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 100%

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

TRACE TO SOURCE

“

TL;DR

This multiphase study developed a person-centred integrated care approach for chronic disease management by synthesizing literature, guidelines, and input from healthcare professionals, patients, and stakeholders in the Netherlands. The main finding is a finalized holistic model emphasizing integral health assessment, patient goal-setting, and shared care planning. A key limitation is that the development process was regional and the model's actual effectiveness is yet to be tested in practice.

Full summary

1,371 CHARS

The study aimed to develop a person-centred integrated care (PC-IC) approach as an alternative to single-disease management programs (DMPs) for chronic conditions like diabetes, COPD, and cardiovascular disease. Using a mixed-method, four-phase process, researchers first conducted a scoping review and document analysis to identify key elements from literature and Dutch guidelines, creating a conceptual model. This was refined through online surveys with 52 healthcare professionals (including GPs, practice nurses, and allied health) and semi-structured interviews with 9 patients, followed by final feedback from primary care cooperatives and health insurers. The final PC-IC approach centers on a practice nurse as a case manager who guides patients through assessing their integral health status (across medical, functional, mental, and social domains), setting personalized goals, choosing tailored interventions, and creating a shared care plan. Stakeholders generally supported the model's potential for more holistic care and patient empowerment but raised concerns about implementation feasibility, time demands, and suitability for patients with limited health literacy. The study concludes that while the co-designed model is theoretically robust, its clinical effectiveness in improving patient outcomes needs to be evaluated in a future feasibility study.

STUDY TYPE

other

SPECIALTY

family medicine

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

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

READ THE FULL PAPER

JUMP TO SECTION

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

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