Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams.

INTRODUCTION: Teamwork between healthcare providers is conditional for the delivery of integrated care. This study aimed to assess the usefulness of the conceptual framework Integrated Team Effectiveness Model for developing and testing of the Integrated Team Effectiveness Instrument. THEORY AND METHODS: Focus groups with healthcare providers in an integrated care setting for people with chronic obstructive pulmonary disease (COPD) were conducted to examine the recognisability of the conceptual framework and to explore critical success factors for collaborative COPD practice out of this framework. The resulting items were transposed into a pilot instrument. This was reviewed by expert opinion and completed 153 times by healthcare providers. The underlying structure and internal consistency of the instrument were verified by factor analysis and Cronbach's alpha. RESULTS: The conceptual framework turned out to be comprehensible for discussing teamwork effectiveness. The pilot instrument measures 25 relevant aspects of teamwork in integrated COPD care. Factor analysis suggested three reliable components: teamwork effectiveness, team processes and team psychosocial traits (Cronbach's alpha between 0.76 and 0.81). CONCLUSIONS AND DISCUSSION: The conceptual framework Integrated Team Effectiveness Model is relevant in developing a practical full-spectrum instrument to facilitate discussing teamwork effectiveness. The Integrated Team Effectiveness Instrument provides a well-founded basis to self-evaluate teamwork effectiveness in integrated COPD care by healthcare providers. Recommendations are provided for the improvement of the instrument.

A process evaluation of a stroke-specific follow-up care model for stroke patients and caregivers; a longitudinal study.

BACKGROUND: There is a need for follow-up care after stroke, but there is no consensus about the way to organise it. An intervention providing follow-up care for stroke patients and caregivers showed favourable effects on the level of social activities, but no other effects were found. The intervention consists of a maximum of five home visits to patients and caregivers during a period of 18 months post-discharge. The home visits are conducted by a stroke care coordinator (SCC) using a structured assessment tool. The objective of this study was to examine process-related factors that could have influenced the effectiveness of the intervention. METHODS: 77 stroke patients, 59 caregivers and 4 SCCs participated in the study. Data on the organisational characteristics of and the satisfaction with the intervention were collected by means of structured assessments, interviews and self-administered questionnaires at 1, 6, 12 and 18 months of follow-up. The intervention was provided between April 2008 and June 2011. RESULTS: Patients received an average of 3.8 home visits (SD 1.4) and 55% of them had a follow-up period of a maximum of 18 months. There were 1074 problems identified and the SCCs initiated 363 follow-up care and referral options. Stroke patients and caregivers were very satisfied with the intervention. The SCCs were satisfied with the assessment tool, but would like to see a structured referral system. CONCLUSIONS: The intervention was only partially performed in accordance with the protocol and was positively evaluated by patients, caregivers and SCCs. It is recommended to add a structured referral system to the intervention.

[Summary of the 'Stroke' guideline of the Dutch College of General Practitioners' (NHG)]. / Samenvatting van de NHG-standaard 'Beroerte'.

The Dutch College of General Practitioners (NHG) guideline 'Stroke' covers the diagnosis, management and long-term care of stroke in general practice. Patients with neurological symptoms suspected to be due to cerebral infarction or haemorrhage should be transferred directly to a stroke unit. The specialized care provided by these units, including emergency interventions (e.g. intravenous thrombolysis) and early mobilization help improve outcomes. If neurological symptoms have resolved completely, the patient should be referred to a TIA service as soon as possible, preferably within 1 day. Stroke often leads to permanent disability and neuropsychological impairments. The general practitioner (GP) should provide patients and caregivers with information and support, and should be alert to the psychological consequences of stroke, both in patients and caregivers. Secondary prevention measures are started as soon as the diagnosis of stroke is confirmed. GPs should regularly evaluate and monitor risk factors and compliance.

Effect of a stroke-specific follow-up care model on the quality of life of stroke patients and caregivers: A controlled trial.

OBJECTIVE: To evaluate the effectiveness of a stroke-specific follow-up care model on quality of life for stroke patients, being discharged home, and their caregivers. DESIGN: A non-randomized, controlled trial, comparing an intervention group with a control group (usual care). SUBJECTS: Stroke patients and their caregivers. METHODS: Intervention involved 5 home visits by a stroke care coordinator over a period of 18 months, using a structured assessment tool. Outcome measures were conducted at baseline (T0) and every 6 months thereafter (T6, T12 and T18) in the domains of quality of life (primary), activities of daily living, social activities, depression, anxiety and caregiver strain. RESULTS: The intervention group (n = 62) had significantly increased its social activities after 18 months, whereas the control group (n = 55) showed significantly decreased levels of social activities. In the first 6 months, levels of depression decreased significantly in caregivers of the intervention group. No differences were found for quality of life and the other outcome measures. CONCLUSION: The intervention was not effective in improving quality of life, but was effective in improving levels of social activities. The intervention may have focussed too much on screening for stroke-related problems and not as much on adequate follow-up care and referral.

Multidisciplinary care for stroke patients living in the community: a systematic review.

OBJECTIVE: A systematic review of randomized controlled trials was performed to evaluate the effectiveness of multidisciplinary care for stroke patients living in the community. DATA SOURCES: Databases PubMed, EMBASE, CINAHL and the Cochrane Library from January 1980 until July 2012. STUDY SELECTION: Randomized controlled trials focused on multidisciplinary interventions for stroke patients living at home after hospitalization or inpatient rehabilitation were selected. The outcome domains were activities of daily living, social participation and quality of life. A total of 14 studies were included. DATA EXTRACTION: Two authors independently extracted the data and independently assessed the quality of reporting of the included studies using the Consolidated Standards of Reporting Trials (CONSORT) statement 2010. DATA SYNTHESIS: None of the studies showed favourable effects of the intervention on activities of daily living and none assessed social participation. Furthermore, two studies reported favourable effects of the intervention in terms of quality of life. These concerned an intervention combining assessment with follow-up care and a rehabilitation intervention. CONCLUSION: There is little evidence for the effectiveness of multidisciplinary care for stroke patients being discharged home. Additional research should provide more insight into potentially effective multidisciplinary care for community-living stroke patients.

Not as transient: patients with transient ischaemic attack or minor stroke experience cognitive and communication problems; an exploratory study.

BACKGROUND: Patients with transient ischaemic attack (TIA) or minor stroke generally receive, besides secondary prevention, no regular follow up care after discharge directly home from the Emergency Room or TIA outpatient clinic; because it is believed that they will experience no consequences. OBJECTIVES: To explore whether the TIA and minor stroke patients have persistent problems due to the event. METHODS: This study has a cross-sectional, comparative non-randomized, exploratory design. Patients with TIA or minor stroke, not requiring hospital admission, and a control group of stroke patients, recently discharged home, were selected and interviewed with a questionnaire by telephone or home visit, between one and eight months after the event. Patients with angina pectoris (AP) were recruited as a second control group. RESULTS: Data showed that 51% of the TIA and minor stroke patients and 71% of the stroke patients experienced five or more problems, as opposed to 32% of patients with AP. Between 39 and 49% of the TIA, minor stroke and the stroke patients reported cognitive and communicative difficulties. Moreover, the TIA and minor stroke patients had more cognitive deficits (n = 27, 49%) and communicative limitations (n = 23, 42%) than the AP group (n = 7, 10% and n = 4, 6%, respectively). CONCLUSION: About half of the TIA and minor stroke patients experienced problems regarding cognition and communication, which were specific to the event. General practitioners should be aware of these potential problems and monitor patients regularly. Future research should focus on prognostic indicators to identify patients at risk.

Towards a better integrated stroke care: the development of integrated stroke care in the southern part of the Netherlands during the last 15 years (Special 10th Anniversary Edition paper).

INTRODUCTION: Stroke care is complex and often provided by various healthcare organisations. Integrated care solutions are needed to optimise stroke care. In this paper, we describe the development of integrated stroke care in the region of Maastricht during the last 15 years. DESCRIPTION OF INTEGRATED CARE CASE: Located in the south of the Netherlands, the region of Maastricht developed integrated stroke care to serve a population of about 180,000 people. Integration was needed to improve the continuity, coordination and quality of stroke care. The development of integrated care in Maastricht was a phased process. The last phase emphasized early discharge from hospital and assessing the best individual rehabilitation track in a specialized nursing home setting. DISCUSSION AND LESSONS LEARNED: The development and implementation of integrated stroke care in the region of Maastricht led to fewer days in hospital, more patients being directly admitted to the stroke unit and an earlier start of rehabilitation. The implementation of early discharge from the hospital and rehabilitation assessment in a nursing home led to some unforeseen problems and lessons learned.

Quality improvement of nurse-led aftercare to outpatients with coronary heart disease: report of a case study.

QUALITY ISSUE: Improving preventive care for patients with coronary disease can be difficult to implement effectively with available resources. Assessing the implementation of a new improvement program can also be challenging when resources are constrained. INITIAL ASSESSMENT: In 2006, a nurse-led outpatient clinic was introduced in the hospital. CHOICE OF SOLUTION: The use of quality indicators (QIs), interviews and regular meetings to enable ongoing assessment of the success of implementation. IMPLEMENTATION: Quality improvement was promoted by providing regular reports on QIs to the CARDIOCARE Steering and Working group. Interviews with stakeholders were held, medical records were investigated and minutes of meetings were analyzed. The main change in CARDIOCARE concerned the targeted patient group. EVALUATION: CARDIOCARE performed well in meeting requirements of quality such as clinical effectiveness. There is, however, still room for improvement and some new QIs should be considered by stakeholders; for example, better registration of risk factors is needed. LESSONS LEARNED: An initial period of time is necessary to examine whether QIs stated in the care protocol are realistic in clinical practice and whether it is feasible to collect data about these criteria. Stakeholders should communicate about these indicators on a regular basis. A Plan-Do-Check-Act cycle is needed in order to improve care processes and performance. In addition, systematic administration of data about indicators is required. For nurse-led outpatient secondary prevention, it is advisable to appoint a single nurse as a case manager who is responsible for checking the registration of QIs and their evaluation.

Experiences of doctors and nurses implementing nurse-delivered cardiovascular prevention in primary care: a qualitative study.

AIM: This paper reports on a study of the experiences of general practitioners and practice nurses implementing nurse-delivered cardiovascular prevention to high risk patients in primary care. BACKGROUND: Difficulties may arise when innovations are introduced into routine daily practice. Whether or not implementation is successful is determined by different factors related to caregivers, patients, type of innovation and context. METHODS: A qualitative study nested in a randomized trial (2006-2008) to evaluate the effectiveness of nurse-delivered cardiovascular prevention. Six primary health care centres in the Netherlands (25 general practitioners, 6 practice nurses) participated in the trial. Interviews were held on two occasions: at 3 and at 18 months after commencement of consultation. The first occasion was a group interview with six practice nurses. The second consisted of semi-structured interviews with one general practitioner and one practice nurse from each centre. FINDINGS: Main barriers to the implementation included: lack of knowledge about the guideline, attitudes towards treatment targets, lack of communication, insufficient coaching by doctors, content of life style advice. At the start of the consultation project, practice nurses expressed concern of losing nursing tasks. Other barriers were related to patients (lack of motivation), the guideline (target population) and organizational issues (insufficient patient recording and computer systems). CONCLUSIONS: Both general practitioners and practice nurses were positive about nurse-delivered cardiovascular prevention in primary care. Nurses could play an important role in successive removal of barriers to implementation of cardiovascular prevention. Mutual confidence between care providers in the healthcare team is necessary.

Adherence to a guideline on cardiovascular prevention: a comparison between general practitioners and practice nurses.

BACKGROUND: Patient non-compliance with prescribed treatment is an important factor in the lack of success in cardiovascular prevention. Another important cause is non-adherence of caregivers to the guidelines. It is not known how doctors and nurses differ in the application of guidelines. Patient compliance to treatment may vary according to the type of caregiver. OBJECTIVE: To compare adherence to cardiovascular prevention delivered by practice nurses and by general practitioners. SETTING: Six primary health care centres in the Netherlands (25 general practitioners, six practice nurses). METHODS: 701 high risk patients were included in a randomised trial. Half of the patients received nurse-delivered care and half received care by general practitioners. For 91% of the patients treatment concerned secondary prevention. The Dutch guideline on cardiovascular prevention was used as protocol. A structured self-administered questionnaire was sent by post to patients. Data were extracted from the practice database and the questionnaire. RESULTS: Intervention was received by 77% of respondents who visited the practice nurse compared to 57% from the general practitioner group (OR = 2.56, p < 0.01). More lifestyle intervention was given by the practice nurse; 46% of patients received at least one lifestyle intervention (weight, diet, exercise, and smoking) compared to 13% in general practitioner group (OR = 3.24, p < 0.001). In addition, after one year more patients from the practice nurse group used cardiovascular drugs (OR = 1.9, p = 0.03). Nurses inquired more frequently about patient compliance to medical treatment (OR = 2.1, p < 0.01). Regarding patient compliance, no statistical difference between study groups in this trial was found. CONCLUSION: Practice nurses adhered better to the Dutch guideline on cardiovascular prevention than general practitioners did. Lifestyle intervention advice was more frequently given by practice nurses. Improvement of cardiovascular prevention is still necessary. Both caregivers should inquire about patient adherence on a regular basis.

Patient perceptions of nurse-delivered cardiovascular prevention: cross-sectional survey within a randomised trial.

BACKGROUND: Studies have shown that in general patients are positive about cardiovascular prevention delivered by general practitioners. Further, it has been found that care by nurses for the chronically ill leads to even greater patient satisfaction. OBJECTIVE: The aim of this survey was to answer the following questions: How do patients perceive cardiovascular prevention delivered by the practice nurse? Are patient characteristics and personal health status associated with experiences of received nurse-led care? DESIGN: A cross-sectional survey after completion of a randomised trial. SETTING: Six primary health care centres in the Netherlands (25 general practitioners, 6 practice nurses, 30,000 patients). PARTICIPANTS: Included in the randomised trial were 701 patients with at least a 10% risk of fatal cardiovascular disease within 10 years. Patients who visited a cardiovascular specialist more often than once a year and patients with diabetes were excluded from the study. In 90% of the patients it concerned secondary prevention. Half of the patients received nurse-delivered care and half received care by the general practitioner. METHOD: A questionnaire was sent by post to all patients after having received one year of cardiovascular prevention. A dual moderator focus group study was held for the development of the questionnaire. FINDINGS: The response rate was 69%. Patients were more satisfied with nurse-delivered cardiovascular prevention compared to standard care by general practitioners. The majority of patients agreed with positive statements regarding received nurse-led care. Patient characteristics such as age, educational level and gender were significantly associated with patients experiences. Furthermore, a significant association between experiences and personal health status was found. In comparison with patients who did not smoke, smokers would recommend the practice nurse less to others (X(2)=4.0, p=0.047), felt more 'rapped on their knuckles' (X(2)=11.5, p=0.003), found the consultation more 'awkward' (X(2)=8.3, p=0.016) and thought the nurse less understanding of their personal situation (X(2)=6.4, p=0.041) and less able to explain clearly (X(2)=6.5, p=0.039). CONCLUSIONS: The majority of patients responded positively to nurse-delivered cardiovascular prevention. Further improvement could be gained by paying more attention to motivational interviewing. Nurses should approach high risk patients more specifically according to the type of risk factor to be treated.

Effectiveness of nurse-delivered cardiovascular risk management in primary care: a randomised trial.

BACKGROUND: A substantial part of cardiovascular disease prevention is delivered in primary care. Special attention should be paid to the assessment of cardiovascular risk factors. According to the Dutch guideline for cardiovascular risk management, the heavy workload of cardiovascular risk management for GPs could be shared with advanced practice nurses. AIM: To investigate the clinical effectiveness of practice nurses acting as substitutes for GPs in cardiovascular risk management after 1 year of follow-up. DESIGN OF STUDY: Prospective pragmatic randomised trial. SETTING: Primary care in the south of the Netherlands. Six centres (25 GPs, six nurses) participated. METHOD: A total of 1626 potentially eligible patients at high risk for cardiovascular disease were randomised to a practice nurse group (n = 808) or a GP group (n = 818) in 2006. In total, 701 patients were included in the trial. The Dutch guideline for cardiovascular risk management was used as the protocol, with standardised techniques for risk assessment. Changes in the following risk factors after 1 year were measured: lipids, systolic blood pressure, and body mass index. In addition, patients in the GP group received a brief questionnaire. RESULTS: A larger decrease in the mean level of risk factors was observed in the practice nurse group compared with the GP group. After controlling for confounders, only the larger decrease in total cholesterol in the practice nurse group was statistically significant (P = 0.01, two-sided). CONCLUSION: Advanced practice nurses are achieving results, equal to or better than GPs for the management of risk factors. The findings of this study support the involvement of practice nurses in cardiovascular risk management in Dutch primary care.

Towards a PropeR combination of patient records and protocols.

PROBLEM: The combination of a computer-based patient record and a decision-support system (DSS) may give physicians the decisive push they need to accept such systems. In the PropeR-project we determine the requirements for a generic interface between both these systems and evaluate its potential impact on patient care. This article reports results from the first year in one of the domains under study. It also provides background information about the project, including design considerations and experimental approach of forthcoming years. PURPOSE: The objectives of the first year were to determine bottlenecks of the current situation and to determine expected improvements and conditions for implementation of a future situation with computer support. METHODS: These topics were investigated in general by literature review and in the local situation by a requirements analysis. For the analysis we used a combination of observation, interviews, and patient record study. For the literature survey we searched for reviews, meta-analyses and original studies concerning experiences with computer-based patient records and DSSs in conventional settings and in integrated care. RESULTS: Main bottleneck was the poor use of shared patient record and paper guidelines. Expected improvements were better protocol adherence and communication. Conditions for implementation of computer support were a proper system interface and adoption by the user. CONCLUSION: Our main conclusion was that the aspect of cooperation needs more decision support than the clinical work itself.