Quality of integrated primary care and coproduction of care with community-living frail older persons

Abstract

Introduction: The Chronic Care Model (CCM) was developed to guide quality improvement efforts in primary care and identifies important elements that promote high-quality integrated care and foster coproduction. We aimed to increase our knowledge on the CCM in the primary care setting for community-dwelling frail older persons in the Netherlands. The objective was therefore to assess congruency of care with (elements of) the CCM, professionals’ perceptions of quality of care and coproduction of care. Methods: A longitudinal study was conducted with a control group (4 GP practices delivering usual primary care) and an intervention group. The intervention group consisted of 11 GP practices that implemented a proactive, integrated care approach for frail older persons, which is called ‘Finding and Follow-up of Frail older persons’ (FFF). The FFF approach combines interrelated components of integrated primary care (e.g. case management, self-management support, multidisciplinary teams) that are assumed to promote high-quality primary care and coproduction of care. We assessed coproduction of care (relational coproduction instrument) and perceived quality of care (Assessment of Chronic Illness Care Short version; ACIC-S) among 75 healthcare professionals. Data were collected at baseline (T0) and 12 months after (T1) and were analyzed by chi-square tests, McNemar test, t-tests and regression analysis. To assess congruency of (integrated) primary care with the CCM, we conducted structured interviews with the 15 GPs. The interview format comprised 64 interventions across six CCM dimensions, i.e. community linkages, healthcare organization, self-management support, delivery system design, decision support, and clinical information systems. We assessed which interventions were implemented successfully in the intervention and control GP practices and we collected additional qualitative data. Results: Each GP practice implemented (various) interventions within each of the six dimensions of the CCM. Intervention GP practices implemented more interventions that are congruent with (dimensions of) the CCM than control GP practices (respectively 33 and 23 interventions on average). At baseline, ACIC-S scores on the CCM dimensions ‘healthcare organization’ and ‘delivery system design’ were significantly higher in the intervention group compared with the control group. Over time, quality of care improved significantly in the intervention group while there were no significant changes in quality of care in the control group. At T1, ACIC-S scores on all dimensions of the CCM were significantly higher in the intervention group compared with the control group. Furthermore, quality of care at baseline and improvements therein positively influenced coproduction of care with frail older persons in the intervention group. Discussion and conclusion: Overall, our study showed that the integrated care approach FFF successfully improved quality of care as perceived by professionals. This conclusion is in line with the finding that intervention GP practices implemented more interventions that are congruent with the CCM. Moreover, (improvements in) quality of care positively influenced coproduction of care with community-living frail older persons. Lessons learned: Redesigning primary healthcare systems and implementing integrated care based on (elements of) the CCM may contribute to improved quality of care and coproduction of care. Limitations: A limitation of our study was the small number of healthcare professionals in the control group. Suggestions for future research: Although the presence of a control group strengthened our findings, we recommend involving a larger sample of professionals providing usual care.