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other·primary care, general practice, chronic disease management, multimorbidity, public health·PMC10001916

Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study

International Journal of Environmental Research and Public Health · 8 authors, 5 centres

AI SUMMARY

FIDELITY 89%

POPULATIONPatients with one or more chronic conditions (at least diabetes mellitus type 2, COPD, or cardiovascular disease) in Dutch primary care

INTERVENTIONPerson-centred integrated care (PC-IC) approach involving integral health status assessment, personal goal setting, shared decision-making on interventions, individual care plan, and case management by practice nurses

COMPARISONCurrent single-disease management programs (DMPs) for COPD, CVD, and DM2

This summary was generated by AI from a single paper. It has not been reviewed by a clinician and is not clinical advice. Verify against the source before acting on it.

AGENT 01 · STRUCTURED SUMMARY

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TL;DR

This paper describes the multiphase development of a person-centred integrated care (PC-IC) approach for managing patients with one or more chronic diseases in Dutch primary care, co-designed with healthcare professionals, patients, insurers, and health literacy experts. The approach shifts from single-disease management programs to holistic care that assesses multiple health domains, sets personal goals through shared decision-making, and uses a case manager (practice nurse) to coordinate care. Stakeholders generally viewed the approach positively, anticipating improved patient motivation and care efficiency, though concerns about time investment and suitability for patients with limited health literacy were noted.

Full summary

4,290 CHARS

**Background:** Chronic diseases are the leading cause of death globally, and in the Netherlands, 59% of the population had one or more chronic diseases in 2020. Single disease management programs (DMPs) for COPD, cardiovascular disease, and diabetes mellitus type 2 are widely implemented in Dutch primary care but have failed to improve patients' health-related quality of life. These programs focus on medical aspects of specific conditions with less attention to multimorbidity or social determinants. Person-centred integrated care (PC-IC) has been proposed as an alternative, aiming to ensure patients' values and concerns shape how long-term conditions are managed. This study describes the development of a PC-IC approach for patients with one or more chronic diseases in Dutch primary care, co-designed with academics, healthcare professionals, patients, and healthcare insurers.

**Methods:** The multiphase development process ran from March 2019 to July 2020, conducted with three large primary care cooperatives in the eastern Netherlands (Nijmegen region: 168 GPs, ~290,000 inhabitants; Arnhem region: 193 GPs, ~440,000 inhabitants; Doetinchem region: 116 GPs, ~150,000 inhabitants). Phase 1 involved a scoping review (searching PubMed, EMBASE, Cochrane, TRIP, and GIN databases up to August 27, 2019) and document analysis of Dutch chronic disease care standards and GP guidelines for COPD, CVD, and DM2. Phase 2 used online qualitative surveys with 52 healthcare professionals (93% response rate from 56 invited), including 16 GPs, 15 practice nurses, and various allied health professionals. Phase 3 involved semi-structured telephone interviews with 9 patients (8 male, mean age 65 years, range 58-79) with DM2, COPD, and/or CVD. Phase 4 gathered feedback from health insurers and the Dutch Centre of Expertise on Health Disparities (Pharos). Data were analyzed using inductive thematic coding with ATLAS.ti version 8.4.15.

**Key Results:** The scoping review identified 18 eligible publications (published 2007-2019, 67% from 2015-2019). Key elements identified included: assessment of multiple domains (medical, functional, mental health, social functioning), case management, clinical assessment including disease burden and treatment burden, eliciting patient preferences and priorities, and collaborative care planning. The document analysis produced a list of unique interventions across categories including physiological functioning, physical functioning, quality of life, and social functioning. Healthcare professionals generally agreed with the PC-IC vision, anticipating improved patient motivation and long-term time savings, but raised concerns about time intensity, suitability for patients with limited health skills, and potential medicalisation of non-medical problems. Patients valued personalized care, longer consultation times, and the partnership approach, but highlighted accessibility concerns for those with low literacy or computer skills. Health insurers requested clearer inclusion criteria and attention to workforce shortages. Pharos experts noted the digital questionnaire (Nijmegen Clinical Screening Instrument) needed language and layout improvements for people with limited health literacy.

**Clinical Implications:** The developed PC-IC approach represents a shift from disease-focused protocols to holistic, patient-centred care for chronic disease management in Dutch primary care. The approach includes cyclical assessment of integral health status across multiple domains, collaborative goal setting, shared decision-making on interventions, and documented individual care plans with case management by practice nurses. While stakeholders anticipated benefits including improved patient motivation, better insight into health status, and more efficient care delivery, the authors acknowledge that the anticipated superiority over current DMPs has yet to be demonstrated. A cluster randomised trial is underway to assess effects on health-related quality of life, self-management behaviour, and patient experience. The study predominantly focused on micro-level service delivery; meso and macro level components (financing, governance, workforce) require further study. A complementary payment model has been published separately.

PICO

PPOPULATION

Patients with one or more chronic conditions (at least diabetes mellitus type 2, COPD, or cardiovascular disease) in Dutch primary care

IINTERVENTION

Person-centred integrated care (PC-IC) approach involving integral health status assessment, personal goal setting, shared decision-making on interventions, individual care plan, and case management by practice nurses

OOUTCOME

Not directly measured; study focused on development and stakeholder feedback. Anticipated outcomes include improved health-related quality of life, patient experience, self-management, and care efficiency

STUDY TYPE

other

SPECIALTY

primary care

SUMMARISED BY

AI pipeline

FIDELITY CHECK

89% · B

ORIGINAL PAPER

PMC10001916

Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study

International Journal of Environmental Research and Public Health

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ABSTRACT

Abstract To reduce the burden of chronic diseases on society and individuals, European countries implemented chronic Disease Management Programs (DMPs) that focus on the management of a single chronic disease. However, due to the fact that the scientific evidence that DMPs reduce the burden of chronic diseases is not convincing, patients with multimorbidity may receive overlapping or conflicting treatment advice, and a single disease approach may be conflicting with the core competencies of primary care. In addition, in the Netherlands, care is shifting from DMPs to person-centred integrated care (PC-IC) approaches. This paper describes a mixed-method development of a PC-IC approach for the management of patients with one or more chronic diseases in Dutch primary care, executed from March 2019 to July 2020. In Phase 1, we conducted a scoping review and document analysis to identify key elements to construct a conceptual model for delivering PC-IC care. In Phase 2, national experts on Diabetes Mellitus type 2, cardiovascular diseases, and chronic obstructive pulmonary disease and local healthcare providers (HCP) commented on the conceptual model using online qualitative surveys. In Phase 3, patients with chronic conditions commented on the conceptual model in individual interviews, and in Phase 4 the conceptual model was presented to the local primary care cooperatives and finalized after processing their comments. Based on the scientific literature, current practice guidelines, and input from a variety of stakeholders, we developed a holistic, person-centred, integrated approach for the management of patients with (multiple) chronic diseases in primary care. Future evaluation of the PC-IC approach will show if this approach leads to more favourable outcomes and should replace the current single-disease approach in the management of chronic conditions and multimorbidity in Dutch primary care. Keywords: person-centred integrated care, person-centred care, chronic conditions, primary care, general practice, chronic care management, multimorbidity

CITATION EXPORT

Lena H A Raaijmakers, Tjard R Schermer, Mandy Wijnen et al.. Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study. International Journal of Environmental Research and Public Health. (2023). https://doi.org/10.3390/ijerph20053824

AUTHORS

8 · 5 CENTRES

Lena H A Raaijmakers, Tjard R Schermer, Mandy Wijnen, Hester E van Bommel, Leslie Michielsen, Floris Boone, Jan H Vercoulen, Erik W M A Bischoff

1Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
2Science Support Office, Gelre Hospitals, P.O. Box 9014, 7300 DS Apeldoorn, The Netherlands
3Pharos, Dutch Centre of Expertise on Health Disparities, P.O. Box 13318, 3507 LH Utrecht, The Netherlands
4Research Group Innovation of Care and Services, HAN University of Applied Sciences, Kapittelweg 33, 6525 EN Nijmegen, The Netherlands
5Department of Medical Psychology, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands