework outlines the following system changes that are expected to result in

productive interaction between patients and health care providers: self-management support

(providing patient-centered care, empowering patients to self-manage their chronic

conditions, and making them proactive participants in care delivery), delivery system design

(which guides health care professionals’ manner of interacting with and delivering care to

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chronically ill patients), decision support [enabling identification of the best (evidence-based)

care and promoting informed decision making in each patient consultation], and clinical

information systems (appropriate use of information systems for care to support productive

interaction between proactive patients and health care professionals).13 Although DMPs

based on the CCM have been shown to improve the quality of chronic care delivery,22

process outcome measures (e.g., numbers of prescribed medications and tests),7 clinical

outcomes (e.g., number of patients with hemoglobin A1c levels > 7 percent),23 health

behaviors (e.g., smoking cessation, increased physical activity),24 and interaction among

health care professionals over time,10 as well as preventing disease complications,25 evidence

that such programs lead to productive interactions between patients and health care providers

is lacking. Thus, the aim of this study was to examine whether the quality of chronic care

delivery in the context of DMPs predicts the productivity of patient–professional interactions,

and thus the patient-centeredness of care.

Methods

To describe the content and experiences of disease management programs, we used a mixed-

methods approach. In such an approach, both qualitative and quantitative data are gathered

simultaneously and are mixed during the analysis phase to broaden the scope of

understanding.

Qualitative Analysis

For the qualitative part of the study structured interviews were held with all project leaders

from the disease management programs. A template based on the chronic care model was

developed for the collection of qualitative data on various approaches to improve care for

chronically ill patients within these Dutch disease management programs. Project leaders

were interviewed and asked about the implementation of interventions and their experiences

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with improving patient outcomes using this template. All interviews were approximately 60 -

90 minutes in length and recorded with permission. After finalizing the templates they were

sent back to the project leaders for a final check. We scored disease management programs

using 34 disease management interventions or more as high-quality of care (1) versus disease

management programs with fewer disease management programs (0). Based on this criteria,

33 percent of the disease management programs are considered to be 'high-quality' disease

management programs.

Quantitative Analysis

Participants. For the quantitative longitudinal study, patients participating in 18 Dutch DMPs

were asked to assess the quality of chronic care delivery over a 2-year period (2010–

2012)and the productivity of interactions with health care professionals. The study was

approved by the ethics committee of the Erasmus University Medical Center of Rotterdam

and informed consent was obtained from all participants. Participating DMPs were

characterized as collaborations between care sectors (e.g., between general practitioners and

hospitals) or within primary care settings (e.g., among pharmacists, physiotherapists,

dieticians, and social workers). They targeted patients with cardiovascular diseases (n = 9),

chronic obstructive pulmonary disease (n = 4), heart failure (n = 1), comorbidity (n = 1), and

diabetes (n = 3).26 All of these DMPs included self-management interventions, such as patient

education, lifestyle coaching, and motivational interviewing. They implemented care

standards and protocols built on multidisciplinary guidelines and supported by information

and communications technology (ICT) tools, such as integrated information systems. In

addition, all DMPs provided training for health care professionals and reallocated tasks from

general practitioners or specialists to practice assistants or nurses. They used more effective

information transfer and appointment scheduling practices, as well as planned interactions

among health care professionals and regular follow-up meetings of care teams.26,27 In the

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appendix a full overview of implemented interventions within each disease management

program can be found.

In 2010, we sent questionnaires to all 5076 patients participating in the 18 DMPs, and

received responses from 2676 (53 percent) patients. One year later (in 2011), questionnaires

were distributed to 4693 patients still participating in the DMPs and completed by 2191 (47

percent) respondents. In 2012, 1722 (40 percent) of 4350 DMP participants completed the

questionnaires. A total of 981 patients completed questionnaires at all three timepoints.

Measures. The questionnaires were used to collect information about participants’

background characteristics, such as age, gender, marital status, and education [dichotomized

as low (no school or primary education) or high (more than primary education)]. We used a

modified version of the relational coordination instrument [five items rated on a four-point

scale; excellent reliability (Cronbach’s α = 0.96)] to elicit patients’ perceptions of the

productivity of interactions (characterized as relational coordination/coproduction of care)28

with general practitioners, practice nurses, dieticians, physical therapists, medical specialists,

and nurses. Patients were asked about three communication dimensions (frequent, accurate,

and problem-solving communication) and two relationship dimensions (shared goals and

mutual respect).

We used a short (11-item) version of the Patient Assessment of Chronic Illness Care

(PACIC),29 called the PACIC-S,30 to assess patients’ perspectives of the alignment of primary

care with the CCM. The PACIC has been used nationally and internationally to evaluate the

delivery of CCM components to patients with diverse chronic health conditions (diabetes,

osteoarthritis, depression, asthma, hypertension, chronic obstructive pulmonary disease, and

cardiovascular conditions).29–35 The PACIC-S, which we previously developed and validated,

asks patients to report the extent to which they have received specific actions and care

congruent with various aspects of the CCM during the past 6 months. Responses were

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structured by a five-point scale (ranging from “almost never” to “nearly always”) in 2010 and

2011 and a four-point scale (ranging from “never” to “always”) in 2012; scores were

standardized for comparability. Cronbach’s alpha values of the PACIC-S at the three

timepoints (2010, 0.89; 2011, 0.86; 2012, 0.88) indicated good reliability.

Statistical analyses. First, descriptive statistics were used to describe the study

population. Second, we employed correlation analyses to investigate associations among

individual characteristics, the quality of chronic care (as assessed by number of implemented

disease management interventions as well as perceived (changes in) chronic care quality),

and productive interaction between patients and (teams of) health care professionals. Third,

we used a multilevel random-effects model to investigate the predictive role of (changes in)

the quality of chronic care delivery in productive patient–professional interaction while

controlling for patients’ age, gender, educational level, and marital status at baseline. All

independent variables were standardized. Results were considered statistically significant if

two-sided p values were ≤0.05.

Results

Table 1 displays the characteristics of the 981 patients who completed questionnaires at all

three timepoints (2010, 2011, and 2012). Of these respondents, 45 percent were female, 37

percent had low educational levels, and 28 percent were single. Their mean age was 65.90 ±

9.70 (range, 20–93) years.

- insert Table 1 about here -

Associations among individual characteristics, high-quality of chronic care according to

number of implemented interventions in each disease management program, the quality of

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chronic care as perceived by patients, and productive interaction between patients and care

providers are displayed in Table 2. These results show that high-quality of chronic care (p ≤

0.01) as well as patients’ perceptions of the quality of chronic care delivery at all three

timepoints were related significantly to their characterization of productive interactions in

2012 (all p ≤ 0.001). In addition, patients’ perceptions of productive interaction in 2012 were

associated negatively with low educational level, meaning that less educated patients found

interaction to be less productive than did more educated patients.


Table 3 displays the results of the multilevel analyses, which controlled for age, marital

status, educational level, and gender at baseline. These results clearly show that both high-

quality of care as assessed by number of implemented disease management interventions(p ≤

0.05), patients’ perceptions of the quality of chronic care in 2010 (p ≤ 0.001), as well as

changes in the perceived quality of this care in the first (2011 – 2010) (p ≤ 0.001) and second

(2012 – 2011) years (p ≤ 0.001), predicted the existence of productive interaction between

patients and health care professionals in 2012. As in the correlation analyses, low education

level was related negatively to productive interaction in 2012 in the multilevel analyses.


Discussion

To our knowledge, this is the first study to investigate the ability of DMPs based on the CCM

to improve the productivity of interactions between chronically ill patients and (teams of)

health care professionals. The results clearly show that (changes in) the quality of chronic

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care delivery predicted the existence of productive interactions over time. Thus, the quality of

communication and collaboration between informed, activated patients and organized,

trained, and equipped health care teams depends on the quality of care delivery. Interaction

must assure consistent patient-centered support, with an emphasis on empowering patients to

be proactive and participate in care delivery.13 Active participation in goal setting and the

development of action plans not only represents high-quality chronic care delivery,

stimulating productive interaction, but also appears to be consonant with emerging concepts

of patient-centered care.13,36

We found that less educated patients perceived less productive interaction than did more

educated patients during the 2-year period of DMP participation. Education level may have

affected the way in which patients coped with a chronic condition over time. For example,

more educated people are expected to be better at self-management, getting necessary care,

and demanding better care,33 making them more proactive participants in care delivery. On

the other hand, health care professionals must be prepared to interact productively with all

types of patients. The quality of care occurring during encounters between patients and health

care professionals, however, has been found to differ due to bias (or prejudice) against

minority patients (those with different cultural/ethnic backgrounds).37 This situation generates

greater clinical uncertainty when interacting with minority patients and stems from care

providers’ beliefs (stereotypes) about these patients’ behavior or health.37 Such bias may also

apply to patients with limited educational backgrounds. Less educated patients and health

care professionals may find it more difficult to relate to and truly understand one other,

resulting in inaccurate and infrequent “finger-pointing” communication characterized by the

lack of respect and knowledge sharing. Thus, care providers participating in DMPs must be

aware of and trained to meet the challenge of supporting productive interaction between

health care professionals and all patient populations. Health care professionals should pay

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special attention to the stimulation of accurate, frequent, and problem-solving communication

with less educated patients based on shared goals and mutual respect, which may entail the

investment of additional time and resources by DMPs. Investing in health care professionals'

competence to deal with diversity issues may help to improve the quality of care delivery and

create productive interaction with patients.

Seeleman and colleagues38 developed a framework to address cultural and ethnic

diversity issues in medical education as a means of improving the quality of care by investing

the professional competencies of knowledge, awareness, and ability. These competencies

may also apply to the provision of care to less educated patients: knowledge of education-

related health inequalities and the possible differential effects of treatment according to

education level; awareness of how educational background affects (health) behavior and

coping with diseases, the social context in which less educated patients live and its effects on

behavior and health outcomes, and health care professionals’ own prejudices and tendency to

stereotype; and the ability to transfer information in an understandable way to less educated

patients and adapt flexibly and creatively to new situations. Efforts to increase these

competencies among health care professionals may stimulate productive interaction with less

educated patients.

We can conclude that patients’ success in dealing with the consequences of chronic

illness requires that they take a proactive role and are able to self-manage their condition and

make productive decisions together with their health care providers. As patients and health

care professionals share responsibility for the management of chronic illness, they must also

share control over interactions and decisions.13 The importance of patient-centeredness is

growing, and this study provides the first example of how productive patient–professional

interactions depend on the quality of chronic care.

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Acknowledgments

This work was supported by The Netherlands Organization for Health Research and

Development (ZonMw), a national organization that promotes quality and innovation in the

field of health research and health care, initiating and fostering new developments (ZonMw

project number 300030201). The authors are grateful to all patients and project leaders that

participated in the research. The authors also thank the following research team members:

Apostolos Tsiachristas, Maureen Rutten-Van Mölken, Bethany Hipple Walters, Samantha

Adams, Roland Bal, Robbert Huijsman, Femke Stoel, and Lotti Kaelen.

Competing interests

The authors declare that they have no competing interests.

Author’s contribution

AN drafted the design for data gathering. JC and AN were involved in acquisition of subjects

and data, performed statistical analysis and interpretation of data. JC drafted the manuscript

and AN helped drafting the manuscript and contributed to refinement. Both authors have read

and approved its final version.

Data sharing statement stating

No additional data available

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30. Cramm JM, Nieboer AP. Factorial validation of the Patient Assessment of Chronic Illness

Care (PACIC) and PACIC short version (PACIC-S) among cardiovascular disease

patients in the Netherlands. Health Qual Life Outcomes 2012;10:104.

31. Gugiu C, Coryn CLS, Applegate B. Structure and measurement properties of the Patient

Assessment of Chronic Illness Care instrument. J Eval Clin Pract 2010;16:509–516.

32. Rosemann T, Laux G, Droesemeyer S, Gensichen J, Szecsenyi J. Evaluation of a

culturally adapted German version of the patient assessment of chronic illness care

(PACIC 5A) questionnaire in a sample of osteoarthritis patients. J Eval Clin Pract

2007;13:806–813.

33. Rosemann T, Laux G, Szecsenyi J, Grol R. The Chronic Care Model: congruency and

predictors among primary care patients with osteoarthritis. Qual Saf Health Care

2008;17:442–446.

34. Schmittdiel J, Mosen DM, Glasgow RE, Hibbard J, Remmers C, Bellows J. Patient

assessment of chronic illness care (PACIC) and improved patient-centered outcomes for

chronic conditions. J Gen Int Med. 2007;23:77–80.

35. Wensing M, van Lieshout J, Jung HP, Hermsen J, Rosemann T. The Patients Assessment

Chronic Illness Care (PACIC) questionnaire in The Netherlands: a validation study in

rural general practice. BMC Health Serv Res 2008;8:182.

36. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic

disease in primary care. JAMA 2002;288:2469–2475.

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37. Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in

health care. In: Smedley BD, Stith AY, Nelson AR, editors. Washington, DC: National

Academies Press; 2003.

38. Seeleman C, Suurmond J, Stronks K. Cultural competence: a conceptual framework for

teaching and learning. Med Educ 2009;43:229–237.

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19

TABLE 1

Descriptive Statistics for 981 Chronically Ill Patients Participating in 18 Dutch Disease

Management Programs

Mean ± SD

(range) or

percentage

No. of

respondents

Baseline (2010) characteristics

Age (years) 65.90 ± 9.70 (20–

93)

934

Gender (female) 45 954

Marital status (single) 28 971

Educational level (low) 37 930

Perceived quality of chronic care

2010 2.96 ± 0.88 (1–5) 907

2011 2.93 ± 0.84 (1–5) 918

2012 2.13 ± 0.71 (1–4) 880

Perceived productive interaction with (teams

of) health care professionals (2012)

2.94 ± 0.73 (1–4) 971

Analyses included only patients who completed questionnaires at all three timepoints (2010,

2011, and 2012). SD is standard deviation.

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TABLE 2

Associations among Individual Characteristics, Quality of Chronic Care, and Productive Interactions between Patients and (Teams of) Health

Care Professionals

1 2 3 4 5 6 7 8

1. Age (2010)

2. Marital status (single; 2010) 0.14***

3. Low educational level (2010) 0.11*** 0.09**

4. Gender (female; 2010) -0.11*** 0.21*** 0.14***

5. Quality of chronic care (2010) -0.09** -0.03 0.02 -0.00

6. Quality of chronic care (2011) -0.12*** -0.08* 0.02 -0.03 0.58***

7. Quality of chronic care (2012) -0.11** -0.03 0.00 -0.03 0.52*** 0.54***

8. High-quality of carea -0.04 0.19 -0.11 0.73* 0.04 -0.03 -0.01

9. Productive interactions between patients and (teams

of) health care professionals (2012)

-0.05 -0.05 -0.07* -0.04 0.32*** 0.31*** 0.43*** 0.09**

***p ≤ 0.001, **

p ≤ 0.01, *p ≤ 0.05 (two-tailed).aBased on implemented interventions in the disease management programs

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TABLE 3

Predictors of Productive Interactions between Patients and (Teams of) Health Care

Professionals in 2012, as Assessed by Multilevel Regression Analyses (Random Intercepts

Model)

β SE

Constant 2.91*** 0.02

Age (2010) -0.01 0.03

Marital status (single; 2010) -0.01 0.02

Low educational level (2010) -0.05* 0.03

Gender (female; 2010) -0.02 0.03

Quality of chronic care (2010) 0.38*** 0.03

First-year changes in quality of chronic care (2011 – 2010) 0.30*** 0.04

Second-year changes in quality of chronic care (2012 – 2011) 0.25*** 0.03

High-quality of carea 0.05* 0.02

***p ≤ 0.001, **

p ≤ 0.01, *p ≤ 0.05 (two-tailed). aBased on implemented interventions in the

disease management programs. Multilevel analyses included only respondents who filled in

questionnaires at all three timepoints (n = 981; n = 716 after listwise deletion of missing

cases). SE is standard error.

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Appendix: Interventions within each disease management program

Cardiovascular disease management program: Onze Lieve Vrouwe Gasthuis Existing /implemented interventions

Organizational support Integrated financing -

Organizational support Specific policies and subsidies for foreign population - Organizational support Sustainable financing agreements with health insurers -

Community Communication platform -

Community Health market -

Community Cooperation with external community partners - Community Multidisciplinary and transmural collaboration -

Community Role model in the area √ Community Regional collaboration for spread of the DMP √ Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design -

Community Regional training course √ Community Family participation -

Self management Promotion of disease specific information √ Self management Individual care plan √ Self management Life-style interventions (physical activity, diet, quit smoking) -

Self management Support of self-management (e.g. email or sms, e-consult) -

Self management Tele-monitoring - Self management Personal coaching √ Self management Motivational interviewing √ Self management Informational meetings -

Self management Diagnosis and treatment of mental health issues √ Self management Reflection meetings -

Self management Group sessions for patients and family -

Self management Cognitive behavioural therapy - Decision Support Care standards / Clinical guidelines √ Decision Support Uniform treatment protocol in outpatient and inpatient care √ Decision Support Training and independence of practise assistants √ Decision Support Professional education and training for care providers √ Decision Support Automatic measurement of process/outcome indicators - Decision Support Care protocols for immigrants -

Decision Support Audit and feedback √ Decision Support Periodic evaluation of interventions and goal achievement -

Decision Support Structural participation in knowledge exchange - Decision Support Quality of Life questionnaire -

Decision Support Qualitative evaluation of care via focus-groups with patients -

Decision Support Measurement of patient satisfaction √ Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic -

Delivery System Design Specific plan for immigrant population - Delivery System Design Meetings of different disciplines for exchanging information -

Delivery System Design Monitoring of high-risk patients √ Delivery System Design Board of clients √ Delivery System Design Periodic discussions between professionals (and patients) √ Delivery System Design Expansion of chain care to the secondary care setting -

Delivery System Design Joint consultation hours -

Delivery System Design Stepped care method -

ICT Electronic Patient Records system with Patient Portal - ICT Hospital or Practice Information System √ ICT Integrated Chain Information System -

ICT Use of ICT for Internal and/or regional benchmarking -

ICT Create a safe environment for data exchange - ICT Systematic registration by every caregiver -

ICT Exchange of information between different care disciplines -

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Cardiovascular disease management program: De Stichting Eerstelijns Samenwerkingsverband Achterveld

Existing /implemented interventions


Organizational support Specific policies and subsidies for foreign population -

Organizational support Sustainable financing agreements with health insurers -



Community Cooperation with external community partners √ Community Multidisciplinary and transmural collaboration √ Community Role model in the area -

Community Regional collaboration for spread of the DMP -

Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design -

Community Regional training course -

Community Family participation -

Self management Promotion of disease specific information √ Self management Individual care plan √ Self management Life-style interventions (physical activity, diet, quit smoking) √ Self management Support of self-management (e.g. email or sms, e-consult) -

Self management Tele-monitoring -

Self management Personal coaching √ Self management Motivational interviewing √ Self management Informational meetings -

Self management Diagnosis and treatment of mental health issues -

Self management Reflection meetings -


Self management Cognitive behavioural therapy -

Decision Support Care standards / Clinical guidelines √ Decision Support Uniform treatment protocol in outpatient and inpatient care -

Decision Support Training and independence of practise assistants √ Decision Support Professional education and training for care providers √ Decision Support Automatic measurement of process/outcome indicators √ Decision Support Care protocols for immigrants -

Decision Support Audit and feedback -

Decision Support Periodic evaluation of interventions and goal achievement -

Decision Support Structural participation in knowledge exchange -

Decision Support Quality of Life questionnaire √ Decision Support Qualitative evaluation of care via focus-groups with patients -


Delivery System Design Specific plan for immigrant population -

Delivery System Design Expansion of chain care to the secondary care setting -


Delivery System Design Meetings of different disciplines for exchanging information √ Delivery System Design Monitoring of high-risk patients √ Delivery System Design Board of clients -

Delivery System Design Periodic discussions between professionals (and patients) -


ICT Electronic Patient Records system with Patient Portal -

ICT Hospital or Practice Information System √ ICT Integrated Chain Information System √ ICT Use of ICT for Internal and/or regional benchmarking -

ICT Create a safe environment for data exchange √ ICT Systematic registration by every caregiver √ ICT Exchange of information between different care disciplines √

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Cardiovascular disease management program: Regionale Organisatie Huisartsen Amsterdam



Organizational support Specific policies and subsidies for foreign population √ Organizational support Sustainable financing agreements with health insurers -



Community Cooperation with external community partners √ Community Multidisciplinary and transmural collaboration √ Community Role model in the area √ Community Regional collaboration for spread of the DMP √ Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design √ Community Regional training course √ Community Family participation -

Self management Promotion of disease specific information √ Self management Individual care plan -

Self management Life-style interventions (physical activity, diet, quit smoking) √ Self management Support of self-management (e.g. email or sms, e-consult) -


Self management Personal coaching √ Self management Motivational interviewing -

Self management Informational meetings -





Decision Support Care standards / Clinical guidelines √ Decision Support Uniform treatment protocol in outpatient and inpatient care √ Decision Support Training and independence of practise assistants √ Decision Support Professional education and training for care providers √ Decision Support Automatic measurement of process/outcome indicators √ Decision Support Care protocols for immigrants -



Decision Support Quality of Life questionnaire -


Decision Support Measurement of patient satisfaction -

Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care -

Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic -

Delivery System Design Specific plan for immigrant population √ Delivery System Design Expansion of chain care to the secondary care setting √ Delivery System Design Joint consultation hours -

Delivery System Design Meetings of different disciplines for exchanging information √ Delivery System Design Monitoring of high-risk patients -

Delivery System Design Board of clients -

Delivery System Design Periodic discussions between professionals (and patients) √ Delivery System Design Stepped care method √ ICT Electronic Patient Records system with Patient Portal -

ICT Hospital or Practice Information System √ ICT Integrated Chain Information System √ ICT Use of ICT for Internal and/or regional benchmarking √ ICT Create a safe environment for data exchange -

ICT Systematic registration by every caregiver √ ICT Exchange of information between different care disciplines √

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Cardiovascular disease management program: De Stichting Gezondheidscentra Eindhoven


Organizational support Integrated financing √ Organizational support Specific policies and subsidies for foreign population √ Organizational support Sustainable financing agreements with health insurers √ Community Communication platform -



Community Regional collaboration for spread of the DMP √ Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design √ Community Regional training course √ Community Family participation √ Self management Promotion of disease specific information √ Self management Individual care plan √ Self management Life-style interventions (physical activity, diet, quit smoking) √ Self management Support of self-management (e.g. email or sms, e-consult) -






Decision Support Care standards / Clinical guidelines √ Decision Support Uniform treatment protocol in outpatient and inpatient care √ Decision Support Training and independence of practise assistants √ Decision Support Professional education and training for care providers √ Decision Support Automatic measurement of process/outcome indicators √ Decision Support Care protocols for immigrants √ Decision Support Audit and feedback √ Decision Support Periodic evaluation of interventions and goal achievement √ Decision Support Structural participation in knowledge exchange √ Decision Support Quality of Life questionnaire √ Decision Support Qualitative evaluation of care via focus-groups with patients √ Decision Support Measurement of patient satisfaction √ Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care -

Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic √ Delivery System Design Specific plan for immigrant population √ Delivery System Design Expansion of chain care to the secondary care setting -


Delivery System Design Meetings of different disciplines for exchanging information √ Delivery System Design Monitoring of high-risk patients √ Delivery System Design Board of clients √ Delivery System Design Periodic discussions between professionals (and patients) √ Delivery System Design Stepped care method √ ICT Electronic Patient Records system with Patient Portal -

ICT Hospital or Practice Information System √ ICT Integrated Chain Information System √ ICT Use of ICT for Internal and/or regional benchmarking √ ICT Create a safe environment for data exchange √ ICT Systematic registration by every caregiver √ ICT Exchange of information between different care disciplines √

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Cardiovascular disease management program: Gezondheidscentrum Maarssenbroek




Organizational support Sustainable financing agreements with health insurers √ Community Communication platform -






Self management Promotion of disease specific information -

Self management Individual care plan √ Self management Life-style interventions (physical activity, diet, quit smoking) √ Self management Support of self-management (e.g. email or sms, e-consult) √ Self management Tele-monitoring -

Self management Personal coaching √ Self management Motivational interviewing √ Self management Informational meetings √ Self management Diagnosis and treatment of mental health issues -









Decision Support Measurement of patient satisfaction √ Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care -





Delivery System Design Meetings of different disciplines for exchanging information √ Delivery System Design Monitoring of high-risk patients √ Delivery System Design Board of clients √ Delivery System Design Periodic discussions between professionals (and patients) -


ICT Electronic Patient Records system with Patient Portal √ ICT Hospital or Practice Information System √ ICT Integrated Chain Information System √ ICT Use of ICT for Internal and/or regional benchmarking √ ICT Create a safe environment for data exchange -


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Cardiovascular disease management program: Rijnstate Existing /implemented interventions

Organizational support Integrated financing √ Organizational support Specific policies and subsidies for foreign population -









Self management Group sessions for patients and family √ Self management Cognitive behavioural therapy -







Decision Support Measurement of patient satisfaction √ Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic √ Delivery System Design Specific plan for immigrant population -


Delivery System Design Joint consultation hours √ Delivery System Design Meetings of different disciplines for exchanging information √ Delivery System Design Monitoring of high-risk patients √ Delivery System Design Board of clients -

Delivery System Design Periodic discussions between professionals (and patients) √ Delivery System Design Stepped care method -



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Cardiovascular disease management program: Medisch Centrum Oud-West Existing /implemented interventions


Organizational support Specific policies and subsidies for foreign population √ Organizational support Sustainable financing agreements with health insurers √ Community Communication platform -

Community Health market √ Community Cooperation with external community partners -

Community Multidisciplinary and transmural collaboration -

Community Role model in the area -


Community Treatment and care pathways in out- and inpatient care -

Community Involvement of patient groups and/or panels in care design -












Decision Support Periodic evaluation of interventions and goal achievement √ Decision Support Structural participation in knowledge exchange √ Decision Support Quality of Life questionnaire -





Delivery System Design Specific plan for immigrant population √ Delivery System Design Expansion of chain care to the secondary care setting -




ICT Hospital or Practice Information System √ ICT Integrated Chain Information System -


ICT Create a safe environment for data exchange -

ICT Systematic registration by every caregiver - ICT Exchange of information between different care disciplines -

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Cardiovascular disease management program: Universiteit Medisch Centrum St. Radboud





Community Communication platform √ Community Health market -

Community Cooperation with external community partners √ Community Multidisciplinary and transmural collaboration √ Community Role model in the area √ Community Regional collaboration for spread of the DMP -











Decision Support Training and independence of practise assistants √ Decision Support Professional education and training for care providers √ Decision Support Automatic measurement of process/outcome indicators -

Decision Support Care protocols for immigrants -


Decision Support Structural participation in knowledge exchange √ Decision Support Quality of Life questionnaire -



Delivery System Design Delegation of care from specialist to nurse/care practitioner -

Delivery System Design Substitution of inpatient with outpatient care -



Delivery System Design Expansion of chain care to the secondary care setting √ Delivery System Design Joint consultation hours -







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Cardiovascular disease management program: Wijkgezondheidscentra Huizen Existing /implemented interventions






Community Cooperation with external community partners -









Self management Individual care plan √ Self management Life-style interventions (physical activity, diet, quit smoking) √ Self management Support of self-management (e.g. email or sms, e-consult) -


Self management Personal coaching -

Self management Motivational interviewing √ Self management Informational meetings -






Decision Support Training and independence of practise assistants √ Decision Support Professional education and training for care providers √ Decision Support Automatic measurement of process/outcome indicators -



Decision Support Periodic evaluation of interventions and goal achievement √ Decision Support Structural participation in knowledge exchange -















ICT Use of ICT for Internal and/or regional benchmarking √ ICT Create a safe environment for data exchange -

ICT Systematic registration by every caregiver √ ICT Exchange of information between different care disciplines -

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Heart failure disease management program: HAFANK (Hartfalen Noord Kennemerland)








Community Regional collaboration for spread of the DMP √ Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design -

Community Regional training course √ Community Family participation √ Self management Promotion of disease specific information √ Self management Individual care plan √ Self management Life-style interventions (physical activity, diet, quit smoking) √ Self management Support of self-management (e.g. email or sms, e-consult) -


















Delivery System Design Joint consultation hours √ Delivery System Design Meetings of different disciplines for exchanging information √ Delivery System Design Monitoring of high-risk patients √ Delivery System Design Board of clients -






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COPD disease management program: Huisartsencoöperatie Midden-Brabant Existing /implemented interventions









Self management Individual care plan -




Self management Motivational interviewing √ Self management Informational meetings -







Decision Support Audit and feedback √ Decision Support Periodic evaluation of interventions and goal achievement √ Decision Support Structural participation in knowledge exchange √ Decision Support Quality of Life questionnaire √ Decision Support Qualitative evaluation of care via focus-groups with patients -


Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients -

Delivery System Design One-stop outpatient clinic -







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COPD disease management program: Archiatros Existing /implemented interventions





Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design √ Community Regional training course √ Community Family participation -

Self management Promotion of disease specific information √ Self management Individual care plan √ Self management Life-style interventions (physical activity, diet, quit smoking) √ Self management Support of self-management (e.g. email or sms, e-consult) √ Self management Tele-monitoring -









Decision Support Structural participation in knowledge exchange √ Decision Support Quality of Life questionnaire √ Decision Support Qualitative evaluation of care via focus-groups with patients -


Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic -










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COPD disease management program: Stichting Gezond Monnickendam Existing /implemented interventions









Self management Motivational interviewing √ Self management Informational meetings √ Self management Diagnosis and treatment of mental health issues √ Self management Reflection meetings -





Decision Support Structural participation in knowledge exchange √ Decision Support Quality of Life questionnaire √ Decision Support Qualitative evaluation of care via focus-groups with patients -


Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic -











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COPD disease management program: Zorggroep Almere Existing /implemented interventions





Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design √ Community Regional training course √ Community Family participation √ Self management Promotion of disease specific information √ Self management Individual care plan √ Self management Life-style interventions (physical activity, diet, quit smoking) √ Self management Support of self-management (e.g. email or sms, e-consult) -


Self management Personal coaching √ Self management Motivational interviewing √ Self management Informational meetings √ Self management Diagnosis and treatment of mental health issues √ Self management Reflection meetings -



Decision Support Audit and feedback √ Decision Support Periodic evaluation of interventions and goal achievement √ Decision Support Structural participation in knowledge exchange √ Decision Support Quality of Life questionnaire √ Decision Support Qualitative evaluation of care via focus-groups with patients √ Decision Support Measurement of patient satisfaction √ Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic -




Delivery System Design Meetings of different disciplines for exchanging information √ Delivery System Design Monitoring of high-risk patients √ Delivery System Design Board of clients √ Delivery System Design Periodic discussions between professionals (and patients) √ Delivery System Design Stepped care method -



ICT Use of ICT for Internal and/or regional benchmarking √ ICT Create a safe environment for data exchange √ ICT Systematic registration by every caregiver - ICT Exchange of information between different care disciplines √

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Diabetes disease management program: Huisartsen Coöperatie Zeist Existing /implemented interventions



Community Communication platform √ Community Health market -

Community Cooperation with external community partners √ Community Multidisciplinary and transmural collaboration √ Community Role model in the area √ Community Regional collaboration for spread of the DMP √ Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design √ Community Regional training course -








Decision Support Audit and feedback √ Decision Support Periodic evaluation of interventions and goal achievement √ Decision Support Structural participation in knowledge exchange √ Decision Support Quality of Life questionnaire √ Decision Support Qualitative evaluation of care via focus-groups with patients -








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Diabetes disease management program: Zorggroep Haaglanden Existing /implemented interventions



Community Cooperation with external community partners √ Community Multidisciplinary and transmural collaboration -


Community Regional collaboration for spread of the DMP √ Community Treatment and care pathways in out- and inpatient care -

Community Involvement of patient groups and/or panels in care design √ Community Regional training course √ Community Family participation -


Self management Life-style interventions (physical activity, diet, quit smoking) -



Self management Personal coaching √ Self management Motivational interviewing -













Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients -





Delivery System Design Meetings of different disciplines for exchanging information -

Delivery System Design Monitoring of high-risk patients -



Delivery System Design Stepped care method √ ICT Electronic Patient Records system with Patient Portal -




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Diabetes disease management program: Gezondheidscentrum De Roerdomp Existing /implemented interventions






Community Treatment and care pathways in out- and inpatient care √ Community Involvement of patient groups and/or panels in care design √ Community Regional training course √ Community Family participation -











Decision Support Qualitative evaluation of care via focus-groups with patients √ Decision Support Measurement of patient satisfaction √ Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic √ Delivery System Design Specific plan for immigrant population -


Delivery System Design Meetings of different disciplines for exchanging information √ Delivery System Design Monitoring of high-risk patients √ Delivery System Design Board of clients √ Delivery System Design Periodic discussions between professionals (and patients) √ Delivery System Design Stepped care method -



ICT Use of ICT for Internal and/or regional benchmarking √ ICT Create a safe environment for data exchange √ ICT Systematic registration by every caregiver √ ICT Exchange of information between different care disciplines -

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Comorbidity disease management program: Chronische Ketenzorg Land van Cuijk en Noord Limburg BV




















Decision Support Qualitative evaluation of care via focus-groups with patients √ Decision Support Measurement of patient satisfaction √ Delivery System Design Delegation of care from specialist to nurse/care practitioner √ Delivery System Design Substitution of inpatient with outpatient care √ Delivery System Design Systematic follow-up of patients √ Delivery System Design One-stop outpatient clinic -







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A longitudinal study to identify the influence of quality of chronic care delivery on productive interactions between

patients and (teams of) healthcare professionals within disease management programs

Journal: BMJ Open

Manuscript ID: bmjopen-2014-005914.R1


Date Submitted by the Author: 13-Aug-2014





Keywords: PRIMARY CARE, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT


BMJ Open on S



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A longitudinal study to identify the influence of quality of chronic care

delivery on productive interactions between patients and (teams of)

healthcare professionals within disease management programs






[email protected]


of care

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Abstract

Objective: The chronic care model (CCM) is an increasingly used approach to improve the

quality of care trough system changes in care delivery. While theoretically these system

changes are expected to increase productive patient-professional interaction empirical

evidence is lacking. This study aims to identify the influence of quality of care on productive

patient-professional interaction.

Setting: Longitudinal study in 18 Dutch regions.

Participants: Questionnaires were sent to all 5076 patients participating in 18 Disease

Management Programs (DMPs) in 2010 [2676 (53%) respondents]. One year later (T1), 4693

patients still participating in the DMPs received a questionnaire [2191 (47%) respondents]

and two years later (in 2012; T2) 1722 patients responded (out of 4350; 40% response).

Interventions: DMPs

Primary outcome measure: Patients’ perceptions of the productivity of interactions

(characterized as relational coordination/coproduction of care) with professionals. Patients

were asked about communication dimensions (frequent, accurate, and problem-solving

communication) and relationship dimensions (shared goals and mutual respect).

Findings: After controlling for background characteristics these results clearly show that

quality of chronic care (T0), first-year changes in quality of chronic care (T1 – T0) and

second-year changes in quality of chronic care (T2 – T1) predicted productive interactions

between patients and professionals at T2 (all at p ≤ 0.001). Furthermore, we found a negative

relationship between lower educational level and productive interactions between patients

and professionals two years later.



their healthcare providers. Since patients and professionals share responsibility for

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management of the chronic illness, they must also share control of interactions and decisions.

The importance of patient-centeredness is growing and this study reports a first example of

how quality of chronic care stimulates productive interactions between patients and

professionals.

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management program.

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Introduction


















patients and (teams of) healthcare professionals, as opposed to interactions that tend to be







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their role in managing the illness). These objectives may be difficult to achieve for

chronically ill patients with low educational levels or different ethnic/cultural backgrounds.

Earlier research showed that better educated patients receive higher quality of chronic care

delivery compared to lower educated patients, which may be caused by differences in the

behavior of professionals toward different patient groups as well as different demands or

ability to clearly explain things of patients of these patient groups.16 Hence the quality of

patient-professional interaction may vary between higher and lower education patients.

Besides informed and activated patients, high-quality care requires teams of care providers

that are organized, trained, and equipped to conduct productive interaction. Productive

interactions between professionals may be recognized by accurate, frequent, and problem-

solving communication that is supported by relationships based on shared goals and mutual

respect, which enables healthcare organizations to better achieve their desired outcomes. Jody

Hoffer Gittell17,18 has demonstrated that this concept, known as “relational coordination,” is

an important predictor of a team’s ability to achieve its performance objectives. Relational

coordination is concerned with the quality of interactions and productive collaboration. An

instrument for the measurement of this concept was originally developed for the airline

industry,19 but has been applied in hospital,20,21 primary care,9,10 and community care22

settings to assess relational coordination among healthcare professionals. However, relational

coordination has not been investigated previously in the context of the coproduction of care,

which refers to the existence of high-quality interactions and productive collaboration

between patients and healthcare professionals.

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productive interaction between patients and healthcare providers: self-management support



(which guides healthcare professionals’ manner of interacting with and delivering care to




interaction between proactive patients and healthcare professionals).13 Although DMPs based

on the CCM have been shown to improve the quality of chronic care delivery,23 process

outcome measures (e.g., numbers of prescribed medications and tests),7 clinical outcomes

(e.g., number of patients with hemoglobin A1c levels > 7 percent),24 health behaviors (e.g.,

smoking cessation, increased physical activity),25 and interaction among healthcare

professionals over time,10 as well as preventing disease complications,26 evidence that such

programs lead to productive interactions between patients and healthcare providers is lacking.

Thus, the aim of this study was to examine whether the quality of chronic care delivery in the

context of DMPs predicts the productivity of patient–professional interactions, and thus the

patient-centeredness of care.

Methods

To describe the content and experiences of DMPs, we used a mixed-methods approach. In

such an approach, both qualitative and quantitative data are gathered simultaneously and are

mixed during the analysis phase to broaden the scope of understanding.


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were asked to assess the quality of chronic care delivery over a 2-year period (2010–2012)

and the productivity of interactions with healthcare professionals. The study was approved by

the ethics committee of the Erasmus University Medical Center of Rotterdam and informed

consent was obtained from all participants. Participating DMPs were characterized as

collaborations between care sectors (e.g., between general practitioners and hospitals) or

within primary care settings (e.g., among pharmacists, physiotherapists, dieticians, and social

workers). They targeted patients with cardiovascular diseases (n = 9), chronic obstructive

pulmonary disease (n = 4), heart failure (n = 1), comorbidity (n = 1), and diabetes (n = 3).27

All of these DMPs included self-management interventions, such as patient education,

lifestyle coaching, and motivational interviewing. They implemented care standards and

protocols built on multidisciplinary guidelines and supported by information and

communications technology (ICT) tools, such as integrated information systems. In addition,

all DMPs provided training for healthcare professionals and reallocated tasks from general

practitioners or specialists to practice assistants or nurses. They used more effective


among healthcare professionals and regular follow-up meetings of care teams.27,28 In

appendix 1 a full overview of implemented CCM interventions within each DMP can be

found.






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as low (no school or primary education) or high (more than primary education)]. We asked

respondents about their experiences with care delivery. This concerns the care they receive

from their team of healthcare professionals (e.g. specialist, GP, practice assistant, dietician)

who treat their chronic condition. We assessed productive interactions among patients and

(teams of) healthcare professionals using an adjusted version of the Relational Coordination

instrument. Although originally developed to assess quality of communication and

coordination among professionals this instrument has also been used to assess relational

coordination between healthcare professionals and informal caregivers of patients.29,30 We

used a modified version of the relational coordination instrument [five items rated on a four-

point scale; excellent reliability (Cronbach’s α = 0.96)] to elicit patients’ perceptions of the





mutual respect).









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Statistical analyses. First, descriptive statistics were used to describe the study population

of patients who completed questionnaires at all three timepoints (2010, 2011, and 2012).

Second, we employed correlation analyses to investigate associations among individual

characteristics of patients, the quality of chronic care (as assessed by number of implemented


and productive interaction between patients and (teams of) healthcare professionals as

perceived by patients. Third, we used a multilevel random-effects model to investigate the

predictive role of (changes in) the quality of chronic care delivery in productive patient–

professional interaction while controlling for patients’ age, gender, educational level, and

marital status at baseline. All independent variables were standardized. Results were

considered statistically significant if two-sided p values were ≤0.05.



from the DMPs. A template based on the CCM was developed for the collection of

qualitative data on various approaches to improve care for chronically ill patients within these

Dutch DMPs. This template incorporates the following six interrelated components of

healthcare systems: (i) self-management support, (ii) delivery system design, (iii) decision

support, (iv) clinical information systems, (v) healthcare organization, and (vi) community

linkages. Project leaders were interviewed and asked about the implementation of their

interventions and their experiences with improving patient outcomes using this CCM

template. All interviews were approximately 60 - 90 minutes in length and recorded with

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permission. After finalizing the templates they were sent back to the project leaders for a final

check. In appendix 1 a full overview is given of all CCM interventions implemented within

each DMP. Earlier research showed that a constellation of interventions is needed and that a

DMP is deemed to be based on the CCM if their constellation of interventions attempted to

make changes can be mapped to at least four elements of the CCM.6,7 The total number of

interventions implemented within each DMP ranged from 13 to 43. All DMPs implemented

interventions within at least four of the CCM dimensions and can therefore be considered to

be a DMP based on the CCM.6 We scored DMPs using 34 (which is 60% out of a total of 56

potential interventions) disease management interventions and implementing interventions

within all 6 CCM dimensions or more as high-quality of care (1) versus DMPs with fewer

disease management interventions (0). Based on this criteria, 33 percent of the DMPs are

considered to be 'high-quality' DMPs.

Results




9.70 (range, 20–93) years.



number of implemented interventions in each DMP, the quality of chronic care as perceived

by patients, and productive interaction between patients and care providers are displayed in

Table 2. These results show that high-quality of chronic care (p ≤ 0.01) as well as patients’

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perceptions of the quality of chronic care delivery at all three timepoints were related

significantly to their characterization of productive interactions in 2012 (all p ≤ 0.001). In

addition, patients’ perceptions of productive interaction in 2012 were associated negatively

with low educational level, meaning that less educated patients found interaction to be less

productive than did more educated patients.








patients and healthcare professionals in 2012. As in the correlation analyses, low education



Discussion



healthcare professionals. The results clearly show that (changes in) the quality of chronic care

delivery predicted the existence of productive interactions over time. Thus, the quality of


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trained, and equipped healthcare teams depends on the quality of care delivery. Interaction











the other hand, healthcare professionals must be prepared to interact productively with all

types of patients. The quality of care occurring during encounters between patients and

healthcare professionals, however, has been found to differ due to bias (or prejudice) against




apply to patients with limited educational backgrounds. Less educated patients and healthcare

professionals may find it more difficult to relate to and truly understand one other, resulting

in inaccurate and infrequent “finger-pointing” communication characterized by the lack of

respect and knowledge sharing. Thus, care providers participating in DMPs must be aware of

and trained to meet the challenge of supporting productive interaction between healthcare

professionals and all patient populations. Healthcare professionals should pay special

attention to the stimulation of accurate, frequent, and problem-solving communication with

less educated patients based on shared goals and mutual respect, which may entail the

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investment of additional time and resources by DMPs. Investing in healthcare professionals'










behavior and health outcomes, and healthcare professionals’ own prejudices and tendency to



competencies among healthcare professionals may stimulate productive interaction with less

educated patients.

Some limitations should be considered when interpreting our study findings. Other

aspects may also influence quality of chronic care delivery and the establishment of

productive patient-professional interaction. Mackenzie and colleagues41 for example

identified a negative relationship between the severity of chronic diseases and quality of care

delivery. Earlier we also found that quality of chronic care delivery was more difficult to

achieve among patients with greater disease severity, namely patients with heart failure,

comorbidity and severe COPD.28 Furthermore, we found that the quality of communication

and coordination varies between professionals9. Future research is necessary to identify

patient as well as professional characteristics that effect patient-professional interactions.

Finally, we did not include the relational coproduction/coordination aspects timely

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communication and shared knowledge. Future research is necessary investigating all seven

aspects among patients.



make productive decisions together with their healthcare providers. As patients and

healthcare professionals share responsibility for the management of chronic illness, they must

also share control over interactions and decisions.13 The importance of patient-centeredness is



Acknowledgments



field of health research and healthcare, initiating and fostering new developments (ZonMw


participated in the research.

Competing interests







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TABLE 1


Management Programs

Mean ± SD

(range) or

percentage

No. of

respondents


Age (years) 65.90 ± 9.70 (20–

93)

934





2010 2.96 ± 0.88 (1–5) 907

2011 2.93 ± 0.84 (1–5) 918

2012 2.13 ± 0.71 (1–4) 880


of) healthcare professionals (2012)

2.94 ± 0.73 (1–4) 971



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TABLE 2

Associations among Individual Characteristics, Quality of Chronic Care, and Productive Interactions between Patients and (Teams of)

Healthcare Professionals

1 2 3 4 5 6 7 8

1. Age (2010)



4. Gender (female; 2010) -0.11*** 0.21*** 0.14***







-0.05 -0.05 -0.07* -0.04 0.32*** 0.31*** 0.43*** 0.09**

***p ≤ 0.001, **


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TABLE 3

Predictors of Productive Interactions between Patients and (Teams of) Healthcare


Model)

β SE

Constant 2.91*** 0.02

Age (2010) -0.01 0.03



Gender (female; 2010) -0.02 0.03





***p ≤ 0.001, **





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[email protected]


of care

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Abstract


quality of care trough system changes in care delivery. While theoretically these system









Interventions: DMPs


(characterized as relational coordination/coproduction of care) with professionals. Patients

were asked about communication dimensions (frequent, accurate, and problem-solving











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professionals.

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management program.

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Introduction

























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between patients and healthcare professionals.

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Methods





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found.






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mutual respect).









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Results




9.70 (range, 20–93) years.






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Discussion






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educated patients.











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Acknowledgments






Competing interests







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References




Engl J Med 2003;349:868–874.


Milbank Q 1996;74:511–544.


Care Q 1996;4(2):12–25.














2012;31(11):2493–2500.

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Health Serv Res 2004;39:1005–1026.










16. Rosemann T, Laux G, Szecsenyi J, Grol R: The Chronic Care Model: congruency and


2008;17(6):442-446.


Res 2002;4: 299–311.









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10.1111/jan.12233




2014;14:3

















2011;11:6.



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29. Weinberg DB, Lusenhop W, Gittell JH, Kautz C: Coordination Between Formal

Providers and Informal Caregivers. Health Care Manage Re. 2007;32(2):140-150.



2013. DOI: 10.1111/jir.12102.






2661.









2007;13:806–813.




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TABLE 1


Management Programs

Mean ± SD

(range) or

percentage

No. of

respondents


Age (years) 65.90 ± 9.70 (20–

93)

934





2010 2.96 ± 0.88 (1–5) 907

2011 2.93 ± 0.84 (1–5) 918

2012 2.13 ± 0.71 (1–4) 880



2.94 ± 0.73 (1–4) 971



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TABLE 2



1 2 3 4 5 6 7 8

1. Age (2010)



4. Gender (female; 2010) -0.11*** 0.21*** 0.14***







-0.05 -0.05 -0.07* -0.04 0.32*** 0.31*** 0.43*** 0.09**

***p ≤ 0.001, **


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TABLE 3



Model)

β SE

Constant 2.91*** 0.02

Age (2010) -0.01 0.03



Gender (female; 2010) -0.02 0.03





***p ≤ 0.001, **





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Appendix 1: Interventions within each disease management program









Community Role model in the area √

Community Regional collaboration for spread of the DMP √

Community Treatment and care pathways in out- and inpatient care √


Community Regional training course √


Self management Promotion of disease specific information √

Self management Individual care plan √




Self management Personal coaching √

Self management Motivational interviewing √


Self management Diagnosis and treatment of mental health issues √




Decision Support Care standards / Clinical guidelines √

Decision Support Uniform treatment protocol in outpatient and inpatient care √

Decision Support Training and independence of practise assistants √

Decision Support Professional education and training for care providers √

Decision Support Automatic measurement of process/outcome indicators -


Decision Support Audit and feedback √





Decision Support Measurement of patient satisfaction √

Delivery System Design Delegation of care from specialist to nurse/care practitioner √

Delivery System Design Substitution of inpatient with outpatient care √

Delivery System Design Systematic follow-up of patients √




Delivery System Design Monitoring of high-risk patients √

Delivery System Design Board of clients √

Delivery System Design Periodic discussions between professionals (and patients) √





ICT Hospital or Practice Information System √

ICT Integrated Chain Information System -



ICT Systematic registration by every caregiver -


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Community Cooperation with external community partners √

Community Multidisciplinary and transmural collaboration √









Self management Life-style interventions (physical activity, diet, quit smoking) √











Decision Support Uniform treatment protocol in outpatient and inpatient care -



Decision Support Automatic measurement of process/outcome indicators √





Decision Support Quality of Life questionnaire √










Delivery System Design Meetings of different disciplines for exchanging information √







ICT Integrated Chain Information System √


ICT Create a safe environment for data exchange √

ICT Systematic registration by every caregiver √

ICT Exchange of information between different care disciplines √

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Organizational support Specific policies and subsidies for foreign population √









Community Involvement of patient groups and/or panels in care design √









Self management Motivational interviewing -






















Delivery System Design Specific plan for immigrant population √

Delivery System Design Expansion of chain care to the secondary care setting √






Delivery System Design Stepped care method √




ICT Use of ICT for Internal and/or regional benchmarking √




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Organizational support Integrated financing √


Organizational support Sustainable financing agreements with health insurers √










Community Family participation √


















Decision Support Care protocols for immigrants √


Decision Support Periodic evaluation of interventions and goal achievement √

Decision Support Structural participation in knowledge exchange √


Decision Support Qualitative evaluation of care via focus-groups with patients √





Delivery System Design One-stop outpatient clinic √
















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Self management Support of self-management (e.g. email or sms, e-consult) √




Self management Informational meetings √





























ICT Electronic Patient Records system with Patient Portal √







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Self management Group sessions for patients and family √




















Delivery System Design Joint consultation hours √













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Community Health market √



















































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Community Communication platform √





















































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Delivery System Design Systematic follow-up of patients -

















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ICT Systematic registration by every caregiver - ICT Exchange of information between different care disciplines √

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A longitudinal study to identify the influence of quality of

chronic care delivery on productive interactions between patients and (teams of) healthcare professionals within

disease management programs

Journal: BMJ Open

Manuscript ID: bmjopen-2014-005914.R2


Date Submitted by the Author: 29-Aug-2014





Keywords: PRIMARY CARE, Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Organisation of health services < HEALTH SERVICES ADMINISTRATION & MANAGEMENT


BMJ Open on S



jopen.bmj.com

/B

MJ O


eptember 2014. D

ownloaded from











[email protected]


of care

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Abstract


quality of care through system changes in care delivery. While theoretically these system









Interventions: DMPs


(measured as relational coordination/coproduction of care) with professionals. Patients were

asked about communication dimensions (frequent, accurate, and problem-solving











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professionals.

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management program.

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Introduction

























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7

between patients and healthcare professionals. Although it has been investigated between

healthcare professionals and family caregivers (Weinberg, et al, 2007; Warfield et al, 2013).



















Methods




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found.






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mutual respect). We did not include the relational coproduction/coordination aspects timely

communication and shared knowledge.








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Results




9.70 (range, 20–93) years.





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Discussion





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educated patients.










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Acknowledgments











Competing interests




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TABLE 1


Management Programs

Mean ± SD

(range) or

percentage

No. of

respondents


Age (years) 65.90 ± 9.70 (20–

93)

934





2010 2.96 ± 0.88 (1–5) 907

2011 2.93 ± 0.84 (1–5) 918

2012 2.13 ± 0.71 (1–4) 880



2.94 ± 0.73 (1–4) 971



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TABLE 2



1 2 3 4 5 6 7 8

1. Age (2010)



4. Gender (female; 2010) -0.11*** 0.21*** 0.14***







-0.05 -0.05 -0.07* -0.04 0.32*** 0.31*** 0.43*** 0.09**

***p ≤ 0.001, **


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TABLE 3



Model)

β SE

Constant 2.91*** 0.02

Age (2010) -0.01 0.03



Gender (female; 2010) -0.02 0.03





***p ≤ 0.001, **





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[email protected]


of care

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Abstract


quality of care through system changes in care delivery. While theoretically these system









Interventions: DMPs


(measured as relational coordination/coproduction of care) with professionals. Patients were

asked about communication dimensions (frequent, accurate, and problem-solving











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professionals.

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management program.

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Introduction

























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between patients and healthcare professionals. Although it has been investigated between

healthcare professionals and family caregivers (Weinberg, et al, 2007; Warfield et al, 2013).



















Methods




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found.






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mutual respect). We did not include the relational coproduction/coordination aspects timely

communication and shared knowledge.








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Results




9.70 (range, 20–93) years.





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Discussion





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educated patients.










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Acknowledgments






Competing interests





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References




Engl J Med 2003;349:868–874.


Milbank Q 1996;74:511–544.


Care Q 1996;4(2):12–25.














2012;31(11):2493–2500.

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Health Serv Res 2004;39:1005–1026.










16. Rosemann T, Laux G, Szecsenyi J, Grol R: The Chronic Care Model: congruency and


2008;17(6):442-446.


Res 2002;4: 299–311.









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10.1111/jan.12233




2014;14:3

















2011;11:6.



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2013. DOI: 10.1111/jir.12102.






2661.









2007;13:806–813.




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TABLE 1


Management Programs

Mean ± SD

(range) or

percentage

No. of

respondents


Age (years) 65.90 ± 9.70 (20–

93)

934





2010 2.96 ± 0.88 (1–5) 907

2011 2.93 ± 0.84 (1–5) 918

2012 2.13 ± 0.71 (1–4) 880



2.94 ± 0.73 (1–4) 971



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TABLE 2



1 2 3 4 5 6 7 8

1. Age (2010)



4. Gender (female; 2010) -0.11*** 0.21*** 0.14***







-0.05 -0.05 -0.07* -0.04 0.32*** 0.31*** 0.43*** 0.09**

***p ≤ 0.001, **


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TABLE 3



Model)

β SE

Constant 2.91*** 0.02

Age (2010) -0.01 0.03



Gender (female; 2010) -0.02 0.03





***p ≤ 0.001, **





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Appendix 1: Interventions within each disease management program
























































ICT Systematic registration by every caregiver -


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Decision Support Care protocols for immigrants √


























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ICT Electronic Patient Records system with Patient Portal √







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