Primary Care Plus Research Articles

Economic Evaluation of New Models of Care: Does the Decision Change Between Cost-Utility Analysis and Multi-Criteria Decision Analysis?

ObjectivesTo experiment with new approaches of collaboration in healthcare delivery, local authorities implement new models of care. Regarding the local decision context of these models, multi-criteria decision analysis (MCDA) may be of added value to cost-utility analysis (CUA), because it covers a wider range of outcomes. This study compares the 2 methods using a side-by-side application. MethodsA new Dutch model of care, Primary Care Plus (PC+), was used as a case study to compare the results of CUA and MCDA. Data of patients referred to PC+ or care-as-usual were retrieved by questionnaires and administrative databases with a 3-month follow-up. Propensity score matching together with generalized linear regression models was used to reduce confounding. Univariate and probabilistic sensitivity analyses were performed to explore uncertainty in the results. ResultsAlthough both methods indicated PC+ as the dominant alternative, complementary differences were observed. MCDA provided additional evidence that PC+ improved access to care (standardized performance score of 0.742 vs 0.670) and that improvement in health-related quality of life was driven by the psychological well-being component (standardized performance score of 0.710 vs 0.704). Furthermore, MCDA estimated the budget required for PC+ to be affordable in addition to preferable (€521.42 per patient). Additionally, MCDA was less sensitive to the utility measures used. ConclusionsMCDA may facilitate an auditable and transparent evaluation of new models of care by providing additional information on a wider range of outcomes and incorporating affordability. However, more effort is needed to increase the usability of MCDA among local decision makers.

Physician Assistants and Nurse Practitioners in Primary Care Plus: A Systematic Review.

Introduction:Shifting specialist care from the hospital to primary care/community care (also called primary care plus) is proposed as one option to reduce the increasing healthcare costs, improve quality of care and accessibility. The aim of this systematic review was to get insight in primary care plus provided by physician assistants or nurse practitioners.Methods:Scientific databases and reference list were searched. Hits were screened on title/abstract and full text. Studies published between 1990–2018 with any study design were included. Risk of bias assessment was performed using QualSyst tool.Results:Search resulted in 5.848 hits, 15 studies were included. Studies investigated nurse practitioners only. Primary care plus was at least equally effective as hospital care (patient-related outcomes). The number of admission/referral rates was significantly reduced in favor of primary care plus. Barriers to implement primary care plus included obtaining equipment, structural funding, direct access to patient-data. Facilitators included multidisciplinary collaboration, medical specialist support, protocols.Conclusions and Discussion:Quality of care within primary care plus delivered by nurse practitioners appears to be guaranteed, at patient-level and professional-level, with better access to healthcare and fewer referrals to hospital. Most studies were of restricted methodological quality. Findings should be interpreted with caution.

Development of claims‐based measures of unplanned acute care with superior power for assessing the effectiveness of interventions following acute care

To develop outcome measures that are more sensitive than current measures for evaluating primary or transitional care after hospitalizations, emergency department (ED) visits, or observation stays. Medicare claims data from January 1, 2015, to October 31, 2017, for 1261707 Medicare fee-for-service beneficiaries served by (a) primary care practices participating in Track 1 of the Comprehensive Primary Care Plus (CPC+) initiative, and (b) their matched comparison practices. Given the poor statistical power in many studies to detect effects on readmissions, we developed two novel claims-based measures of unplanned acute care (UAC) following an index acute care event. The first measure assesses the proportion of hospitalizations followed by an unplanned readmission, ED visit, or observation stay within 30days of discharge; the second assesses the proportion of ED visits and observation stays followed by a hospitalization, ED visit, or observation stay within 30days. We calculate minimum detectable effects (MDEs) for both measures and for a conventional measure of 30-day unplanned readmissions, using CPC+data. Repeat UAC events are common among Medicare beneficiaries served by the CPC+practices. In 2017, 22% of discharges and 21% of ED visits and observation stays had a UAC event within 30days. Readmissions were the most common UAC event following discharge, whereas ED visits were most common following index ED visits or observation stays. MDEs are 25%-40% lower for the new measures than for the standard 30-day readmissions measure, indicating better statistical power to detect impacts of primary or transitional care interventions. This study introduces two new claims-based measures to assess quality of care during a patient's vulnerable period following acute care. The new measures complement existing measures, covering a broader range of UAC events than the standard 30-day readmissions measure, and yielding greater statistical power.

Exploring and Overcoming the Challenges Primary Care Practices Face with Care Management of High-Risk Patients in CPC+: a Mixed-Methods Study.

Longitudinal care management (LCM) for high-risk patients is a cornerstone of primary care models aiming to improve quality and reduce costs. Describe the extent to which LCM was implemented in the second year of Comprehensive Primary Care Plus (CPC+), and barriers to and facilitators of implementation. Mixed-methods. Quantitative: 2715 practices participating in CPC+ in 2018. Qualitative: Interviews with practitioners and staff in 23 representative CPC+ practices. Across all CPC+ practices, we report median percentages of empaneled patients placed in the highest-risk tiers and, of those, the median percentage receiving LCM. Across 23 CPC+ practices, we report qualitative findings on LCM implementation. While practices reported benefits of LCM, a small proportion of patients received LCM. Practices placed 2.4% (median) of patients in the highest-risk tier; of these, 30% (median) received LCM. Practices placed 10% (median) of patients in the second-highest-risk tier; of these, 7% (median) received LCM. Interviews revealed LCM uptake across tiers was low because of insufficient care manager staffing. Other challenges included lack of practitioner buy-in to using risk stratification to identify high-risk patients, patients' reluctance to engage in LCM or change behaviors, and limited health information technology functionality for developing, maintaining, and accessing high-risk patients' care plans. Facilitators included embedding care managers within practices and electronic health record functionalities that support LCM. Despite substantial financial and other supports, and practices' perceived benefits of LCM, insufficient care manager staffing and other barriers have limited its potential in CPC+ to date. To expand LCM's reach, practices need additional care managers, training to overcome barriers to patient engagement, better identification of patients who might benefit from LCM, improved information technology tools for risk stratification and care plans, and more practitioner buy-in to risk stratification.

PNS40 Economic Evaluation of New Models of Care: Does the Decision Change between Cost-Utility Analysis and MULTI-Criteria Decision Analysis?

Abstract Objectives To experiment with new approaches of collaboration in healthcare delivery, local authorities implement new models of care. Regarding the local decision context of these models, multi-criteria decision analysis (MCDA) may be of added value to cost-utility analysis (CUA), because it covers a wider range of outcomes. This study compares the 2 methods using a side-by-side application. Methods A new Dutch model of care, Primary Care Plus (PC+), was used as a case study to compare the results of CUA and MCDA. Data of patients referred to PC+ or care-as-usual were retrieved by questionnaires and administrative databases with a 3-month follow-up. Propensity score matching together with generalized linear regression models was used to reduce confounding. Univariate and probabilistic sensitivity analyses were performed to explore uncertainty in the results. Results Although both methods indicated PC+ as the dominant alternative, complementary differences were observed. MCDA provided additional evidence that PC+ improved access to care (standardized performance score of 0.742 vs 0.670) and that improvement in health-related quality of life was driven by the psychological well-being component (standardized performance score of 0.710 vs 0.704). Furthermore, MCDA estimated the budget required for PC+ to be affordable in addition to preferable (€521.42 per patient). Additionally, MCDA was less sensitive to the utility measures used. Conclusions MCDA may facilitate an auditable and transparent evaluation of new models of care by providing additional information on a wider range of outcomes and incorporating affordability. However, more effort is needed to increase the usability of MCDA among local decision makers.

Measuring physician practice site characteristics: A comparison of data from SK&A and a practice site survey.

To evaluate the comparability of commercially available practice site data from SK&A with survey data to understand the implications of using SK&A data for health services research. Responses to the Comprehensive Primary Care Plus (CPC+) Practice Survey and SK&A data. Comparison of CPC+Practice Survey responses to SK&A information for 2698 primary care practice sites. CPC+Practice Survey data collected through a web-only survey from April through September 2017, and SK&A data purchased in November 2016. Information was similar across data sources, although some discrepancies were common. For example, 56% of practice sites had differences in the reported number of practitioners, and larger sites tended to have larger differences. Among practice sites with 1 practitioner in the survey, only 1.3% had a difference of 3 or more practitioners between the data sources, whereas 63% of practice sites with 11 or more practitioners had a difference of 3 or more practitioners. Discrepancies between data sources could reflect differences of interpretation when defining practice site characteristics, changes over time in those characteristics, or data errors in either SK&A or the survey. Researchers using SK&A data should consider possible ramifications for their studies.

Participation in the Comprehensive Primary Care Plus Initiative

Comprehensive Primary Care Plus (CPC+) is the largest test of primary care payment and delivery reform. This program aims to strengthen primary care via enhanced and alternative payment, data feedback, learning, and health information technology support for practice transformation for more than 3,000 practices. We analyzed participation rates and how CPC+ practices differ from other primary care practices in CPC+ regions. We assembled a unique data set describing all US primary care practices and compared primary care practices in CPC+ regions, CPC+ applicants, and CPC+ participants. Among CPC+ participants, we compared across 2 model tracks. Of the primary care practices in CPC+ regions, 22% applied for CPC+ and 15% participated. Practices that applied to CPC+ were diverse, but they were generally larger, more sophisticated electronic health record users, more likely to be owned by a hospital or health system, more likely to have experience with transformation efforts, and more likely to be in urban areas than practices that did not apply. Applicants also generally served slightly healthier and more advantaged Medicare fee-for-service beneficiaries. Differences between practices that applied but did not join CPC+ and CPC+ participants were smaller yet systematic. Participants in CPC+ are diverse but not representative of all primary care practices, underscoring the need to further engage practices that are small, independent, in rural areas, and lack experience with practice and payment transformation models, as well as the need to extrapolate evaluation results carefully.

Patients' perspectives on a new delivery model in primary care: A propensity score matched analysis of patient-reported outcomes in a Dutch cohort study.

Rationale, aims and objectivePrimary Care Plus (PC+) focuses on the substitution of hospital‐based medical care to the primary care setting without moving hospital facilities. The aim of this study was to examine whether population health and experience of care in PC+ could be maintained. Therefore, health‐related quality of life (HRQoL) and experienced quality of care from a patient perspective were compared between patients referred to PC+ and to hospital‐based outpatient care (HBOC).MethodsThis cohort study included patients from a Dutch region, visiting PC+ or HBOC between December 2014 and April 2018. With patient questionnaires (T0, T1 and T2), the HRQoL and experience of care were measured. One‐to‐two nearest neighbour calliper propensity score matching (PSM) was used to control for potential selection bias. Outcomes were compared using marginal linear models and Pearson chi‐square tests.ResultsOne thousand one hundred thirteen PC+ patients were matched to 606 HBOC patients with well‐balanced baseline characteristics (SMDs <0.1). Regarding HRQoL outcomes, no significant interaction terms between time and group were found (P > .05), indicating no difference in HRQoL development between the groups over time. Regarding experienced quality of care, no differences were found between PC+ and HBOC patients. Only travel time was significantly shorter in the HBOC group (P ≤ .001).ConclusionResults show equal effects on HRQoL outcomes over time between the groups. Regarding experienced quality of care, only differences in travel time were found. Taken as a whole, population health and quality of care were maintained with PC+ and future research should focus more on cost‐related outcomes.

Reorganising dermatology care: predictors of the substitution of secondary care with primary care

BackgroundThe substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision.MethodsThis retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors.ResultsA total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+.ConclusionThe aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

Improving Effect Estimates by Limiting the Variability in Inverse Propensity Score Weights

This study describes a novel method to reweight a comparison group used for causal inference, so the group is similar to a treatment group on observable characteristics yet avoids highly variable weights that would limit statistical power. The proposed method generalizes the covariate-balancing propensity score (CBPS) methodology developed by Imai and Ratkovic (2014) to enable researchers to effectively prespecify the variance (or higher-order moments) of the matching weight distribution. This lets researchers choose among alternative sets of matching weights, some of which produce better balance and others of which yield higher statistical power. We demonstrate using simulations that our penalized CBPS approach can improve effect estimates over those from other established propensity score estimation approaches, producing lower mean squared error. We discuss applications where the method or extensions of it are especially likely to improve effect estimates and we provide an empirical example from the evaluation of Comprehensive Primary Care Plus, a U.S. health care model that aims to strengthen primary care across roughly 3000 practices. Programming code is available to implement the method in Stata.

Referral decisions and its predictors related to orthopaedic care. A retrospective study in a novel primary care setting

Due to the ageing population, the prevalence of musculoskeletal disorders will continue to rise, as well as healthcare expenditure. To overcome these increasing expenditures, integration of orthopaedic care should be stimulated. The Primary Care Plus (PC+) intervention aimed to achieve this by facilitating collaboration between primary care and the hospital, in which specialised medical care is shifted to a primary care setting. The present study aims to evaluate the referral decision following orthopaedic care in PC+ and in particular to evaluate the influence of diagnostic tests on this decision. Therefore, retrospective monitoring data of patients visiting PC+ for orthopaedic care was used. Data was divided into two periods; P1 and P2. During P2, specialists in PC+ were able to request additional diagnostic tests (such as ultrasounds and MRIs). A total of 2,438 patients visiting PC+ for orthopaedic care were included in the analysis. The primary outcome was the referral decision following PC+ (back to the general practitioner (GP) or referral to outpatient hospital care). Independent variables were consultation- and patient-related predictors. To describe variations in the referral decision, logistic regression modelling was used. Results show that during P2, significantly more patients were referred back to their GP. Moreover, the multivariable analysis show a significant effect of patient age on the referral decision (OR 0.86, 95% CI = 0.81–0.91) and a significant interaction was found between the treating specialist and the period (p = 0.015) and between patient’s diagnosis and the period (p ≤ 0.001). Despite the significant impact of the possibility of requesting additional diagnostic tests in PC+, it is important to discuss the extent to which the availability of diagnostic tests fits within the vision of PC+. In addition, selecting appropriate profiles for specialists and patients for PC+ are necessary to further optimise the effectiveness and cost of care.

Communication strategy in Primary Health Care plus project in Poland

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Evaluating Primary Care Plus interventions in the Netherlands: discussion of methods and results regarding the Quadruple Aim

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)

Substitution of hospital care with Primary Care Plus: differences in referral patterns according to specialty, specialist and diagnosis group

BackgroundPrimary Care Plus (PC+) is an intervention where patients consult specialists in a primary care setting outside the hospital. Two facilities have been founded in the city of Maastricht, the Netherlands. Main aim is to achieve substitution of hospital care with primary care and hence reduce costs. The objective of this study is to evaluate referral patterns per specialty, specialist and diagnosis group, as input for deliberations to optimise substitution.MethodsProspectively collected referral data after PC+ consultations between November 2014 and March 2016 was analysed for eight participating specialties. Primary outcomes were differences in referral patterns per specialty, specialist and diagnosis group. Absolute counts and percentages were recorded for categorical variables, means and standard deviations for continuous variables. Statistical analyses were performed using IBM SPSS Statistics 23 (SPSS Inc., Chicago, IL).ResultsIn total 4536 patients were seen in PC+; 3132 (69.0%) were referred back to the general practitioner (GP), whereas 1275 (28.1%) were referred to secondary care. Referral information of 130 (2.9%) patients was unknown. Large differences in referral numbers to secondary care after PC+ consultation were found between specialties (from 8.6% (gynaecology) to 43.8% (orthopaedic surgery)), specialists (14.5 to 65.2%) and diagnosis groups (11.1 to 93.4%).ConclusionsWide variation in referral numbers to secondary care between specialties, specialists and diagnosis groups exists after PC+ consultations. This data indicates that deliberation and further research is needed in order to optimize substitution initiatives like PC+.

Substituting hospital-based outpatient cardiology care: The impact on quality, health and costs.

BackgroundMany Western countries face the challenge of providing high-quality care while keeping the healthcare system accessible and affordable. In an attempt to deal with this challenge a new healthcare delivery model called primary care plus (PC+) was introduced in the Netherlands. Within the PC+ model, medical specialists perform consultations in a primary care setting. PC+ aims to support the general practitioners in gatekeeping and prevent unnecessary referrals to hospital care. The aim of this study was to examine the effects of a cardiology PC+ intervention on the Triple Aim outcomes, which were operationalized by patient-perceived quality of care, health-related quality of life (HRQoL) outcomes, and healthcare costs per patient.MethodsThis is a quantitative study with a longitudinal observational design. The study population consisted of patients, with non-acute and low-complexity cardiology-related health complaints, who were referred to the PC+ centre (intervention group) or hospital-based outpatient care (control group; care-as-usual). Patient-perceived quality of care and HRQoL (EQ-5D-5L, EQ-VAS and SF-12) were measured through questionnaires at three different time points. Healthcare costs per patient were obtained from administrative healthcare data and patients were followed for nine months. Chi-square tests, independent t-tests and multilevel linear models were used to analyse the data.ResultsThe patient-perceived quality of care was significantly higher within the intervention group for 26 out of 27 items. HRQoL outcomes did significantly increase in both groups (P <0.05) but there was no significant interaction between group and time. At baseline and also at three, six and nine months’ follow-up the healthcare costs per patient were significantly lower for patients in the intervention group (P<0.001).ConclusionsWhile this study showed no improvements on HRQoL outcomes, PC+ seemed to be promising as it results in improved quality of care as experienced by patients and lower healthcare costs per patient.

Expanding Palliative Care Accessibility: Models for Palliative Care delivery in Primary Care and Hospital-Based Settings (TH369)

•Compare and contrast primary palliative care and consult based care delivery.•Describe interdisciplinary peer education strategies.•Describe longitudinal support system from academic center to rural community hospital to improve palliative care access for patients in rural communities.•Evaluate successes and barriers in supporting palliative care planning and implementation in rural ICU setting. Primary palliative care is a model to deliver palliative care that can be used by treatment teams without access to full palliative care consult teams. This includes primary care offices which are the center of care for many patients with serious illness, especially those in rural and underserved regions. Ensuring excellent palliative care delivery within these models is critical to improving quality of care across the trajectory of serious illness. Primary palliative care benefits patients and families by decreasing symptom burden, suffering, conflict and non-beneficial treatments while increasing quality of life, comprehension and satisfaction. It similarly benefits clinicians and health systems by decreasing conflict, costs, length of stay and delivery of non-beneficial therapies. Primary palliative care can use triggers, guidelines and decision support tools to aid primary providers in palliative interventions and communication. This is increasingly recognized in value-based payment models such as Accountable Care Organizations (ACOs) and the Comprehensive Primary Care Plus program, thus creating an opportunity for palliative care clinicians. This concurrent session will present unique, multidisciplinary approaches to enhance primary palliative care delivery. These models vary from providing training for hospital-based and primary care clinicians to integrating palliative specialists in primary care. They include:1.Focused geriatrics and palliative care skills training for primary care physicians within an ACO.2.A trial of home-based palliative care embedded within a primary care practice vs. usual office-based care enriched with palliative care training for primary care clinicians.3.A systematic intervention to improve serious illness communication in primary care.4.A curriculum on best practice approaches to delivering primary palliative care for hospital-based teams with community education and outreach. Both primary care and palliative care needs and resources vary widely by region and practice. Each model presented will emphasize the process of needs assessment and stakeholder engagement preceding program design and implementation. This will equip attendees to return to their own communities and begin to engage with primary care practices around developing models of care.

A closer look at Primary Care Plus

Primary Care Plus is the latest systemic review that has already begun to be implemented, or at least considered, by GP practices that are either forward thinking or have cash flow issues. Jonathan McCutcheon looks at some of the advantages

How to design and implement integrated care programmes: Coordinated care models and Primary Health Care PLUS project in Poland

This abstract presents assumptions of the project "Preparation, testing and implementation of coordinated care in the healthcare system. Stage I Development of integrated / coordinated healthcare models for Poland and Stage II. Pilot phase – Primary Care PLUS model” co-financed from the European Social Fund under the Operational Program Knowledge Education Development financed under the European Commission Priority Axis 4 and 5.Introduction: The National Health Fund (Narodowy Fundusz Zdrowia – NFZ) is the sole public payer accountable for securing access to health care services throughout Poland for all eligible persons. Its 16 voivodship branches are responsible for contracting services with all types of healthcare providers. Entitlement to out- and in-patients services for adults is dependent on payment of monthly contribution (healthcare insurance).Description of policy context and objective: Present system is focused on specialized and inpatient care, which are reactive and remedial, mostly on ad-hoc basis. Patients are passive, poorly informed, dependent on the system. Their medical care is driven by and dependent on individual efforts of physicians, which are regarded as only partners. The aim of the project is to implement a pilot study introducing the model of care focused on patients’ needs and primary health care to be pro-active and preventive, based on planning, continuous, driven by family medicine teams, delivered to active, self-monitoring, well informed patient. All health professionals should be regarded as patients’ partners. The level of technology support should be adequate to the system goals.Targeted population: About 300 000 patients in 45 primary care practices out of which 45 000 will participate in the project.Highlights: Project implementation was divided into 3 phases: I. Creation of concept - developing 3 models; II. Implementation of the model chosen as a pilot; III. Implementation of chosen measures. Neutral (no link with politics) partner (The World Bank) is involved.Transferability: Most countries experience accelerated progress towards Universal Health Coverage resulting in an economical challenges. Longevity gains lead to chronic health conditions and increased health and long-term care needs, and related spending is outpacing economic growth even in most developed countries. There is a pressure to improve health outcomes and patient experiences, without further increase of health care costs. Therefore countries look for more effective ways of delivering high-quality health care services in more coordinated manner.Conclusions: Future reform targets the entire population of Poland with around 38 million people (6th in Europe). By year 2060 the number of seniors in Poland is expected to double from 5,5 to 11 million.Key stages of the project implementation:Implementation of chosen model as a pilotStage 1: Selection of representative (urban vs. rural areas etc.) project participants (PHC practices) carried out by all voivodships . Enrolment of each site preceded by an ex-ante audit.Stage 2: Adjustment of PHCs (organizational structure and IT systems) to the conditions of the model; ex-ante audit recommendations’ implementation.Stage 3: Creation of IT platform for NFZ and PHCs cooperation; to be used for processing data and enabling introduction of recommendations derived from coordination indicators, allowing knowledge exchange between participants of the study, containing health education information to be made available to patients. Data collected will serve also to Minister of Health as a basis for development or amendment of legal acts necessary for future effective implementation of coordinated healthcare in Poland.Stage 4: Providing health services and monitoring the quality of care.

How to design and implement integrated care programmes: Coordinated care models and Primary Health Care PLUS project in Poland

This abstract presents assumptions of the project Preparation, testing and implementation of coordinated care in the healthcare system. Stage I Development of integrated / coordinated healthcare models for Poland and Stage II. Pilot phase – Primary Care PLUS model” co-financed from the European Social Fund under the Operational Program Knowledge Education Development financed under the European Commission Priority Axis 4 and 5. Introduction: The National Health Fund (Narodowy Fundusz Zdrowia – NFZ) is the sole public payer accountable for securing access to health care services throughout Poland for all eligible persons. Its 16 voivodship branches are responsible for contracting services with all types of healthcare providers. Entitlement to out- and in-patients services for adults is dependent on payment of monthly contribution (healthcare insurance). Description of policy context and objective: Present system is focused on specialized and inpatient care, which are reactive and remedial, mostly on ad-hoc basis. Patients are passive, poorly informed, dependent on the system. Their medical care is driven by and dependent on individual efforts of physicians, which are regarded as only partners. The aim of the project is to implement a pilot study introducing the model of care focused on patients’ needs and primary health care to be pro-active and preventive, based on planning, continuous, driven by family medicine teams, delivered to active, self-monitoring, well informed patient. All health professionals should be regarded as patients’ partners. The level of technology support should be adequate to the system goals. Targeted population: About 300 000 patients in 45 primary care practices out of which 45 000 will participate in the project. Highlights: Project implementation was divided into 3 phases: I. Creation of concept - developing 3 models; II. Implementation of the model chosen as a pilot; III. Implementation of chosen measures. Neutral (no link with politics) partner (The World Bank) is involved. Transferability: Most countries experience accelerated progress towards Universal Health Coverage resulting in an economical challenges. Longevity gains lead to chronic health conditions and increased health and long-term care needs, and related spending is outpacing economic growth even in most developed countries. There is a pressure to improve health outcomes and patient experiences, without further increase of health care costs. Therefore countries look for more effective ways of delivering high-quality health care services in more coordinated manner. Conclusions: Future reform targets the entire population of Poland with around 38 million people (6th in Europe). By year 2060 the number of seniors in Poland is expected to double from 5,5 to 11 million. Key stages of the project implementation: Implementation of chosen model as a pilot Stage 1: Selection of representative (urban vs. rural areas etc.) project participants (PHC practices) carried out by all voivodships . Enrolment of each site preceded by an ex-ante audit. Stage 2: Adjustment of PHCs (organizational structure and IT systems) to the conditions of the model; ex-ante audit recommendations’ implementation. Stage 3: Creation of IT platform for NFZ and PHCs cooperation; to be used for processing data and enabling introduction of recommendations derived from coordination indicators, allowing knowledge exchange between participants of the study, containing health education information to be made available to patients. Data collected will serve also to Minister of Health as a basis for development or amendment of legal acts necessary for future effective implementation of coordinated healthcare in Poland. Stage 4: Providing health services and monitoring the quality of care.

Substituting hospital care with primary care: The evaluation of a cardiology Primary Care Plus intervention

Introduction: To deal with the pressures on the healthcare system, the healthcare system should focus on high-value health care by pursuing the three aims: improving the health of the population, improving the quality of care as experienced by patients and reducing the increase of healthcare costs. In the Netherlands, several initiatives focus on strengthening the primary care and substituting hospital care with primary care in order to keep the health care system sustainable. This study is concentrated on a cardiology primary care plus PC+ centre where cardiologists provide specialist consultations in a primary care setting. This PC+ intervention aims to improve the health of the population and patients’ experience of care while reducing the healthcare costs by decreasing the number of unnecessary referrals to specialist care in the hospital setting. Methods: This is a practice-based study with a longitudinal observational design. The study population consisted of adult patients with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre intervention group or hospital-based outpatient cardiology care control group. Data of the PC+ centre and the hospital were used to investigate the referral and follow-up patterns of intervention group patients compared to the control group. Furthermore, patients were asked to complete questionnaires at three different time points before consultation, directly after consultation, three months after consultation consisting of items about their demographics, health status SF-12, EQ-5D-5L and EQ-VAS and experience of care. Results: The data of the PC+ centre and the hospital consists of 1838 intervention patients and 2155 control patients. Preliminary results show that 27.9 % n= 513 of the intervention group was referred to hospital care after a consultation at the PC+ centre. Moreover, 437 intervention patients and 328 control patients were included in the questionnaire study. In 25 out of 27 items PC+ results in significantly higher levels of patient satisfaction compared to hospital-based outpatient care. The results of the EQ5D-5L indicate no differences in health status between the groups, taking into account the follow-up period of three months F=0.133; P=0.865. Discussion: PC+ is a new concept in the Dutch healthcare system and evidence about its effects is scarce. The findings of this study will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. Conclusion: Whilethis study showed no effects on the health status of the patients, there are promising results looking at the patients’ experience of care and healthcare utilization. Lessons learned: The implementation, as well as the evaluation, of PC+ initiatives is a dynamic process which requires time and continuous interaction with the stakeholders. Limitations: This study does not yet provide insight in the actual effects of PC+ on healthcare costs. Suggestions for future research: Future research, concentrated on PC+, should continue focusing on the Triple Aim outcomes, with a particular focus on healthcare costs.