General practitioners' views on the influence of long-term care reforms on integrated elderly care in the Netherlands: a qualitative interview study.

This study explores the long-term care (LTC) reform in the Netherlands and its relation to the day-to-day integrated care for frail elderly people, from the perspective of general practitioners (GPs). We assessed GP perspectives regarding which elements of the LTC reform have promoted and hindered the provision of person-centred, integrated care for elderly people in the Netherlands. We performed case studies conducted by semi-structured interviews, using the Healthy Alliances (HALL) framework as a framework for thematic analysis. GPs reported that the ideals of the LTC reform (self-reliance) were largely achievable and listed a number of positive effects, including increased healthcare professional engagement and the improved integration of the medical and social domains through the close involvement of social support teams. The reported negative implications were a lack of co-ordination in the implementation of the reforms by the municipality, insufficient funding for multidisciplinary team meetings and the reinforced fragmentation of home care. In particular, the implementation of the system reforms took place with little regard for the local context. We suggest that the implementation of national care reforms should be aligned with factors operating at the micro level and make the following recommendations: use one central location for primary health and social services, integrate regional ICT structures to improve the exchange of patient information, and reduce fragmentation in home care.

Professional Care Networks of Frail Older People: An Explorative Survey Study from the Patient Perspective.

BACKGROUND: Frail older people living in the community require multidisciplinary care. Despite the fact that patient participation is high on the public agenda, studies into multidisciplinary care mainly focus on the viewpoints of professionals. Little is known about frail older patients' experiences with care delivered by multidisciplinary teams and their perception of collaboration between professional and informal caregivers. OBJECTIVE: To gain more insight into the experiences of frail older patients with integrated multidisciplinary care by mapping the care networks of this patient group and their perception of the interconnection between professional and informal caregivers. METHODS: Survey study to facilitate a care network analysis. Due to the vulnerable health status of the respondents, questionnaires were completed during interviews. Analysis was performed using an iterative process, using both visual and metric techniques. PARTICIPANTS: 44 older persons, considered 'frail' by their general practitioner. SETTING: Four general practices in The Netherlands. RESULTS: The networks of the participants consisted of an average of 15 actors connected by 54 ties. General practitioners were the most common actors in the networks, and were well connected to medical specialists and in-home care providers. The participants did not always perceive a connection between their general practitioner and their informal caregiver. The network analyses resulted in the identification of three subtypes: simple star (n = 16), complex star (n = 16), and sub-group networks (n = 12). CONCLUSIONS: Our findings indicate that the elderly often do not experience the integration of multidisciplinary care as such. This is a real opportunity for MTs to improve their care and to make the patients' experiences better in line with what they are aiming: allowing patients to live at home as healthy and independently as possible for as long as possible. We showed that informal caregivers often form communication bridges between patients and professionals. Having a better knowledge of the patient perspective enables the gaps in professional care networks of frail older people to be filled and facilitates the anticipation of crisis situations.

Mirror meetings with frail older people and multidisciplinary primary care teams: Process and impact analysis.

OBJECTIVES: To analyse the process and impact of confronting multidisciplinary teams (MTs) in primary care with the experiences of frail older patients through mirror meetings (MMs), with the aim of supporting teams to organize care in a more patient-oriented way. METHODS: Process and impact analyses were performed using a mixed-method approach. MMs were held with 14 frail older patients and four MTs comprising 23 health-care professionals (HCPs) in primary care in the Netherlands. RESULTS: Mirror meetings were feasible for frail older people living at home, although their recruitment was time-consuming. Interaction between the patients was scarce, but they valued the opportunity to share their stories. HCPs preferred MMs overwritten reports about patient experiences. An impact analysis revealed four dominant professional areas for improvement: improve alignment with patient goals, improved communication with patients both orally and in writing, developing new pathways to connect with informal caregivers and an increased understanding that most HCPs are relative strangers to their patients. CONCLUSIONS: Mirror meetings are a relatively simple and promising method for exploring the ways in which frail older patients experience care. PRACTICE IMPLICATIONS: Given the right conditions, MMs could result in valuable processes to enable MTs to improve their working methods.

The role of the general practitioner in multidisciplinary teams: a qualitative study in elderly care.

BACKGROUND: In the western world, a growing number of the older people live at home. In the Netherlands, GPs are expected to play a pivotal role in the organization of integrated care for this patient group. However, little is known about how GPs can play this role best. Our aim for this study was to unravel how GPs can play a successful role in elderly care, in particular in multidisciplinary teams, and to define key concepts for success. METHODS: A mixed qualitative research model in four multidisciplinary teams for elderly care in the Netherlands was used. With these four teams, consisting of 46 health care and social service professionals, we carried out two rounds of focus-group interviews. Moreover, we performed semi-structured interviews with four GPs. We analysed data using a hybrid inductive/deductive thematic analysis. RESULTS: According to the health care and social service professionals in our study, the role of GPs in multidisciplinary teams for elderly care was characterized by the ability to 'see the bigger picture'. We identified five key activities that constitute a successful GP role: networking, facilitating, team building, integrating care elements, and showing leadership. Practice setting and phase of multidisciplinary team development influenced the way in which GPs fulfilled their roles. According to team members, GPs were the central professionals in care services for older people. The opinions of GPs about their own roles were diverse. CONCLUSIONS: GPs took an important role in successful care settings for older people. Five key concepts seemed to be important for best practices in care for frail older people: networking (community), facilitating (organization), team building (professional), integrating care elements (patient), and leadership (personal). Team members from primary care and social services indicated that GPs had an indispensable role in such teams. It would be advantageous for GPs to be aware of this attributed role. Attention to leadership competencies and to the diversity of roles in multidisciplinary teams in GP training programmes seems useful. The challenge is to convince GPs to take a lead, also when they are not inclined to take this role in organizing multidisciplinary teams for older people.

Addition of a general practitioner to the accident and emergency department: a cost-effective innovation in emergency care.

BACKGROUND: Many patients visit the accident and emergency department (AED) on their own initiative, although their medical problem can be adequately treated by a general practitioner (GP). Objective To evaluate the cost-effectiveness of addition of a GP to the AED (new care method) in comparison with usual care (usual care method). METHODS: This study followed a before/after design. Patients attending the AED without a referral on weekdays from 10:00 to 17:00 were invited to participate. Main outcome measures were process time, patient satisfaction and number of correct diagnoses. Costs were measured from a societal perspective. Bootstrapping was used to estimate uncertainty around differences in costs and incremental cost-effectiveness ratios. Cost-effectiveness planes and acceptability curves were presented. RESULTS: Addition of a GP to the AED resulted in significantly lower process time, significantly higher patient satisfaction and no statistically significant difference in the number of correct diagnoses. Total costs per patient were €217 in the new care period and €288 in the usual care period (mean difference -€71, 95% CI -121 to -23). The cost-effectiveness analysis showed that the new care method was dominant (more effective, less expensive) in comparison with the usual care method for process time and patient satisfaction. The new care method was considered cost-effective in comparison with the usual care method for ceiling ratios between €0 and €1363 for the number of correct diagnoses. CONCLUSION: The new care method consisting of addition of a GP to the AED is cost-effective in comparison with usual care for all outcome parameters measured.

Effectiveness of GPs in accident and emergency departments.

BACKGROUND: Many self-attending patients make inappropriate use of accident and emergency departments. AIM: To determine whether a new care method consisting of the involvement of a GP during the day with the staff of the accident and emergency department of an academic city hospital and application of the Nederlands Triage System by a practice nurse is more effective than usual care. DESIGN: Before and after intervention design. SETTING: Accident and emergency department in the VU University Medical Center in Amsterdam. METHOD: Participants were patients (n = 1527) attending the accident and emergency department without a referral, on weekdays from 10.00-17.00 hours, from 1 November 2006 to 30 April 2007. The intervention consisted of a new care method that combined the involvement of a GP in the accident and emergency department and allocation of patients by triage to either the GP or the accident and emergency department physician. Main outcome measures were patient satisfaction, number and type of additional examinations, quality of diagnosis, process time, and treatment time. RESULTS: Patient satisfaction with the treatment increased significantly. Compared to the usual care method, this new care method resulted in a 13% decrease in additional examinations. The percentage of incorrect diagnoses (1 %), as a measure of quality of care, was similar with the two methods. The mean process time decreased from 93 to 69 minutes (P<0.001). The mean treatment time decreased from 60 to 35 minutes (P<0.001). CONCLUSION: The new care method resulted in greater patient satisfaction and maintained the quality of care, with fewer additional examinations. It reduced both the process time and the treatment time.