Quality Of Chronic Care Delivery Research Articles

Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients.

US primary care practices are actively identifying strategies to improve outcomes and reduce costs among high-need high-cost (HNHC) patients. HNHC patients are adults with high health care utilization who suffer from multiple chronic medical and behavioral health conditions such as depression or substance abuse. HNHC patients with behavioral health conditions face heightened challenges accessing timely primary care and managing their conditions, which is reflected by their high rates of emergency department (ED) utilization and preventable spending. Structural capabilities (i.e., care coordination, chronic disease registries, shared communication systems, and after-hours care) are key attributes of primary care practices which can enhance access and quality of chronic care delivery. The purpose of this study was to analyze the association between structural capabilities and ED utilization among HNHC patients with behavioral health conditions. We merged cross-sectional survey data on structural capabilities from 240 primary care practices in Arizona and Washington linked with Medicare claims data on 70,182 HNHC patients from 2019. Using multivariable Poisson models, we found shared communication systems were associated with lower rates of all-cause and preventable ED utilization among HNHC patients with alcohol use (all-cause: aRR 0.72, 95% CI: 0.62, 0.84; preventable: aRR 0.5, 95% CI: 0.40, 0.64) and HNHC patients with substance use disorders (all-cause: aRR 0.76, 95% CI: 0.68, 0.85; preventable: aRR 0.61, 95% CI: 0.52, 0.71). Care coordination was also associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders. Shared communication systems and care coordination have the potential to increase the effectiveness of primary care delivery for specific HNHC patients.

Disaggregating the Differential Impact of Healthcare IT in Complex Care Delivery: Insights from Field Research in Chronic Care

This study focuses on the impact of digitizing medical information on the efficiency and perceived quality of chronic care delivery at the individual physician level. This study extends the theory of task technology fit to activity systems consisting of highly interdependent tasks. We find that the outcomes of efficiency and quality gains are driven by the structure of interdependencies between tasks that physicians perform. While structured information plays a key role in enabling both decision-making and task execution, we find that physician-created semistructured information is also an important predictor of both efficiency and quality gains. We show that the structure of activity systems (task interdependencies) has a strong moderating influence on the factors that drive efficiency and quality gains. We find that digitization enables physicians to preprocess patients’ records prior to their visit which in turn drives gains in both the efficiency and the perceived quality of care delivered.

Is "disease management" the answer to our problems? No! Population health management and (disease) prevention require "management of overall well-being".

BackgroundDisease management programs based on the chronic care model have achieved successful and long-term improvement in the quality of chronic care delivery and patients’ health behaviors and physical quality of life. However, such programs have not been able to maintain or improve broader self-management abilities or social well-being, which decline over time in chronically ill patients. Disease management efforts, population health management initiatives and innovative primary care solutions are still mainly focused on clinical and functional outcomes and health behaviors (e.g., smoking cessation, exercise, and diet) failing to address individuals’ overall quality of life and well-being. Individuals’ ability to achieve well-being can be assessed with great specificity through the application of social production function (SPF) theory. This theory asserts that people produce their own well-being by trying to optimize the achievement of instrumental goals (stimulation, comfort, status, behavioral confirmation, affection) that provide the means to achieve the larger, universal goals of physical and social well-being.DiscussionA shift in focus from the management of physical function, disease limitations, and lifestyle behaviors alone to an approach that fosters self-management abilities such as self-efficacy and resource investment as well as overall quality of life, is urgently needed. Disease management interventions should be aimed at adequately addressing all difficulties chronically ill patients face in life, such as the effects of pain and fatigue on the ability to maintain a job and social life and to participate in activities promoting physical and social well-being. Patients’ ability to maintain engagement in stimulating work and social activities with the people who are important to them may be even more important than aspects of disease self-management such as blood pressure or glycemic control. Interventions should aim to make chronically ill patients capable of managing their own well-being and adequately addressing their needs in a broader sense.SummarySo, is disease management the answer to our problems in the time of aging populations and increased prevalence of unhealthy lifestyles, chronic illnesses, and comorbidity? No! Effective (disease) prevention, disease management, patient-centered care, and high-quality chronic care and/or population health management calls for management of overall well-being.

The changing nature of chronic care and coproduction of care between primary care professionals and patients with COPD and their informal caregivers.

The aim of this study was to investigate whether care delivery in accordance with a care model is associated with co-productive relationships between professionals and COPD patients and their informal caregivers. A co-productive relationship refers to productive patient–professional interaction or shared decision making. This cross-sectional study was conducted in 2014 among 411 patients (out of 981) enrolled in the Dutch COPD care program Kennemer Lucht and 62 professionals treating them (out of 97). Kennemer Lucht COPD involved multicomponent interventions within all six dimensions of the chronic care model (organizational support, community, self-management, decision support, delivery system design, and information and communications technology) to improve the quality of care for patients with COPD. This approach was expected to improve relational coproduction of care between professionals and patients with COPD and their informal caregivers. Results show clearly that the perceived quality of chronic care delivery is related significantly to productive interaction/relational coproduction of care. The strength of the relationship between perceptions of quality of chronic care and relational coproduction among patients is strong (r=0.5; P≤0.001) and among professionals moderate (r=0.4; P≤0.001 relational coproduction with patients and informal caregivers). Furthermore, patients’ perceptions of the quality of chronic care were associated with the existence of productive interaction with health care professionals (β=0.7; P≤0.001). The changing nature of chronic care is associated with coproduction of care, leading to the development of more productive relationships between primary care professionals and COPD patients and their informal caregivers. Further research is necessary to determine how best to sustain these developments.

Chronically ill patients' self-management abilities to maintain overall well-being: what is needed to take the next step in the primary care setting?

BackgroundAlthough widespread problems in patient–professional interaction and insufficient support of patients’ self-management abilities have been recognized, research investigating the relationships among care quality, productive interaction, and self-management abilities to maintain overall well-being is lacking. Furthermore, studies have revealed differences in these characteristics among certain groups (e.g., less-educated and older patients). This longitudinal study thus aimed to identify relationships among background characteristics, quality of care, productivity of patient–professional interaction, and self-management abilities to maintain overall well-being in chronically ill patients participating in 18 Dutch disease management programs.MethodsThis longitudinal study included patients participating in 18 Dutch disease management programs. Surveys were administered in 2011 (T1; n = 2191 (out of 4693), 47 % response rate) and 2012 (T2: n = 1722 (out of 4350), 40 % response rate). A total of 1279 patients completed questionnaires at both timepoints (T1 and T2) (27 % response rate). Self-management abilities to maintain well-being were measured using the short (18-item) version of the Self-Management Ability Scale (SMAS-S), patients’ perceptions of the productivity of interactions with health care professionals were assessed with the relational coordination instrument and the short (11-item) version of the Patient Assessment of Chronic Illness Care (PACIC-S) was used to assess patients’ perceptions of the quality of chronic care delivery.ResultsPerceived and objective quality of care and the productivity of patient–professional interaction were found to be related to patients’ self-management abilities to maintain overall well-being. These abilities were related negatively to and significantly predicted by low educational level, single status, and older age, despite the mediating role of productive interaction in their relationship with patients’ perceptions of care quality.ConclusionsThese findings suggest that patient–professional interaction is not yet sufficiently productive to successfully protect against the deterioration of self-management abilities in some groups of chronically ill patients, although such interaction and high-quality care are important factors in such protection. Improvement of the quality of chronic care delivery should thus always be accompanied by investment in high-quality communication and patient–professional relationships.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0340-8) contains supplementary material, which is available to authorized users.

Better experiences with quality of care predict well-being of patients with chronic obstructive pulmonary disease in the Netherlands.

This study was conducted to (1) identify improvements in care quality and well-being of patients with chronic obstructive pulmonary disease in the Netherlands and (2) investigate the longitudinal relationship between these factors. This longitudinal study was conducted among patients diagnosed with chronic obstructive pulmonary disease enrolled in the Kennemer Lucht care programme in the Netherlands. Biomarker data (lung capacity) were collected at patients' health care practices in 2012. Complete case analysis was conducted, and the multiple imputation technique allowed us to report pooled results from imputed datasets. Surveys were filled out by 548/1303 (42%) patients at T0 (2012) and 569/996 (57%) remaining participants at T1. Quality of care improved significantly (p < 0.05). Analyses adjusted for well-being at T0, age, educational level, marital status, gender, lung function and health behaviours showed that patients' assessments of the quality of chronic care delivery at T0 (p < 0.01) and changes therein (p < 0.001) predicted patients' well-being at T1. These results clearly show that the quality of care and changes therein are important for the well-being of patients with chronic obstructive pulmonary disease in the primary care setting. To improve quality of care for chronically ill patients, multicomponent interventions may be needed.

The importance of productive patient-professional interaction for the well-being of chronically ill patients.

ObjectiveTo investigate patient–professional interactions and identify the association between quality of care, productivity of patient–professional interaction, and chronically ill patients’ well-being.MethodsQuestionnaires were distributed to chronically ill patients [T1 (2011), 2,191/4,693 (47 %) respondents; T2 (2012), 1,722/4,350 (40 %) respondents].ResultsPatients perceived a higher degree of productive interaction with general practitioners compared to other professionals. Bivariate analyses showed that patients’ well-being at T2 was positively related to well-being at T1 (r = 0.70), quality of care (r = 0.12), and productive patient–professional interaction (r = 0.31; all p ≤ 0.001). Single status (r = –0.14), low education (r = –0.11), and female gender (r = –0.11; all p ≤ 0.001) were negatively associated with well-being. Multivariate analyses showed that after controlling for background characteristics and well-being at baseline quality of care is associated with patients’ well-being at T2 (p ≤ 0.01). When productive patient–professional interactions were entered into the equation, they not only were related to patients’ well-being (p ≤ 0.001) but also mediated the relationship between the quality of care and well-being. More productive patient–professional interactions were related to better well-being at T2 (B = 0.11), assuming that all other factors in the model remained constant.ConclusionsProductive patient–professional interactions are associated with chronically ill patients’ well-being over time and mediate the relationship between well-being and quality of care. Improvement of the quality of chronic care delivery should always be accompanied by investment in the quality of relationships and communication between patients and professionals.

A longitudinal study to identify the influence of quality of chronic care delivery on productive interactions between patients and (teams of) healthcare professionals within disease management programmes

ObjectiveThe chronic care model is an increasingly used approach to improve the quality of care through system changes in care delivery. While theoretically these system changes are expected to increase productive patient–professional interaction empirical evidence is lacking. This study aims to identify the influence of quality of care on productive patient–professional interaction.SettingLongitudinal study in 18 Dutch regions.ParticipantsQuestionnaires were sent to all 5076 patients participating in 18 Disease Management Programmes (DMPs) in 2010 (2676 (53%) respondents). One year later (T1), 4693 patients still participating in the DMPs received a questionnaire (2191 (47%) respondents) and 2 years later (in 2012; T2) 1722 patients responded (out of 4350; 40% response).InterventionsDMPsPrimary outcome measurePatients’ perceptions of the productivity of interactions (measured as relational coordination/coproduction of care) with professionals. Patients were asked about communication dimensions (frequent, accurate, and problem-solving communication) and relationship dimensions (shared goals and mutual respect).FindingsAfter controlling for background characteristics these results clearly show that quality of chronic care (T0), first-year changes in quality of chronic care (T1—T0) and second-year changes in quality of chronic care (T2—T1) predicted productive interactions between patients and professionals at T2 (all at p≤0.001). Furthermore, we found a negative relationship between lower educational level and productive interactions between patients and professionals 2 years later.ConclusionsWe can conclude that successfully dealing with the consequences of chronic illnesses requires proactive patients who are able to make productive decisions together with their healthcare providers. Since patients and professionals share responsibility for management of the chronic illness, they must also share control of interactions and decisions. The importance of patient-centeredness is growing and this study reports a first example of how quality of chronic care stimulates productive interactions between patients and professionals.

The role of team climate in improving the quality of chronic care delivery: a longitudinal study among professionals working with chronically ill adolescents in transitional care programmes

ObjectivesThis study aimed to (1) evaluate the effectiveness of implementing transition programmes in improving the quality of chronic care delivery and (2) identify the predictive role of (changes in) team...

Short and long term improvements in quality of chronic care delivery predict program sustainability

Empirical evidence on sustainability of programs that improve the quality of care delivery over time is lacking. Therefore, this study aims to identify the predictive role of short and long term improvements in quality of chronic care delivery on program sustainability.In this longitudinal study, professionals [2010 (T0): n=218, 55% response rate; 2011 (T1): n=300, 68% response rate; 2012 (T2): n=265, 63% response rate] from 22 Dutch disease-management programs completed surveys assessing quality of care and program sustainability. Our study findings indicated that quality of chronic care delivery improved significantly in the first 2 years after implementation of the disease-management programs. At T1, overall quality, self-management support, delivery system design, and integration of chronic care components, as well as health care delivery and clinical information systems and decision support, had improved. At T2, overall quality again improved significantly, as did community linkages, delivery system design, clinical information systems, decision support and integration of chronic care components, and self-management support. Multilevel regression analysis revealed that quality of chronic care delivery at T0 (p<0.001) and quality changes in the first (p<0.001) and second (p<0.01) years predicted program sustainability. In conclusion this study showed that disease-management programs based on the chronic care model improved the quality of chronic care delivery over time and that short and long term changes in the quality of chronic care delivery predicted the sustainability of the projects.

High-quality chronic care delivery improves experiences of chronically ill patients receiving care

ObjectiveInvestigate whether high-quality chronic care delivery improved the experiences of patients.DesignThis study had a longitudinal design.Setting and ParticipantsWe surveyed professionals and patients in 17 disease management programs targeting patients with cardiovascular diseases, chronic obstructive pulmonary disease, heart failure, stroke, comorbidity and eating disorders.Main Outcome MeasuresPatients completed questionnaires including the Patient Assessment of Chronic Illness Care (PACIC) [T1 (2010), 2637/4576 (58%); T2 (2011), 2314/4330 (53%)]. Professionals' Assessment of Chronic Illness Care (ACIC) scores [T1, 150/274 (55%); T2, 225/325 (68%)] were used as a context variable for care delivery. We used two-tailed, paired t-tests to investigate improvements in chronic illness care quality and patients' experiences with chronic care delivery. We employed multilevel analyses to investigate the predictive role of chronic care delivery quality in improving patients' experiences with care delivery.ResultsOverall, care quality and patients' experiences with chronic illness care delivery significantly improved. PACIC scores improved significantly from 2.89 at T1 to 2.96 at T2 and ACIC-S scores improved significantly from 6.83 at T1 to 7.18 at T2. After adjusting for patients' experiences with care delivery at T1, age, educational level, marital status, gender and mental and physical quality of life, analyses showed that the quality of chronic care delivery at T1 (P < 0.001) and changes in care delivery quality (P < 0.001) predicted patients' experiences with chronic care delivery at T2.ConclusionThis research showed that care quality and changes therein predict more positive experiences of patients with various chronic conditions over time.

The relationship between self-management abilities, quality of chronic care delivery, and wellbeing among patients with chronic obstructive pulmonary disease in The Netherlands

BackgroundThis cross-sectional study aimed to identify the relationship between quality of chronic care delivery, self-management abilities, and wellbeing among patients with chronic obstructive pulmonary disease (COPD).MethodsThe study was conducted in 2012 and included 548 (out of 1303; 42% response rate) patients with COPD enrolled in a COPD care program in the region of Noord-Kennemerland in The Netherlands. We employed a multilevel random-effects model (548 patients nested in 47 healthcare practices) to investigate the relationship between quality of chronic care delivery, self-management abilities, and patients’ wellbeing. In the multilevel analyses we controlled for patients’ background characteristics and health behaviors.ResultsMultilevel analyses clearly showed a significant relationship between quality of chronic care delivery and wellbeing of patients with COPD (P ≤ 0.001). When self-management abilities were included in the equation while controlling for background characteristics, health behaviors, and quality of chronic care delivery, these abilities were found to have a strong positive relationship with patients’ wellbeing (P ≤ 0.001). Low educational level, single marital status, and physical exercise were not significantly associated with wellbeing when self-management abilities were included in the equation.ConclusionSelf-management abilities and the quality of chronic care delivery are important for the wellbeing of patients with COPD. Furthermore, self-management abilities acted as mediators between wellbeing and low educational level, single status, and physical exercise among these patients.

In The Netherlands, Rich Interaction Among Professionals Conducting Disease Management Led To Better Chronic Care

Disease management programs based on the Chronic Care Model are expected to improve the quality of chronic care delivery. However, evidence to date for such improvement and how it is achieved is scarce. In 2010 and again in 2011, we surveyed professionals in twenty-two primary care practices in the Netherlands that had implemented the Chronic Care Model of disease management beginning in 2009. The responses showed that, over time, chronic illness care delivery improved to advanced levels. The gains were attributed primarily to improved relational coordination-that is, raising the quality of communication and task integration among professionals from diverse disciplines who share common objectives. These findings may have implications for other disease management efforts by collaborative care teams, in that they suggest that diverse health care professionals must be strongly connected to provide effective, holistic care.

Relational coordination promotes quality of chronic care delivery in Dutch disease-management programs

Previous studies have shown that relational coordination is positively associated with the delivery of hospital care, acute care, emergency care, trauma care, and nursing home care. The effect of relational coordination in primary care settings, such as disease-management programs, remains unknown. This study examined relational coordination between general practitioners and other professionals in disease-management programs and assessed the impact of relational coordination on the delivery of chronic illness care. Professionals (n = 188; response rate = 57%) in 19 disease-management programs located throughout the Netherlands completed surveys that assessed relational coordination and chronic care delivery. We used a cross-sectional study design. Our study demonstrated that the delivery of chronic illness care was positively related to relational coordination. We found positive relationships with community linkages (r = .210, p < .01), self-management support (r = .217, p < .01), decision support (r = .190, p < .01), delivery system design (r = .278, p < .001), and clinical information systems (r = .193, p < .01). Organization of the health delivery system was not significantly related to relational coordination. The regression analyses showed that even after controlling for all background variables, relational coordination still significantly affected chronic care delivery (β = .212, p ≤ .01). As expected, our findings showed a lower degree of relational coordination among general practitioners than between general practitioners and other core disease-management team members: practice nurses (M = 2.69 vs. 3.73; p < .001), dieticians (M = 2.69 vs. 3.07; p < .01), physical therapists (M = 2.69 vs. 3.06; p < .01), medical specialists (M = 2.69 vs. 3.16; p < .01), and nurse practitioners (M = 2.69 vs. 3.19; p < .001). The enhancement of relational coordination among core disease-management professionals with different disciplines is expected to improve chronic illness care delivery.