A personalized care plan in chronic care: implementation and evaluation

Abstract

Purpose: Implementation and evaluation of a personalized care plan for approximately 350 people with (an increased risk of) cardio­ vascular disease in ten general practices in the Netherlands. Context: The ‘Healthy Vessels’ (‘Vitale Vaten’) care standard of 2009 describes the optimum care for people with (an increased risk of) cardiovascular disease and is based on the Chronic Care Model. New: working with a personalized care plan, with detailed attention for the promotion of self­management and shared decision­making (SDM). This requires patients to adopt a more active attitude, with a more coaching role from care providers. Vilans has developed the personalized care plan for cardiovascular disease (the booklet ‘Zorgplan Vitale Vaten’) and the personalized care plan for diabetes and for COPD in 2011. In 2011 Vilans also started with the development of a general care plan for patients with multi morbidity diseases. Data sources: Patients: quantitative survey with a written questionnaire sent to approximately 75 patients. Baseline and end points for 40 patients, plus in­depth interviews with eight patients. Care providers: Quantitative survey with a written questionnaire sent to 45 care providers. Baseline and end points for 22 care providers, plus in­depth interviews with 10 care providers. Case description: The personalized care plan is produced by a shared decision­making process and consists of: A prioritised list of the patient’s SMART objectives • A personalized plan for achieving those objectives • Agreements concerning what the patient will do himself/herself and the support or advice needed • Agreements concerning contact to review the progress (how and when) • The patient or the care provider notes the plan in the patient’s booklet (the ‘Zorgplan Vitale Vaten’=‘Healthy Vessels Care Plan’). This booklet also contains information about the risk factors for cardiovascular disease, the importance of the patient adopting an active role, measurement values, medication and the patient’s care providers. Advisers from Vilans, the knowledge centre for long­term care in the Netherlands, provide participating organisations guidance for the implementation of the personalized care plan with: work conferences, supporting products and monthly support phone­calls or e­mails. The project consists of the following phases: Jan 2010 to Jun 2010: development of materials • Jun 2010 to Oct 2011: implementation and evaluation in ten general practices • Nov 2011 to Feb 2012: project completion and reporting • The results will be available in February 2012 •