Transmural Care Research Articles

Reducing discrepancies between MS patients' needs and use of healthcare services by applying a transmural care model.

The Dutch healthcare system is effective for patients with acute, uncomplicated health problems but ineffective for patients with complex, chronic health problems such as multiple sclerosis (MS). To tackle these deficits, special working parties and the Dutch Ministry of Health concluded that healthcare professionals from primary and hospital settings should, by mutual agreement, cooperation, and shared responsibility, better coordinate their care and tailor care to meet patients' individual needs. In the Netherlands this approach is called transmural care. A transmural care model for MS (TCMMS) was developed to assist healthcare professionals in different settings cooperate with one another, comprehensively assess the needs of MS patients, and define an integrated care plan for each patient. The overall aim of the TCMMS was to reduce the discrepancies between the patients' needs and use of healthcare services and to test whether the TCMMS is applicable in practice. Outcomes using the TCMMS were measured using Kurtzke's Expanded Disability Status Scale (EDSS), Incapacity Status Scale (ISS), Environmental Status Scale (ESS), and RAND 36-Item Health Survey (RAND-36). In the study period, many different expressed needs were reported. For the total group the expressed needs decreased significantly from 57 needs 5 months before the implementation of the TCMMS to 19 needs at the end of the study. There were no significant changes over time in EDSS, ISS, ESS, and RAND-36. Overall, the TCMMS was applicable to practice and decreased the discrepancies between needs and services.

Demonstration of a combination of patient management software for COPD (DiseaseControl) and implementation support

In The Netherlands (local) experiments to improve the healthcare system have been numerous, but most of these experiments have remained local, due either to the original customisation or to its complexity. Therefore the distribution of improvements has been poor and patchy and the effects of the learning curve have been limited. Following a number of pilot experiments in many indications during 1999-2001, Diagnosis4Health introduced in early 2002 the latest release of DiseaseControl, its patient management software supporting transmural care for COPD patients. Accompanying the patient management software Diagnosis4Health provides practice organisation and implementation support. This comprehensive package provides the following features: 1. Implementation of a protocolised electronic COPD patient record (DiseaseControl© by Diagnosis4Health), shared between GP and pulmonologist, enabling TeleAdvice by the pulmonologist. 2. COPD care - comprised of diagnosis, treatment and follow-up - based upon national clinical COPD guidelines (NHG, LTA). 3. Implementation of a categorical COPD surgery in the participating GP practices to concentrate all routine care, enabling the delegation of this routine care to the practice assistant or nurse practitioner. This approach yields benefits for all stakeholders: 1. Better care for patients resulting in preservation of pulmonary function and quality of life. 2. Better quality of care by the GP without the burden of elevated work pressure. 3. More efficient and effective practice organisation. 4. Well-defined responsibility and contribution by the practice assistant or nurse practitioner. 5. Mutually beneficial co-operation between GP and pulmonologists. In summary this approach to the management of COPD delivers: 1. Comprehensive package of patient management software plus its successful implementation. 2. Controlled delegation from GP of routine care, including spirometry, to practice assistant or nurse practitioner. 3. Implementation of the best possible care through the execution of the national guidelines. 4. Supervision and support by the pulmonologist through electronic TeleAdvice. 5. Communication from crucial COPD data into the GP's clinical system. 6. Mirror information and benchmarking for self-education and improvements. The COPD software and its implementation will be presented, demonstrated and discussed.

Effective transmural co-operation between the pulmonologists in an average peripheral general hospital and the referring GP's in Zutphen, The Netherlands

The number of patients with COPD is strongly on the rise. This leads to a sharp increase of related workload for both the pulmonologist as well as the GP. In The Netherlands during 2001 the organisations of the GP's (NHG) and the pulmonologists (NVALT) have reached an national co-operative agreement (LTA) on how to effectively and efficiently manage the trias of increase in demand, limited human and financial resources and need for quality of care. This LTA comprises diagnosis, treatment and follow-up and defines both the specific tasks of GP and pulmonologist as well as the areas of co-operation. In The Netherlands (local) experiments to improve the healthcare system have been numerous, but most of these experiments have remained local, due to the original customisation or to its complexity. Therefore the distribution of improvements has been poor and patchy and the effects of the learning curve have been limited. Following a number of pilot experiments, the pulmonologists of the general hospital Het Spittaal in Zutphen decided in December 2001 to develop a transmural care system for COPD patients, which should adhere to the following principles: 1. Approach based upon national clinical COPD guidelines (NHG, LTA). 2. Organisation of a COPD Knowledge Centre in the Hospital to train, coach and assist GP's and their practice assistants or nurse practitioners. 3. Transmural co-operation with at least 50% of all referring GP's. 4. Implementation of a categorical COPD surgery in the participating GP practices to concentrate all routine care (actual organisational work done by an outside agency). 5. Delegation of routine COPD care from the GP to the practice assistant or nurse practitioner with support from the nurse-specialist in the COPD Knowledge Centre. 6. Implementation of a protocolised electronic COPD patient record (DiseaseControl© by Diagnosis4Health), shared between GP and pulmonologist, enabling TeleAdvice by the pulmonologist (software and implementation done by an outside agency). 7. Development of detailed scripts of all principles for easy copying by other hospitals. Globally our care system uses the following approach (supported by the DiseaseControl© software),: COPD patients are invited to the categorical surgery every 6 months for a routine check of their pulmonary status (incl. spirogram) and their well-being. The practice assistant or nurse practitioner executes this check. Every 12th month the GP evaluates key clinical parameters. Only when the patient, the assistant/nurse or the software give a specific reason, the GP is involved for his/her expert opinion. In case the GP is in need of support, he/she can push a software button for a TeleAdvice by the pulmonologist. The logistics and software are supplied by an outside agency, financed by health insurance companies and sponsors. The pulmonologists and the COPD nurses from the COPD Knowledge Centre in Het Spittaal supply the technical know-how. The most important intervention with many COPD patients is to quit smoking. The COPD Knowledge Centre in Het Spittaal offers a Quit Smoking Support programme. Both GPs as well as the pulmonologists may refer smoking COPD patients to this programme. The COPD nurses execute the programme. The objectives of this approach are: 1. COPD patients will suffer fewer exacerbations and preserve their pulmonary function. 2. COPD patient will experience improvements in their quality of life. 3.These results will be reached without additional efforts from GP and pulmonologist. All data will be (anonymously) collected in a dedicated database. This will provide the opportunity to evaluate the results compared to the objectives. Additionally each participating GP is provided with mirror information and benchmarking information. 1. Folmer H. et al: Landelijke Transmurale Afspraak COPD. Huisarts Wet 2001;44(5):220-5 2. Geijer R.M.M. et al: NHG-Standaard COPD en Astma bij Volwassenen: Diagnostiek. Huisarts Wet 2001;44(3):107-17 3. Geijer R.M.M. et al: NHG-Standaard COPD: Behandeling. Huisarts Wet 2001;44(5):209-19 4. Lugt H.A.M.M. van der et al: Behandeling van COPD kan beter, integrale aanpak biedt voordelen. Medisch Contact 2000;55;10:351-2

The birth of integration: explorative studies on the development and implementation of transmural care in the Netherlands, 1994–2000

The birth of integration: explorative studies on the development and implementation of transmural care in the Netherlands, 1994–2000

Integration of care in The Netherlands: the development of transmural care since 1994

Background: integration of primary and hospital services has been the subject of health policy in The Netherlands in the 1990s. A bottom-up facilitating approach was chosen to stimulate development of ‘transmural care’ between traditionally separate sectors. Transmural care has been defined as, care, attuned to the needs of the patient, provided on the basis of co-operation and co-ordination between general and specialised caregivers with shared overall responsibility and the specification of delegated responsibilities’. We conducted a national survey to determine the success of the bottom-up policy and the extent of the development of transmural care. Methods: a written questionnaire was distributed among members of two national networks of transmural care executives and project co-ordinators, which are representative for hospitals and home care organisations in The Netherlands. A total of 271 facilities were included in the study representing 71% of hospitals and 63% of the home care organisations in The Netherlands. The questionnaire covered topics as; type of care provided, participants, population, goals and type of evaluation. Results: all hospitals in The Netherlands provide one or more of the seven types of transmural care, however, there is a great variation in the number of facilities per organisation. Most facilities cater to one or more groups of chronically ill patients. Project co-ordinators experience difficulties finding adequate financing options for the facilities. Evidence on the effects of transmural care on quality and efficiency is lacking. Conclusion: the bottom-up approach towards the development of transmural care has been successful but needs to be followed by top-down measures to insure adequate evaluation and encourage wide-spread implementation.

Effects of transmural care on coordination and continuity of care

Although health care in The Netherlands is of a high quality with strong emphasis on primary care and high accessibility to hospital care, care deficits may arise in patients with chronic complex health problems who need the attention of several caregivers. Because no regular coordinating centre or person exists, coordination of care may be deficient leading to a poor continuity of care. This may be particularly true for those patients being cared for by both primary and hospital care teams, as is the case for most terminal cancer patients. Therefore, a transmural home care intervention programme for terminal cancer patients was introduced which intended to optimize coordination of care and thereby improve continuity of care. This quasi-experimental study investigated the effects of this intervention (intervention group 79 patients) on indicators of coordination and continuity of care. When compared to standard care (control group 37 patients) moderate positive effects (mainly for the nursing disciplines) on the various indicators of coordination and continuity of care by the transmural home care intervention programme were found. Future prospective studies are needed to further elucidate the effects of transmural care on these aspects of care.

Dutch transmural nurse clinics for chronic patients: a descriptive study

‘Transmural care’ can be defined as patient-tailored care provided on the basis of close collaboration and joint responsibility between hospitals and home care organizations. One form of transmural care is transmural nurse clinics for chronically ill. This study describes 62 transmural nurse clinics in the Netherlands. It was established that most of these nurse clinics are held by a specialized community nurse at a hospital outpatient clinic. The principal tasks of the specialized nurse at the clinic are providing illness-related information and supporting patients in dealing with the illness. Only a few unpublished evaluations of Dutch transmural nurse clinics have been conducted. Future research has to provide more insight into the impact of transmural nurse clinics on the quality and continuity of care.

The use of a telephone triage (TT) for an out of hours service in transmural palliative care

The use of a telephone triage (TT) for an out of hours service in transmural palliative care

Transmural care: A new approach in the care for terminal cancer patients: its effects on re-hospitalization and quality of life

Despite their wishes, terminal cancer patients are frequently readmitted to hospitals. This appears in part to be due to poor communication amongst professional caregivers and/or the overburdening of their (informal) caregivers. This quasi-experimental study investigated the effects of a transmural home care programme on re-hospitalization, quality of life and place of death for terminal cancer patients. The programme intended to optimize communication, cooperation and coordination between intra- and extra-mural health care organizations (transmural care). Initial patient characteristics of the intervention group (n=79) matched those of the control group (n=37) well. When compared to the control group, which received the standard community care, patients in the intervention group underwent significantly less re-hospitalization during the terminal phase of their illness (5.8 versus 11.5 days; P<0.01) while the intervention contributed significantly positive to the patients' “physical” quality of life 1 month after the start of the intervention. A higher, but not significant (P=0.06) percentage of patients in the intervention group also died at home (81 versus 65%). The introduction of measures to enhance coordination and cooperation of intra- and extramural care, seems to be an improvement compared to standard community care.

Care for the chronically ill: the future role of health care professionals and their patients

In future decades the number of chronically ill will increase drastically. A function-orientated approach, substitution and transmural care would seem to be the key objectives for the necessary improvement in care. There will be significant changes in the task division of care provided by specialists, general practitioners and paramedics. At the same time, patients will be able to increase their own potential for self-care. Who will play which role in future will have to be considered against the background of the various phases in the course of a chronic disease. In the initial stages, in particular, there will be ample opportunity to involve patients more in their own care. This will have a positive influence on learning to live with a chronic disease, dependence on medical help and the course of the disease itself. Transdisciplinary collaboration, that means interactive collaboration with the necessary mutual knowledge and understanding of the working methods, should form the basis of the care in all phases of a chronic disease. Different carers are involved in each phase of care for the chronically ill, but since the general practitioner is involved in all phases, it is obvious that the necessary organization of collaboration between the various carers (including the patient) should be coordinated by the general practitioner.

Cost analysis of transmural home care for terminal cancer patients

The economic implications of home care service programmes for oncology patients remain unclear. This quasi-experimental study investigated the costs of a transmural home care programme for terminal cancer patients and compared them to those of the standard care available. The programme intended to optimize communication, cooperation and coordination between the intra- and extra- mural health care organizations (transmural care). Complete sets of data could be retrieved for 57 of the 79 patients in the intervention group, and for 29 of the 37 patients in the control group. Comparison of the intervention and control group revealed significantly lower pharmaceutical and rehospitalization costs in the intervention group, whilst community nursing and home help costs were significantly higher. However, no significant difference could be found for total health care costs between the groups. In view of this, and that the programme has proved to have significantly positive effects on both the patient's and direct caregiver's quality of life, the installation of such programmes in every hospital with a multidisciplinary oncology unit is recommended.

The problems presented by ophthalmic patients during a post-discharge telephone-reassurance programme

Although health care in The Netherlands is of a high quality with strong emphasis on primary care and high accessibility to hospital care, care deficits may arise in patients with chronic complex health problems who need the attention of several caregivers. Because no regular coordinating centre or person exists, coordination of care may be deficient leading to a poor continuity of care. This may be particularly true for those patients being cared for by both primary and hospital care teams, as is the case for most terminal cancer patients. Therefore, a transmural home care intervention programme for terminal cancer patients was introduced which intended to optimize coordination of care and thereby improve continuity of care. This quasi-experimental study investigated the effects of this intervention (intervention group 79 patients) on indicators of coordination and continuity of care. When compared to standard care (control group 37 patients) moderate positive effects (mainly for the nursing disciplines) on the various indicators of coordination and continuity of care by the transmural home care intervention programme were found. Future prospective studies are needed to further elucidate the effects of transmural care on these aspects of care.

Transmural care of terminal cancer patients: effects on the quality of life of direct caregivers

Transmural care of terminal cancer patients: effects on the quality of life of direct caregivers

Overall conclusions and recommendations

It was recognised that the application of IT in health care is evolving rapidly. Major developments are: 1. the support of the primary process with the Electronic Patient Record (EPR) as focal point together with order management and protocols/nursing care plans; 2. increasing exchange of data beyond the walls of the institution (shared care, transmural care); 3. the growing use of the Internet; 4. introduction of multimedia functionality in the health information systems. These developments have a significant impact on the security provisions required, so attention for security was unanimously judged to be more necessary than ever. 2. Access to patient’s data

Compliance

In future decades the number of chronically ill will increase drastically. A function-orientated approach, substitution and transmural care would seem to be the key objectives for the necessary improvement in care. There will be significant changes in the task division of care provided by specialists, general practitioners and paramedics. At the same time, patients will be able to increase their own potential for self-care. Who will play which role in future will have to be considered against the background of the various phases in the course of a chronic disease. In the initial stages, in particular, there will be ample opportunity to involve patients more in their own care. This will have a positive influence on learning to live with a chronic disease, dependence on medical help and the course of the disease itself. Transdisciplinary collaboration, that means interactive collaboration with the necessary mutual knowledge and understanding of the working methods, should form the basis of the care in all phases of a chronic disease. Different carers are involved in each phase of care for the chronically ill, but since the general practitioner is involved in all phases, it is obvious that the necessary organization of collaboration between the various carers (including the patient) should be coordinated by the general practitioner.