Unknown makes unloved:A case study on improving integrated health and social care in the Netherlands using a participatory approach

Many initiatives integrating health and social care have been implemented in order to provide adequate care and support to older people living at home. Further development of existing initiatives requires iterative processes of developing, implementing and evaluating improvements to current practice. This case study provides insight into the process of improving an existing integrated care initiative in the Netherlands. Using a participatory approach, researchers and local stakeholders collaborated to develop and implement activities to further improve collaboration between health and social care professionals. Improvement activities included interprofessional meetings focussing on reflection and mutual learning and workplace visits. Researchers evaluated the improvement process, using data triangulation of multiple qualitative and quantitative data sources. According to participating professionals, the improvement activities improved their communication and collaboration by establishing mutual understanding and trust. Enabling factors included the safe and informal setting in which the meetings took place and the personal relationships they developed during the project. Different organisational cultures and interests and a lack of ownership and accountability among managers hindered the improvement process, whereas issues such as staff shortages, time constraints and privacy regulations made it difficult to implement improvements on a larger scale. Still, the participatory approach encouraged the development of partnerships and shared goals on the level of both managers and professionals. This case study highlights that improving communication between professionals is an important first step in improving integrated care. In addition, it shows that a participatory approach, in which improvements are co-created and tailored to local priorities and needs, can help in the development of shared goals and trust between stakeholders with different perspectives. However, stakeholders' willingness and ability to participate in such an improvement process is challenged by many factors

Infrared optical properties of the spin-1/2 quantum magnet TiOClTiOCl

We report results on the electrodynamic response of $TiOCl$, a low-dimensional spin-1/2 quantum magnet that shows a spin gap formation for T$<T_{c1}$= 67 $K$. The Fano-like shape of a few selected infrared active phonons suggests an interaction between lattice vibrations and a continuum of low frequency (spin) excitations. The temperature dependence of the phonon mode parameters extends over a broad temperature range well above $T_{c1}$, indicating the presence of an extended fluctuation regime. In the temperature interval between 200 $K$ and $T_{c1}$ there is a progressive dimensionality crossover (from two to one), as well as a spectral weight shift from low towards high frequencies. This allows us to identify a characteristic energy scale of about 430 $K$, ascribed to a pseudo spin-gap

Strategies to improve preoperative care

The contents and organization of the preoperative care have gained increasing attention over the past decade. Several strategies have emerged to evaluate and optimize patients before surgery, aiming to minimize the risk of complications. In this thesis two different strategies for preoperative evaluation and optimization were studied: outpatient preoperative evaluation clinics (OPE clinics) and preoperative interventions embedded in clinical pathways for gastrointestinal surgery. At an OPE clinic the anaesthetist timely evaluates the preoperative condition of patients to asses the risk on complications during and after surgery. Formerly, this evaluation was performed by internists and surgeons or by the anaesthetist just before he started anaesthesia. The implementation of OPE clinics was evaluated by a nationwide survey with questionnaires. Cooperation of anaesthetists was most frequently mentioned as facilitating factor for implementation of OPE clinics. Lack of finance was most frequently reported as limiting factor, but significantly more often in hospitals without than in with an OPE clinic (

Chronisch hartfalen.

De cardioloog en de hartfalenverpleegkundige kunnen gezien worden als de centrale zorgverleners. In de thuissituatie spelen de huisarts en de thuiszorg een belangrijke rol. Er zijn recent twee landelijke afstemmingsafspraken gepubliceerd: de Multidisciplinaire richtlijn Chronisch Hartfalen en het Protocol Multidisciplinaire Voorlichting Hartfalen. Voor de regionale multidisciplinaire afstemmingsafspraken geldt dat er 22 zijn gevonden in het literatuuronderzoek en 28 in de enquête. Regionale afstemmingsafspraken worden voornamelijk gemaakt door ziekenhuis, specialist (cardioloog) en gespecialiseerd) verpleegkundige. Bij de helft van de afspraken zijn de huisarts en de thuiszorg betrokken. In de enquête worden ook andere zorgaanbieders genoemd die betrokken zijn bij de afstemmingsafspraken. Regionale afstemmingsafspraken gaan vooral over afbakening van taken en verantwoordelijkheden, patiëntgerichtheid, kwaliteit van zorg, zorginhoud, toegankelijkheid van zorg en bekwaamheid en deskundigheid van de zorgaanbieders. Patiënten ervaren dat de voorlichting te wensen overlaat: de inhoud en de timing zijn voor verbetering vatbaar. Knelpunten in de zorg voor patiënten met chronisch hartfalen liggen vooral op het vlak van patiëntgerichtheid, financiering en afstemming tussen zorgaanbieders

Angststoornissen.

De belangrijkste behandelingsvormen van angststoornissen zijn cognitieve gedragstherapieën, in vivo blootstelling en farmacotherapieën. De behandeling is vooral gericht op stabilisatie en symptoomreductie. Bij de zorg voor mensen met angststoornissen spelen de huisarts, apotheek en de GGZ een aanzienlijke rol. In mindere mate geldt dit voor de bedrijfsarts, fysiotherapeut, thuiszorg en informele en alternatieve hulpverleners. Er zijn twee landelijke ziektespecifieke afstemmingsafspraken tussen zorgverleners gevonden: één monodisciplinaire richtlijn (NHG-standaard) en één recentelijk verschenen multidisciplinaire richtlijn die wordt geïmplementeerd. Op regionaal niveau zijn er via de literatuur/databanken twee afstemmingsafspraken gevonden voor angststoornissen en via de schriftelijke enquête acht. De acht gevonden regionale afspraken hadden vooral tot doel om de zorg doeltreffender, inzichtelijker en meer patiëntgericht te maken. Dit gebeurt meestal door de ontwikkeling van een gezamenlijke zorgvisie en gezamenlijke protocollen. De implementatie van deze afspraken in de dagelijkse patiëntenzorg is nog niet afgerond. Over de ervaringen van de patiënten in de zorgverlening zijn nauwelijks gegevens beschikbaar. Volgens betrokken zorgaanbieders liggen de knelpunten vooral bij opsporing en diagnose, gegevensoverdracht tussen zorgverleners, beschikbaarheid van gespecialiseerde zorgverleners, de coördinatie binnen de zorg en andere financiële en organisatorische belemmeringen

Een populatiegerichte aanpak voor verbinding van preventie, zorg en welzijn: De beweging in beeld

Doel Het inventariseren van Nederlandse initiatieven met een populatiegerichte aanpak voor verbinding van preventie, zorg en welzijn. Opzet Beschrijvend onderzoek, gebaseerd op gesprekken en gestructureerde interviews. Methode Gezocht werd naar initiatieven waarin aanbieders op het gebied van preventie, zorg en welzijn zich samen met zorgverzekeraars, gemeenten of beide inzetten voor de ‘triple aim’: het verbeteren van de gezondheid van de populatie en de kwaliteit van de zorg, en het beheersen van de kosten. Wij vonden potentiële initiatieven op basis van gesprekken met sleutelfiguren, projectdatabases en congresprogramma’s. Op websites en bij contactpersonen zochten wij nadere informatie om te bepalen of het initiatief voldeed aan de inclusiecriteria. Een initiatief moest preventie, welzijn en zorg verbinden, waarbij minimaal 3 partijen actief een populatiegericht doel na moesten streven met meerdere interventies voor een niet-ziektespecifieke en wijkoverstijgende populatie. Op basis van interviews in de periode augustus-december 2015 met managers van de geïncludeerde initiatieven beschreven wij het doel, de organisatiestructuur, de betrokken partijen, de activiteiten en de bekostiging. Resultaten We vonden 19 initiatieven die aan de criteria voldeden, waarin geëxperimenteerd werd met organisatievormen, niveaus van participatie, interventies en bekostiging. Opvallend was dat ingezette interventies vooral medische zorg betroffen. Inzicht in de effecten op de triple aim ontbrak, voornamelijk omdat gegevensuitwisseling tussen partijen moeizaam verliep. Conclusie Er verschijnen steeds meer initiatieven die een populatiegerichte aanpak volgen. Hoewel de verschillende partijen gezamenlijk naar verbinding over de domeinen heen streven, is men nog op zoek naar optimale vormen van samenwerking, organisatie, gegevensuitwisseling en financiering

Meta-analysis and meta-regression analyses explaining heterogeneity in outcomes of chronic care management for depression

Rationale, aims and objectives: Chronic care management programmes for depression show variation in effectiveness. This study aims to examine the clinical diversity and methodological heterogeneity related to the effectiveness of such programmes and to explain the heterogeneity in clinical outcomes. Objectives are to enable the understanding of and the decision-making about depression management programmes and to contribute to the implementation of chronic care management strategies for depression as part of advances in person-centered mental healthcare. Method: We performed a systematic review of reviews and empirical studies, including meta-analyses and meta-regression analyses on the most frequently reported outcomes. We explored to what extent the observed heterogeneity can be explained by study quality, length of follow-up, number of components of the Chronic Care Model (CCM) and patient characteristics. Results: Pooled effects of depression management programmes show significant improvement in treatment response (RR=1.38; p<0.05) and treatment adherence (RR=1.36; p<0.05). In meta-regression analysis, study quality and depression severity explain the substantial heterogeneity in respectively treatment response (36.6%; p=0.0352) and treatment adherence (88.7%; p=0.0083). Conclusions: The observed heterogeneity in depression outcomes cannot be explained by the number of intervention components and length of follow-up. Yet, the heterogeneity in treatment response can be explained partly by study quality, demonstrating the importance of good quality studies. Heterogeneity in treatment adherence can be explained partly by severity of the depression, indicating that taking account of depression severity contributes to maximising the effectiveness of chronic care management. Other potential sources of heterogeneity should be investigated to support informed decision-making on treating depression as a chronic condition as part of person-centered mental healthcare

Meta-analysis of the effectiveness of chronic care management for diabetes: Investigating heterogeneity in outcomes

Purpose  The study aims to support decision making on how best to redesign diabetes care by investigating three potential sources of heterogeneity in effectiveness across trials of diabetes care management. Methods  Medline, CINAHL and PsycInfo were searched for systematic reviews and empirical studies focusing on: (1) diabetes mellitus; (2) adult patients; and (3) interventions consisting of at least two components of the chronic care model (CCM). Systematic reviews were analysed descriptively; empirical studies were meta-analysed. Pooled effect measures were estimated using a meta-regression model that incorporated study quality, length of follow-up and number of intervention components as potential predictors of heterogeneity in effects. Results  Overall, reviews (n = 15) of diabetes care programmes report modest improvements in glycaemic control. Empirical studies (n = 61) show wide-ranging results on HbA1c, systolic blood pressure and guideline adherence. Differences between studies in methodological quality cannot explain this heterogeneity in effects. Variety in length of follow-up can explain (part of) the variability, yet not across all outcomes. Diversity in the number of included intervention components can explain 8–12% of the heterogeneity in effects on HbA1c and systolic blood pressure. Conclusions  The outcomes of chronic care management for diabetes are generally positive, yet differ considerably across trials. The most promising results are attained in studies with limited follow-up (<1 year) and by programmes including more than two CCM components. These factors can, however, explain only part of the heterogeneity in effectiveness between studies. Other potential sources of heterogeneity should be investigated to ensure implementation of evidence-based improvements in diabetes care

[The effectiveness of disease management in diabetes: a meta-analysis]

Item does not contain fulltextOBJECTIVE: Systematic evaluation of the effectiveness of innovative care concepts for diabetes, taking into account heterogeneity of study results. DESIGN: Systematic review, meta-analysis and meta-regression analysis. METHOD: Medline, CINAHL and PsycINFO were searched for reviews and empirical studies into adult patients with diabetes in whom interventions were used that consisted of a minimum of 2 components from the Chronic Care Model. In the meta-analysis, a random-effects model was used to pool results on HbA1c and systolic blood pressure. Meta-regression analysis was used to examine the extent to which 3 differences in study design - (a) methodological quality, (b) length of follow-up, and (c) number of intervention components - could explain the heterogeneity in effect measures. RESULTS: The reviews (n = 15) generally reported modest improvements in glycaemic control. The empirical studies (n = 56) differed greatly in the direction and magnitude of measured effects on HbA1c (mean: -5 mmol/mol; 95% CI: -7- -3.5) and systolic blood pressure (mean: -2.8 mmHg; 95% CI: -4.7- -0.95). Variation in methodological quality between the studies could not explain this. Short-term studies (/= 1 year), but this difference was not significant. The variation in the number of intervention components explained 8-12% of the heterogeneity in effects of diabetes care innovations. CONCLUSION: Diabetes care interventions that include more than 2 components have the most positive effects on clinical outcomes. Considering the connection between length of follow-up and results as well as the fact that the targets of these innovations focus primarily on the future, the impact of such interventions should be measured in the long term