Mobiele menu

A whole system multimorbidity approach to improve patient centred chronic disease management in primary care: development, optimisation, and evaluation

Projectomschrijving

Nieuwe en toekomstbestendige ketenzorg

Diabetes mellitus (DM), COPD en hart- en vaatziekten (HVZ) behoren tot de meest voorkomende chronische aandoeningen. De huidige zorg, ketenzorg genaamd, houdt geen rekening met multimorbiditeit, d.w.z. het hebben van meerdere chronische ziekten. Ketenzorg biedt weinig ruimte voor maatwerk, vergt veel registratie en lijkt niet effectief. De druk op de zorg neemt toe door een toename van chronische patiënten. De behoefte aan een nieuw en toekomstbestendig ketenzorgmodel is groot.

Doel en werkwijze

Dit project beoogt de kwaliteit van leven en de tevredenheid over zorg van patiënten met DM, COPD en/of HVZ te verbeteren en de zorgkosten beheersbaar te maken. In 6 jaar ontwikkelt, optimaliseert en evalueert het Radboudumc samen met patiënten, zorgverleners en zorgverzekeraars een nieuw, duurzaam en persoonsgericht ketenzorgmodel. De patiënt met al zijn of haar gezondheidsproblemen en het bevorderen van zelfregie staan daarin centraal. Het ideaal is om het nieuwe ketenzorgmodel landelijk te implementeren.

Producten

Titel: How Can a Bundled Payment Model Incentivize the Transition from Single-Disease Management to Person-Centred and Integrated Care for Chronic Diseases in the Netherlands?
Auteur: Bour SS, Raaijmakers LHA, Bischoff EWMA, Goossens LMA, Rutten-van Mölken MPMH
Magazine: Int J Environ Res Public Health.
Begin- en eindpagina:
Link: https://europepmc.org/article/MED/36900870#free-full-text
Titel: Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study.
Auteur: Raaijmakers LHA, Schermer TR, Wijnen M, van Bommel HE, Michielsen L, Boone F, Vercoulen JH, Bischoff EWMA.
Magazine: Int J Environ Res Public Health.
Begin- en eindpagina:
Link: https://europepmc.org/article/MED/36900842
Titel: Towards a patient centred multimorbidity approach for chronic disease management in primary care
Auteur: Lena Raaijmakers, Erik Bischoff, Tjard Schermer, Jan Vercoulen, Maria van den Muijsenbergh, Pim Assendelft
Titel: Rapport Bekostigingsopties persoonsgerichte zorg
Auteur: Sterre Bour, Maureen Rutten-van Molken
Titel: Rapport Online interviews
Auteur: Lena Raaijmakers, Mandy Wijnen, Erik Bischoff en Tjard Schermer
Titel: www.ketenzorgontketend.nl
Auteur: Lena Raaijmakers
Link: http://www.ketenzorgontketend.nl

Verslagen


Samenvatting van de aanvraag

Background: Diabetes Mellitus type 2 (DM2), Chronic Obstructive Pulmonary Disease (COPD), and cardiovascular diseases (CVD) are among the most prevalent chronic conditions in primary care. To improve the quality of care and health-related outcomes of these diseases chronic disease management programmes have been implemented in Dutch primary care. However, these programmes show major limitations. First, disease-specific chronic disease management does not focus on multimorbidity. DM2, COPD, and CVD often occur together and with other co-morbidities. Multimorbidity is associated with greater disability and poorer quality of life and places a high burden on primary care by high rates of healthcare utilisation and costs. However, dealing with multimorbidity needs a patient-centred rather than a disease-oriented approach. Second, the results of studies on the effects of chronic disease management in primary care are inconclusive. Besides, current chronic care organisation is inefficient; patients with multimorbidity are included in multiple chronic disease management programmes that share very similar elements of care but may be provided by different healthcare professionals. Third, patients experience chronic disease management as fragmented with only little focus on the person and his/her context. Patients wish to play a more active role in their own care planning with a changing role of the general practitioner into a coach who supports self-management and knows the ‘whole person’. Improving chronic care very much depends on reforming the current system. There is a need for a “whole-system approach” that puts the individual patient with all his morbidities at the centre of care and not a single disease and that responds to the needs and the context of the patient to provide the right care in the right place at the right time. To simplify this complexity, there is a need for innovative tools that helps to identify individual needs and motivate patients to achieve individual treatment goals. Objectives: 1. to develop, in close collaboration with patients and healthcare professionals, a primary care whole-system patient centred multimorbidity management programme as a substitute for the current separate chronic disease management programmes for DM2, COPD and CVD; 2. to test the feasibility of and to optimise the whole-system multimorbidity management programme for patients with DM2, COPD and CVD in primary care; 3. to evaluate the effects and costs of, and experiences with the whole-system multimorbidity management programme in primary care; Methods: We will follow the framework for the development and evaluation of complex interventions of the Medical Research Council. In our primary care based patient-centred multimorbidity intervention we will embed the Nijmegen Clinical Screening Instrument (NCSI)-method as innovative tool to support healthcare professionals and patients. This project will take place in three different regions in the Netherlands, i.e. Nijmegen, Oosterhout-Breda, and Nijkerk. In Stage 1 we will support healthcare professionals and their patients in developing the intervention by (i) conducting a extensive literature review to collect the essential evidence-based components for the multimorbidity programme, (ii) conducting a Delphi study in each participating region to reach consensus among patients and healthcare professionals on the exact content and structure of the multimorbidity intervention, and (iii) developing a region-specific training programme using the input from in-depth interviews with patients and healthcare professionals. In Stage 2, we will pilot the regionally developed multimorbidity intervention in each region for feasibility and to obtain information on effect sizes and variability and rates of recruitment and retention. In Stage 3, we will perform a pragmatic cluster randomised controlled trial using triple aim outcomes. We will compare our patient-centred multimorbidity intervention with the current disease-specific chronic disease management programmes and assess differences in health status, self-management, physiological outcomes, costs, and experiences of patients and healthcare professionals. Innovation: Our study will provide new information about the efficiency of implementing a whole-system patient-centred multimorbidity approach in the Dutch primary care structure of chronic disease management. The results of our study and our experiences with the effectuation of it can be used by all stakeholders (i.e. patients, healthcare professionals, healthcare policy makers, health insurance companies, and researchers) to further develop and implement multimorbidity programmes in Dutch primary care. Our results and experiences can also be used in vocational training programmes for healthcare professionals working with chronic disease patients in primary care, such as general practitioners, practice nurses, physiotherapists, and dieticians.

Kenmerken

Projectnummer:
839110024
Looptijd: 82%
Looptijd: 82 %
2018
2025
Gerelateerde subsidieronde:
Projectleider en penvoerder:
dr. E. Bischoff PhD
Verantwoordelijke organisatie:
Radboud Universitair Medisch Centrum
Afbeelding

Onderzoek naar huisartsgeneeskunde door aioto’s

Om de behandeling van patiënten te verbeteren, financieren we onderzoek naar wetenschappelijke vragen uit de dagelijkse praktijk. Doordat de onderzoeken worden uitgevoerd door artsen in opleiding tot onderzoeker dragen ze ook bij aan de academisering van de opleidingen. Lees meer over deze onderzoeken.