Emotional Dimensions in Integrated Care for People with Multiple Complex Problems

Cross-boundary collaboration, both multiprofessional and interorganizational, is needed when providing integrated care for people with multiple problems, who need services at the same time from diverse care providers. Multiple problems of clients also pose extra challenges for interaction between care professionals and clients. Emotional dynamics are always present in everyday interaction between human beings, but seldom explicitly addressed in research on integrated care. The aim of this reflective paper is to illustrate the emotional dimensions of integrated care in light of the experiences of care professionals in the context of care for people with multiple complex problems. The paper draws on a Finnish study on integrated care reflecting its findings from the perspective of emotional labor. The difficult life situations of people with multiple complex problems form an emotional burden, which is mirrored in the interaction between clients and professionals and affects relational dynamics among professionals. Professionals' fear of emotions and the different feeling rules' of care professions and sectors pose extra challenges to professionals' collaboration in this emotionally loaded context. Alongside the structural and functional aspects of integrated care, it is important that emotions embedded in everyday cross-boundary collaboration are recognized and taken into account in order to ensure the success of integrated care.Peer reviewe

Sote-ammattilaisten monialainen yhteistyö : Paljon palveluja tarvitsevat asiakkaat etusijalle

Non peer reviewe

Cost-effectiveness analysis for a tele-based health coaching program for chronic disease in primary care

Background: The burden of chronic disease and multimorbidity is rapidly increasing. Self-management support interventions are effective in reduce cost, especially when targeted at a single disease group; however, economical evidence of such complex interventions remains scarce. The objective of this study was to evaluate a cost-effectiveness analysis of a tele-based health-coaching intervention among patients with type 2 diabetes (T2D), coronary artery disease (CAD) and congestive heart failure (CHF). Methods: A total of 1570 patients were blindly randomized to intervention (n = 970) and control (n = 470) groups. The intervention group received monthly individual health coaching by telephone from a specially trained nurse for 12-months in addition to routine social and healthcare. Patients in the control group received routine social and health care. Quality of life was assessed at the beginning of the intervention and follow-up measurements were made after 12 months health coaching. The cost included all direct health-care costs supplemented with home care and nursing home-care costs in social care. Utility was based on a Health Related Quality of Life (HRQoL) measurement (15D instrument), and cost effectiveness was assessed using incremental cost-effectiveness ratios (ICERs). Results: The cost-effectiveness of health coaching was highest in the T2D group (ICER €20,000 per Quality-Adjusted Life Years [QALY]). The ICER for the CAD group was more modest (€40,278 per QALY), and in the CHF group, costs increased with no marked effect on QoL. Probabilistic sensitivity analysis indicated that at the societal willingness to pay threshold of €50,000 per QALY, the probability of health coaching being cost effective was 55% in the whole study group. Conclusions: The cost effectiveness of health coaching may vary substantially across patient groups, and thus interventions should be targeted at selected subgroups of chronically ill. Based on the results of this study, health coaching improved the QoL of T2D and CAD patientswith moderate costs. However, the results are grounded on a short follow-up period, and more evidence is needed to evaluate the long-term outcomes of health-coaching programs.Peer reviewe

Health coaching by telephony to support self-care in chronic diseases: clinical outcomes from The TERVA randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>The aim was to evaluate the effect of a 12-month individualized health coaching intervention by telephony on clinical outcomes.</p> <p>Methods</p> <p>An open-label cluster-randomized parallel groups trial. Pre- and post-intervention anthropometric and blood pressure measurements by trained nurses, laboratory measures from electronic medical records (EMR). A total of 2594 patients filling inclusion criteria (age 45 years or older, with type 2 diabetes, coronary artery disease or congestive heart failure, and unmet treatment goals) were identified from EMRs, and 1535 patients (59%) gave consent and were randomized into intervention or control arm. Final analysis included 1221 (80%) participants with data on primary end-points both at entry and at end. Primary outcomes were systolic and diastolic blood pressure, serum total and LDL cholesterol concentration, waist circumference for all patients, glycated hemoglobin (HbA_1c) for diabetics and NYHA class in patients with congestive heart failure. The target effect was defined as a 10-percentage point increase in the proportion of patients reaching the treatment goal in the intervention arm.</p> <p>Results</p> <p>The proportion of patients with diastolic blood pressure initially above the target level decreasing to 85 mmHg or lower was 48% in the intervention arm and 37% in the control arm (difference 10.8%, 95% confidence interval 1.5–19.7%). No significant differences emerged between the arms in the other primary end-points. However, the target levels of systolic blood pressure and waist circumference were reached non-significantly more frequently in the intervention arm.</p> <p>Conclusions</p> <p>Individualized health coaching by telephony, as implemented in the trial was unable to achieve majority of the disease management clinical measures. To provide substantial benefits, interventions may need to be more intensive, target specific sub-groups, and/or to be fully integrated into local health care.</p> <p>Trial registration</p> <p>ClinicalTrials.gov Identifier: NCT00552903</p