Abstract
BackgroundCurrent health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated.ObjectiveTo describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR).MethodsWe used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups.ResultsWe developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program.ConclusionsThis paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.
Highlights
Current healthcare systems are not optimally designed to meet the needs of our aging populations.[1]
The two main objectives for the program were: (1) to facilitate self-management and shared-decision making by frail older people and their informal caregivers and (2) to improve collaboration among professionals by enhancing and facilitating information sharing, through a multidisciplinary shared electronic health record (EHR) and personal health record (PHR)
Step 1: Results of the needs assessment An overview of the results of the needs assessment for self-management of frail older people is provided in the logic model shown in Figure 1;5,7,13,18-34 a second logic model, concerning collaboration among professionals is shown in Figure 2.4,7,10,21,23,29-31,33-49 Each logic model describes the problem, followed by behavioral and environmental factors that contribute to the problem and the determinants that influence those factors
Summary
Current healthcare systems are not optimally designed to meet the needs of our aging populations.[1]. In a fragmented healthcare system, care for a single patient, especially care for a frail older patient, is often provided by multiple professionals who work in a variety of settings.[1,10,11] As a consequence, continuity of care, which is the degree to which a series of discrete healthcare events is experienced as coherent, connected and consistent with the patient’s medical needs and personal context,[11] is limited This undermines the quality of care provided.[12,13] coordination of care across settings and services, by the sharing of accurate information between professionals and by the effective collaboration of professionals, patients and informal caregivers, is badly-needed.[10,14,15] we developed a program aimed at: (1) facilitating self-management and shared-decision making by frail older people, and (2) reducing fragmentation of care by enhancing collaboration among professionals involved in the care of frail older people, through a multidisciplinary shared electronic health record (EHR) and personal health record (PHR). Future studies will establish the effects of the ZWIP on selfmanagement and shared-decision making by frail older people as well as on collaboration among the professionals involved
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