Guus Schrijvers

The Effects on Health Behavior and Health Outcomes of Internet-Based Asynchronous Communication Between Health Providers and Patients With a Chronic Condition: A Systematic Review

Background In support of professional practice, asynchronous communication between the patient and the provider is implemented separately or in combination with Internet-based self-management interventions. This interaction occurs primarily through electronic messaging or discussion boards. There is little evidence as to whether it is a useful tool for chronically ill patients to support their self-management and increase the effectiveness of interventions. Objective The aim of our study was to review the use and usability of patient-provider asynchronous communication for chronically ill patients and the effects of such communication on health behavior, health outcomes, and patient satisfaction. Methods A literature search was performed using PubMed and Embase. The quality of the articles was appraised according to the National Institute for Health and Clinical Excellence (NICE) criteria. The use and usability of the asynchronous communication was analyzed by examining the frequency of use and the number of users of the interventions with asynchronous communication, as well as of separate electronic messaging. The effectiveness of asynchronous communication was analyzed by examining effects on health behavior, health outcomes, and patient satisfaction. Results Patients’ knowledge concerning their chronic condition increased and they seemed to appreciate being able to communicate asynchronously with their providers. They not only had specific questions but also wanted to communicate about feeling ill. A decrease in visits to the physician was shown in two studies (P=.07, P=.07). Increases in self-management/self-efficacy for patients with back pain, dyspnea, and heart failure were found. Positive health outcomes were shown in 12 studies, where the clinical outcomes for diabetic patients (HbA1c level) and for asthmatic patients (forced expiratory volume [FEV]) improved. Physical symptoms improved in five studies. Five studies generated a variety of positive psychosocial outcomes. Conclusions The effect of asynchronous communication is not shown unequivocally in these studies. Patients seem to be interested in using email. Patients are willing to participate and are taking the initiative to discuss health issues with their providers. Additional testing of the effects of asynchronous communication on self-management in chronically ill patients is needed.

Motivation for treatment in substance-dependent patients. Psychometric evaluation of the TCU motivation for treatment scales.

The objective of this paper is to analyze the psychometric properties of the TCU Motivation for Treatment (MfT) scale in alcohol- and drug-dependent patients in an inpatient treatment facility in the Netherlands, to see whether it is useful in European populations as well. In the study, 279 consecutive patients were enrolled: 132 drug and 147 alcohol dependents. Exploratory and confirmatory factor analysis revealed 4 subscales: recognition of general problems (4 items), recognition of specific problems (5), desire for help (5) and treatment readiness (8). The results of the analyses showed that the MfT scale is a valid instrument for measuring treatment motivation, both in drug- and in alcohol-dependent patients. We demonstrated evidence for consistency of the scale through cultural barriers, in different populations and in different treatment settings.

Coping with caring: Profiles of caregiving by informal carers living with a loved one who has dementia

Background and aim: While the number of people suffering from dementia in the Netherlands will double in the next 25 years, there are no plans to expand the capacity of residential care facilities for these patients. This will almost inevitably lead to an increase in the burden placed on informal carers. We investigated how caregivers living with a loved one who has dementia experience their caregiving situation. Methods: For this study, 53 caregivers ranked a structured set of opinion statements covering a representative range of aspects of caregiving. By-person factor analysis was used to uncover patterns in the rankings of statements. Results: Five distinct profiles of caregiving were identified that provide information on the various care situations that can occur, the needs and dilemmas that these caregivers face, and the subjective burden and perseverance time of the carers. Conclusions: The findings contribute to the development of interventions for the support of informal caregivers.

The Perseverance Time of Informal Carers of Dementia Patients: Validation of a New Measure to Initiate Transition of Care at Home to Nursing Home Care

BACKGROUND Health care systems aim to involve as much informal care as possible and dementia patients prefer to stay home as long as they can. In this context, perseverance time (Pt)-the period that the informal carer indicates to be able to maintain current care if the situation remains stable-is an important concept. OBJECTIVE The aim of this study was to introduce the concept Pt and validate it in a sample of informal carers of dementia patients living at home. METHODS Data were collected from 223 informal carers of dementia patients. Convergent validity was assessed by looking at associations of Pt with validated instruments for measuring subjective burden (CSI, CarerQol-7D, and SRB) and happiness (CarerQol-VAS). Content validity was evaluated by performing multivariate correlations between Pt and characteristics of dementia patients, informal carers, and care situations. The Medical Ethics Committee of Utrecht MC advised positively about the study protocol. RESULTS Correlation coefficients between Pt and the measures of burden CSI, SRB, and CarerQol-VAS were -0.46, -0.63, and 0.23 (p < 0.01), respectively. Health of dementia patient, informal carer living apart from the patient, and male gender of caregiver were positively associated with Pt; need for supervision, intensity of informal care provision, and reductions in working hours and hobbies in order to be able to provide care were negatively associated. CONCLUSIONS Pt is helpful in monitoring need for support and planning the transition of care from home to nursing home. This study provides a first indication of its validity, but replication is necessary.

How spouses evaluate Nursing Home Placement of their demented partner: a study about the end of perseverance time

AIM This study was about the final decision by spouses to have their demented partner placed in a nursing home. The central question was whether the admission took place in the right time in their point of view. METHOD Fourteen partners of persons with dementia evaluated the nursing home placement. They were interviewed at home using a semi-structured questionnaire. Grounded theory was used to explore the process of decision-making. In addition to the interviews, quantitative data were used from a 2-year follow-up study. RESULTS Results underline that the placement decision had to be made in phases over time. The first decision is about placement of the relative on a waiting list, and the second decision is about the actual placement in a nursing home once a place becomes available. This second and final decision often had to be taken under time pressure to avoid a place in the nursing home being left empty. If they had been given more time and space to reconsider their admission decision, most partners said they could have had continued providing homecare longer. During the investigation, the following classification in timeliness of the admission emerged: Placement was at the right time, too early, too late or out of control. CONCLUSION Spouses indicated they could have kept on giving care for a longer period of time if they had been given more time and space to make their final decision about the admission of their partner. It may be helpful for informal and formal carers to focus on perseverance time in considering placement or prolonged support at home. Placement at an appropriate time may lead to a higher degree of well-being of informal carers before and especially after the admission.

Exploring the effects of patients taking a vigilant role in collaborating on their e-medication administration record.

OBJECTIVE Errors in the electronic medication administration record (eMAR) occur in 25.6% of cases, mainly due to communication errors. The aim of this study is to investigate whether the quality of the eMAR improves when patients play a vigilant role by checking their medication using a patient communication tool linked to their eMAR (eMAR-PCT) to communicate asynchronously with the pharmacist about errors. Effects on health outcomes and self-care are also explored. METHODS In this quasi-experimental study, polypharmacy patients using five or more medications were randomly selected and invited to use their eMAR-PCTs. Participants also received two digital questionnaires assessing health and self-care (week 0 and 26). Statistical analyses were performed on two subgroups: eMAR-PCT users and non-users. RESULTS An inclusion rate of 43.5% (n=152) was achieved. Women were more prevalent than men among the users group (56.4% vs. 43.6%). Among the eMAR-PCT users, 75% logged in more than once, and 17.9% communicated asynchronously with the pharmacist. The content of the e-mails shows that eMAR-PCT was used as intended. No improvement in the quality of the eMAR was found. The self-care variables self-efficacy (p=.006) and collaboration with the pharmacist (p=.021) showed significant improvement in the users group. CONCLUSION AND DISCUSSION The results showed no effect on eMAR quality and a modest improvement in self-care. Active digital patient participation to improve the quality of eMAR merits further investigation as, in line with other research, tentatively positive results are shown on self-care. Possibilities for implementation are promising as half of the patients who pledged to use eMAR-PCT actually did, and used it as intended.

Case-Managers and Integrated Care

This chapter on case management starts with a case story about Julia, a person with dementia, and her case manager, John (Sect. 4.1). It shows six innovations which are necessary to introduce case managers. Julia and John live in the year 2025, in a rich western country with a health system that supports integrated care by means of adequate financing and digitalization of care. Section 4.2 introduces a definition of the concept of case management and discusses important terms in it. Then (Sect. 4.3), two specific competences of case managers are discussed: (1) the assessments of care and social needs and (2) empowering interviewing of clients. The chapter continues (Sect. 4.4) with the comparison of the “ideal world” in the case story in 2025 with the real world in 2015 by focusing on case management practices in The Netherlands and France. The chapter ends (Sect. 4.5) by offering theories to support the implementation of the case manager. The chapter emphasises that case managers are not only for clients with dementia but are relevant as an approach to support other people with health, educational and financial problems; clients with developmental delays; patients with severe mental illness; patients with cancer and metastases; and persons with more than one chronic condition. In this chapter, the words clients, patients and persons are used as synonyms occurring in different care contexts.

The challenge of involving elderly patients in primary care using an electronic communication tool with their professionals : A mixed methods study

Background Elderly patients in primary care often have multiple health problems, with different healthcare professionals involved. For consistency in care, it is required that communication amongst professionals and patient-systems (patient and informal-carers) be well tuned. Electronic-communication can make it easier for patient-system to be active in care. Objective To examine whether an e-communication tool (Congredi) designed for professionals, including a care plan and secure e-mail, is usable for patient-systems and what their experiences are. Methods In a multi-method study, home-dwelling elderly patients with two or more professionals were invited to use Congredi; data were gathered from the system after 42 weeks. Also semi-structured interviews were undertaken with patient-systems with topics retrieved from literature. Analysis took place by two researchers independently; the themes were extracted together by consensus. Results Data about actual use of the tool were gathered from 22 patients. Four profiles of Congredi-users were distinguished, varying in intensity of use. Data from interviews with members of patient-systems (n = 7) showed that they were motivated and able to use Congredi. Barriers in daily use were limited participation of professionals, unanswered e-mail and not being alerted about actions. Despite limitations, patient-systems retained their motivation. Conclusion Congredi was usable for patient-systems. The barriers found seem not to be tool-related but primarily user-related. An important barrier for daily use was limited active participation of involved professionals in a complete feedback loop. Potential for future implementation was found, as patient-systems were intrinsically motivated for better feedback with the professionals, even though in this study it only partly met their expectations.

Bundled payments in the context of Triple Aim and Behavioural economics

In 2007 the Netherlands introduced bundled payments for diabetes care. Under this BP system, health insurers pay a single fee to a contracting entity – the care group – which serves as the general contractor for DMPs and which is responsible for organizing care and ensuring its delivery. Care groups subcontract care services by individual health care providers or employ providers to deliver these services themselves. Health insurers freely negotiate with care groups about the fee for the DMP in a BP contract. The care services included in the BP contracts are determined by the Dutch Diabetes Federation Health Care Standard. Principal investigator dr. Jeroen Struijs shows in the first half of the lecture the effects of this payment reform on health care delivery process, quality of care and health care expenditures. Then health economist Guus Schrijvers compares these results with the theory of Triple Aim, aiming at 1. More health 2. More quality of care and 3. Less per capita costs. At the end Schrijvers places the Theory of Triple Aim in the domain of behavioural economics. He gives suggestions for new research and demonstration projects.

Integrated primary care, the collaboration imperative inter-organizational cooperation in the integrated primary care field a theoretical framework

Purpose Capacity problems and political pressures have led to a rapid change in the organization of primary care from mono disciplinary small business to complex inter-organizational relationships. It is assumed that inter-organizational collaboration is the driving force to achieve integrated (primary) care. Despite the importance of collaboration and integration of services in primary care, there is no unambiguous definition for both concepts. The purpose of this study is to examine and link the conceptualisation and validation of the terms inter-organizational collaboration and integrated primary care using a theoretical framework. Theory The theoretical framework is based on the complex collaboration process of negotiation among multiple stakeholder groups in primary care. Methods A literature review of health sciences and business databases, and targeted grey literature sources. Based on the literature review we operationalized the constructs of inter-organizational collaboration and integrated primary care in a theoretical framework. The framework is being validated in an explorative study of 80 primary care projects in the Netherlands. Results and conclusions Integrated primary care is considered as a multidimensional construct based on a continuum of integration, extending from segregation to integration. The synthesis of the current theories and concepts of inter-organizational collaboration is insufficient to deal with the complexity of collaborative issues in primary care. One coherent and integrated theoretical framework was found that could make the complex collaboration process in primary care transparent. This study presented theoretical framework is a first step to understand the patterns of successful collaboration and integration in primary care services. These patterns can give insights in the organization forms needed to create a good working integrated (primary) care system that fits the local needs of a population. Preliminary data of the patterns of collaboration and integration will be presented.