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__Background:__ eHealth applications are constantly increasing and are frequently considered to constitute a promising strategy for cost containment in health care, particularly if the applications aim to support older persons. Older persons are, however, not the only major eHealth stakeholder. eHealth suppliers, caregivers, funding bodies, and health authorities are also likely to attribute value to eHealth applications, but they can differ in their value attribution because they are affected differently by eHealth costs and benefits. Therefore, any assessment of the value of eHealth applications requires the consideration of multiple stakeholders in a holistic and integrated manner. Such a holistic and reliable value assessment requires a profo

Currently, many policymakers try to encourage client involvement during the public service delivery process and make it a co-production. Clients are encouraged to act as active agents and embrace an integrated approach to address their problems to empower them. However, different studies have raised questions regarding to what extent these ambitions are appropriate for clients with vulnerabilities, such as clients with multiple problems. Aiming to further explore this issue, we studied the expectations of clients with multiple problems concerning the co-production of public services. We interviewed 46 clients with multiple problems at the start of their support trajectory. All 46 participants lived in five districts in Rotterdam, the Netherlands, and were recruited via community-based primary care teams. Our study indicates that co-production ambitions might not resonate with clients with multiple problems. The study shows that these clients’ expectations are driven by their feelings of being overwhelmed and stressed out by their situation, feelings of being a victim of circumstances, bad experiences with public services in the past, their evaluation of what counts as a problem and the envisioned solutions. These clients expect public service providers to take over, fix their main problem(s) and not interfere with other aspects of their lives (not an integrated approach). Although participants seek a ‘normal’ life with, e.g., a house, work, partner, children, holidays, a pet, and no stress (a white picket fence life) as ideal, they do not feel that this is attainable for them. More insight into the rationale behind these expectations could help to bridge the gap between policymakers’ ambitions and clients’ expectations.

Background Most interventions to improve patient safety (Patient Safety Practices (PSPs)), are introduced without engaging front-line professionals. Administrative staff, managers and sometimes a few professionals, representing only one or two disciplines, decide what to change and how. Consequently, PSPs are not fully adapted to the professionals’ needs or to the local context and as a result, adoption is low. To support adoption, two theoretical concepts, Participatory Design and Experiential Learning were combined in a new model: Adaptive Design. The aim was to explore whether Adaptive Design supports adaptation and adoption of PSPs by engaging all professionals and creating time to (re) design, reflect and learn as a team. The Time Out Procedure (TOP) and Debriefing (plus) for improving patient safety in the operating theatre (OT) was used as PSP. Methods Qualitative exploratory multi-site study using participatory action research as a research design. The implementation process consisted of four phases: 1) start-up: providing information by presentations and team meetings, 2) pilot: testing the prototype with 100 surgical procedures, 3) small scale implementation: with one or two surgical disciplines, 4) implementation hospital-wide: including all surgical disciplines. In iterations, teams (re) designed, tested, evaluated, and if necessary adapted TOPplus. Gradually all professionals were included. Adaptations in content, process and layout of TOPplus were measured following each iteration. Adoption was monitored until final implementation in every hospital’s OT. Results 10 Dutch hospitals participated. Adaptations varied per hospital, but all hospitals adapted both procedures. Adaptations concerned the content, process and layout of TOPplus. Both procedures were adopted in all OTs, but user participation and time to include all users varied between hospitals. Ultimately all users were actively involved and TOPplus was implemented in all OTs. Conclusions Engagi

Voor de structurele financiering van e-health is het belangrijk om de toegevoegde waarde hiervan inzichtelijk te maken. Dat gebeurt op dit moment op verschillende manieren. Soms kijkt men alleen naar de financiële opbrengsten voor de zorginstelling of leverancier, soms wordt ook de maatschappelijke waarde meegenomen. In het onderzoeksproject Waardemodel e-health ontwikkelde we een integraal model dat alle kosten en inspanningen afzet tegen alle baten en opbrengsten, voor verschillende stakeholders. In het rapport wordt een overzicht gegeven van de verschillende methoden om waarde te bepalen, met uitleg over het doel, voor- en nadelen van iedere methode. Daarnaast wordt het model uitgelegd en een handleiding gegeven hoe je met het model kunt werken.

BACKGROUND: A proper application of the Delphi technique is essential for obtaining valid research results. Medical researchers regularly use Delphi studies, but reports often lack detailed information on methodology and controlled feedback: in the medical literature, papers focusing on Delphi methodology issues are rare. Since the introduction of electronic surveys, details on response times remain scarce. We aim to bridge a number of gaps by providing a real world example covering methodological choices and response times in detail. METHODS: The objective of our e(lectronic)-Delphi study was to determine minimum standards for emergency departments (EDs) in the Netherlands. We opted for a two-part design with explicit decision rules. Part 1 focused on gathering and defining

_Background:_ To provide effective tailor made case management in Child Protection Services (CPS) a insight is needed into the specific characteristics of the target group. Using the ecological perspective of maltreatment, this study explored poorly known characteristics of the CPS population. _Objective:_ To distinguish CPS subgroups based on risk and protective factors enables tailor made case management that fits the specific needs of these subgroups. Participants and setting: We studied 250 Dutch CPS cases of family supervision by court order that had completed the LIRIK and Action Plan checklists in August 2014–March 2015. _Methods:_ This quantitative study analyzed risk and protective factors for children and parents reported in client files. Subgroups were identified by two-step cluster analyses. Chi-square analyses identified relations between parental risk subgroups and other groups. _Results:_ Building on the interplay between risk and protective factors on the levels of child, parent and environment, we found five distinct subgroups in the CPS population. The most vulnerable is parents with multiple problems (31%) or socio-economic problems (13%). Parts of both subgroup have limited protective factors. Parents with major life events (16%) or poor parenting (13%) are characterized by single-level problems. One subgroup (28%), the unaccepted, has no parental risk factors registered. _Conclusions:_ Studying client files can lead to a better understanding of the healthcare needs of the CPS population. To develop and implement more effective case management requires constant dialogue between science, policy, and the experiences of both clients and professional.

Background: Nationwide optimization of the emergency department (ED) landscape is being discussed in The Netherlands. The emphasis is put mostly on the num

Background: A fundamental issue in elderly care is targeting those older people at risk and in need of care interventions. Frailty is widely used to capture variations in health risks but there is no general consensus on the conceptualization of frailty. Indeed, there is considerable heterogeneity in the group of older people characterized as frail. This research identifies frailty profiles based on the physical, psychological, social and cognitive domains of functioning and the

Integrated care is increasingly promoted as an effective and cost-effective way to organise care for community-dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost-effectiveness of preventive, integrated care for community-dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost-effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk-of-bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom-reported outcomes such as well-being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost-effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost-effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected.

Background: Hospitals are confronted with increasing safety demands from a diverse set of stakeholders, including governmental organisations, professional associations, health insurance companies, patient associations and the media. However, little is known about the effects of these institutional and competitive pressures on hospital safety management. Previous research has shown that organisations generally shape their safety management approach along the lines of control- or commitment-based management. Using a heuristic framework, based on the contextually-based human resource theory, we analysed how environmental pressures affect the safety management approach used by hospitals. Methods: A qualitative study was conducted into hospital care in the Netherlands. Five hospitals were selected for participation, based on organisational characteristics as well as variation in their reputation for patient safety. We interviewed hospital managers and staff with a central role in safety management. A total of 43 semi-structured interviews were conducted with 48 respondents. The heuristic framework was used as an initial model for analysing the data, though new codes emerged from the data as well. Results: In order to ensure safe care delivery, institutional and competitive stakeholders often impose detailed safety requirements, strong forces for compliance and growing demands for accountability. As a consequence, hospitals experience a decrease in the room to manoeuvre. Hence, organisati

A child protection system is not just about minimizing child abuse but also maximizing welfare (Munro, 2008). Therefore, the new Youth Act in the Netherlands promotes empowerment in child protection (Ministry of Health, Welfare and Sport & Ministry of Security and Justice, 2014). The last decade, empowering child protection services was dominated by the Signs of Safety (SoS) approach of Andrew Turnell and Steve Edwards (1999), a strength-based method with a strong client focused perspective. The current study evaluates a multilevel implementation process of a SoS approach within a Child Protection Service (CPS) in the Netherlands as per

Background: The impact of integrated working on professionals’ objective burden and job satisfaction was examined. An evidence-based intervention targeting frail elderly patients was implemented in the Walcheren region of the Netherlands in 2010. The intervention involved the primary care practice as a single entry point, and included proactive frailty screening, a comprehensive assessment of patient needs, case management, multidisciplinary teams, care plans and protocols, task delegation and task specialisation, a shared information system, a geriatric care network and integrated funding. Methods: A quasi-experimental design with a control group was used. Data regarding objective burden involved the professionals’ time investments over a 12-month period that were collected from patient medical records (n = 377) time registrations, transcripts of meetings and patient questionnaires. Data regarding job satisfaction were collected using questionnaires that were distributed to primary care and home-care professionals (n = 180) after the intervention’s implementation. Within- and between-groups comparisons and regression analyses were performed. Results: Non-patient related time was significantly higher in the experimental group than in the control group, whereas patient-related time did not differ. Job satisfaction remained unaffected by the intervention. Conclusion and Discussion: Integrated working is likely to increase objective burden as it requires profes­sionals to perform additional activities that are largely unrelated to actual patient care. Implications for research and practice are discussed.

Background: This study explored the effectiveness of a pro-active, integrated care model for community-dwelling frail older people compared to care as usual by evaluating the effects on a comprehensive set of outcomes: health outcomes (experienced health, mental health and social functioning); functional abilities; and quality of life (general, health-related and well-being). Methods: The design of this study was quasi-experimental. In this study, 184 frail older patients of three GP practices that implemented the Walcheren Integrated Care Model were compared with 193 frail older patients of five GP practices that provided care as usual. In the Walcheren Integrated Care Model, community-dwelling elderly were pro-actively screened for frailty from the GP practice using the Groningen Frailty Indicator, and care needs were assessed with the EASYcare instrument. The GP practice functioned as single entry point from which case management was provided, and the GP was the coordinator of care. The entire process was supported by multidisciplinary meetings, multidisciplinary protocols and web-based patient files. The outcomes of this study were obtained at baseline, after 3 months and after 12 months and analyzed with linear mixed models of repeated measures. Results: The Walcheren Integrate

Objective: This study explores the processes of integration that are assumed to underlie integrated care delivery. Design: A quasi-experimental design with a control group was used; a new instrument was developed to measure integration from the professional perspective. Setting and participants: Professionals from primary care practices and home-care organizations delivering care to the frail elderly in the Walcheren region of the Netherlands. Intervention: An integrated care intervention specifically targeting frail elderly patients was implemented. Main Outcome Measures: Structural, cultural, social and strategic integration and satisfaction with integration. Results: The intervention significantly improved structural, cultural and social integration, agreement on goals, interests, power and resources and satisfaction with integration. Conclusions: This study confirms that integrated care structures foster processes of integration among professionals. Trial registration: Current Controlled Trials ISRCTN05748494.

Background.: An important aim of integrated care for frail elderly is to generate more cost-effective health care. However, empirical research on the cost-effectiveness of integrated care for community-dwelling frail elderly is limited. Objective.: This study reports on the cost-effectiveness of the Walcheren Integrated Care Model (WICM) after 12

Background. Online platforms offer opportunities for support in changing lifestyle and taking responsibility for one's health, but engaging patients with type 2 diabetes is challenging. Previous studies have shown that patients interested in platforms were more often male, younger, and higher educated. This study aims to investigate differences in clinical and psychological characteristics between users and nonusers of a newly developed platform. Methods. A prospective study started in the Drenthe region of Netherlands. Participants in the study concerning quality of care and quality of life were additionally invited to use the platform. Results. 633 patients were registered after they opted for platform use. Of these patients, 361 (57.0%) never logged on, 184 (29.1%) were labeled "curious" users, and 88 (13.9%) were identified as "active" users. Users had lower HbA1c levels and more often hypertension compared to nonusers, and reported higher quality of life, better well-being, lower diabetes-related distress, and better medication adherence. Discussion. Platform use was associated with more favorable clinical and psychological characteristics relative to nonuse. Those with greater severity of disease, lower mood, and progression of disease used the platform the least. Other approaches need to be developed to reach these patients. Furthermore, improving the platform could also help to reach them. This trial is registered with Clinicaltrials.gov NCT01570140.

Objective: To investigate what influences patients' health care decisions and what the implications are for the provision of information on the quality of health care providers to patients. Data Sources/Study Setting: Dutch patient samples between November 2006 and February 2007. Study Design: Discrete choice experiments were conducted in three patient groups to explore what influences choice for health care providers. Data Collection: Data were obtained from 616 patients with knee arthrosis, 368 patients with chronic depression, and 421 representatives of patients with Alzheimer's disease. Principal Findings: The three patients groups chose health care providers on a different basis. The most valued attributes were effectiveness and safety (knee arthrosis); continuity of care and relationship with the therapist (chronic depression); and expertise (Alzheimer's disease). Preferences differed between subgroups, mainly in relation to patients' choice profiles, severity of disease, and some background characteristics. Conclusions: This study showed that there is substantial room for (quality) information about health care providers in patients' decision processes. This information should be tailor-made, targeting specific patient segments, because different actors and factors play a part in their search and selection process.

We know more about the effectiveness of chronic care itself than we know about how to implement these effective practices and care models. The result of this mismatch is that too often the implementation of inherently good innovations fails. Luckily, this is recognised as a problem and we are beginning to use methods which combine implementation with research so that we can more quickly improve care and learn about what works best for whom and where. This report presents a synthesis of what a diverse group of experts across the European Union see as research priorities to speed up and spread improvements to chronic care. It will contribute to the future EU Research Agenda and also seeks to stimulate research funding for rigorous and timely implementation research in chronic care. But it is also of immediate use to improvers and researchers across Europe for the insights and discussions about implementation, chronic care and improvement science and practice.

Background Franchising is a promising and increasingly used organizational form to improve strategic, organizational, professional and client-related results in healthcare. However, evidence is scarce regarding how franchises should be operated to actualize such results. This paper aimed to explore the association between the results achieved by healthcare franchises and the working relationships among actors in these franchises. Methods A sequential mixed methods approach was used to obtain both in-depth and broader quantifiable insights into a little-investigated phenomenon. We first employed a qualitative multiple embedded case study. Data were collected through observations, document analyses, and 96 in-depth semi-structured interviews in three Dutch healthcare franchises. Withincase and cross-case comparative analyses were conducted. Subsequently, a crosssectional survey was developed based on the qualitative study and disseminated among 19 healthcare franchises. 40 franchisors and 346 unit actors filled in the questionnaire. Findings It seems important to have open, committed, cooperative franchise relationships in which professional franchisees and unit managers feel and trust that they have the opportunity to introduce ideas and articulate their needs to the franchisor. Such relationships help ensure satisfaction, survival, and quality of care, because they serve to foster synergy realization and local fit and prevent reinventing the wheel and professional resistance.

__Abstract__ Background: This study explored the effects of an integrated care model aimed at the frail elderly on the perceived health, objective burden, subjective burden and quality of life of informal caregivers. Methods. A quasi-experimental design with before/after measurement (with questionnaires) and a control group was used. The analysis encompassed within and between groups analyses and regression analyses with baseline measurements, control variables (gender, age, co-residence with care receiver, income, education, having a life partner, employment and the duration of caregiving) and the intervention as independent variables. Results: The intervention significantly contributed to the reduction of subjective burden and significantly contributed to the increased likelihood that informal caregivers assumed household tasks. No effects were observed on perceived, health, time investment and quality of life. Conclusions: This study implies that integrated care models aimed at the frail elderly can benefit informal caregivers and that such interventions can be implemented without demanding additional time investments from informal caregivers. Recommendations for future interventions and research are provided. Trial registration. Current Controlled Trials. Registration date: 14/03/2013.

__Abstract__ Purpose: This study explores the short-term value of integrated care for the frail elderly by evaluating the effects of the Walcheren Integrated Care Model on health, quality of life, health care use and satisfaction with care after three months. Intervention: Frailty was preventively detected in elderly living at home with the Groningen Frailty Indicator. Geriatric nurse practitioners and secondary care geriatric nursing specialists were assigned as case managers and co-ordinated the care agreed upon in a multidisciplinary meeting. The general practitioner practice functions as a single entry point and supervises the co-ordination of care. The intervention encompasses task reassignment between nurses and doctors and consultations between primary, secondary and tertiary care providers. The entire process was supported by multidisciplinary protocols and web-based patient files. Methods: The design of this study was quasi-experimental. In this study, 205 frail elderly patients of three general practitioner practices that implemented the integrated care model were compared with 212 frail elderly patients of five general practitioner practices that provided usual care. The outcomes were assessed using questionnaires. Baseline measures were compared with a three-month follow-up by chi-square tests, t-tests and regression analysis. Results and conclusion: In the short term, the integrated care model had a significant effect on the attachment aspect of quality of life. The frail elderly patients were better able to obtain the love and friendship they desire. The use of care did not differ despite the preventive element and the need for assessments followed up with case management in the integrated care model. In the short term, there were no significant changes in health. As frailty is a progressive state, it is assumed that three months are too short to influence changes in health with integrated care models. A more longitudinal approach is required to study

__Abstract__ Er was eens… Vijf jaar geleden, bij de voorbereiding van Op één lijn, kreeg ik van ZonMw de opdracht om een onderzoeksagenda voor dat programma te ontwikkelen. Bij deze initiatiefase was het plan twee derde deel van het programmabudget te besteden aan praktijk- en opschalingsprojecten en een derde deel te reserveren voor onderzoek. En zo ontstond de opdracht: ‘Ontwikkel een onderzoeksagenda over renderend ondernemerschap in de eerste lijn.’ De focus lag op thema’s als ondernemerschap, nieuwe organisatievormen en betere bedrijfsvoering van eerstelijnsorganisaties, dus expliciet niet op de zorginhoudelijke thema’s. Dat betekent bijvoorbeeld dat ‘innovatie’ gaat over organisatieprocessen, taakverdelingen en netwerken of allianties. De scope was breed, op zoek naar overstijgende thema’s die breed spelen in de gehele eerste lijn. Maar er lag een accent op huisartsenzorg en de disciplines waarmee huisartsen vaak samenwerken.

__Abstract__ Objective: Investigate the effects of disease management program (DMP) implementation on physical activity, smoking, and physical quality of life among chronically ill patients. Methods: This study used a mixed-methods approach involving qualitative (35 interviews with project managers) and quantitative (survey of patients from 18 DMPs) data collection. Questionnaire response rates were 51% (2010; 2619/5108) at T0 and 47% (2011; 2191/4693) at T1. Results: Physical activity and the percentage of smokers improved significantly over time, whereas physical quality of life declined. After adjusting for patients' physical quality of life at T0, age, educational level, marital status, and gender, physical activity at T0 (p< 0.01), changes in physical activity (p< 0.001), and percentage of smokers at T0 (p< 0.05) predicted physical quality of life at T1. Project managers reported that DMPs improved patient-professional interaction. The ability to set more concrete targets improved patients' health behaviors. Conclusions: DMPs appear to improve physical activity among chronically ill patients over time. Furthermore, (changes in) health behavior are important for the physical quality of life of chronically ill patients. Practice implications: Redesigning care systems and implementing DMPs based on the chronic care model may improve health behavior among chronically ill patients.

__Abstract__ Background: Business format franchising is an organizational form that originates from the business sector. It is increasingly used in healthcare, being a promising organizational form for improving the competitiveness and efficiency of organizations, the quality of care, and the professional work environment. However, evidence is lacking concerning how these healthcare franchises should be designed to actually deliver the promised benefits. This study explores how the design of the central element in franchising, the business format (i.e., brand name, support systems, specification of the products and services), helps or hinders the achievement of positive results. Methods: A qualitative comparative embedded case study was conducted. The cases focused on three Dutch healthcare franchises providing mental healthcare, hospital care and care for the intellectually disabled. The data were collected through document analyses, observations, and 96 in-depth, semi-structured interviews with franchisors and unit actors (franchisees, unit managers, professionals). The interviews were recorded and transcribed verbatim. A conceptual model based on a systematic review of studies in other industries was used as an initial method for coding the data. New inductive codes were used to enrich and extend the analysis. The data were subjected to within-case and cross-case comparative thematic analyses. Results: Different business format designs have different effects on results, as perceived by franchisors and unit actors. The analysis revealed how this variation in perceived effects can be explained by different dynamics with regard to system-wide adaptation, local adaptation, professionals' resistance to change, ease of knowledge sharing, bureaucracy, overhead, uniform brand presentation, accelerating effects and reliable performance levels. The analysis resulted in a new typology of four types of business formats, showing how combinations of business format elements fa

In het ZonMw programma ‘Disease Management Chronische Ziekten’ (DMCZ) zijn 22 praktijkprojecten ontwikkeld, gevolgd en geëvalueerd. Deze ZonMw-praktijkprojecten hadden een looptijd van ongeveer drie jaar. Gedurende deze periode zijn de projecten systematisch gevolgd op een aantal proces- en effectmaten en kosten-effectiviteit. De verwachting is dat disease management programma's gebaseerd op Ed Wagner's chronische zorgmodel bijdragen aan betere kwaliteit van chronische zorgverlening. Inzicht in de korte en lange termijn effecten van implementatie van dit type programma's voor verschillende chronische aandoeningen is echter nog schaars. [...]

Background: This study explored the effects of an integrated care model for the frail elderly on informal caregivers' satisfaction with care and support services. Methods. A 62-item instrument was developed and deployed in an evaluative before/after study using a quasi-experimental design and enrolling a control group. The definitive study population (n = 63) consisted mainly of female informal caregivers who did not live with the care recipient. Analysis of separate items involved group comparisons, using paired and unpaired tests, and regression analyses, with baseline measurements, control variables (sex, age and living together with care recipient) and the intervention as independent variables. Subsequently, the underlying factor structure of the theoretical dimensions was investigated using primary component analysis. Group comparisons and regression analyses were performed on the resulting scales. Results: Satisfaction with the degree to which care was provided according to the need for care of the recipients increased, while satisfaction with the degree to which professionals provided help with administrative tasks, the understandability of the information provided and the degree to which informal caregivers knew which professionals to call, decreased. Primary component analysis yielded 6 scales for satisfaction with care and 5 scales for satisfaction with caregiver support, with sufficient reliability. Conclusions: The results suggest that expectations regarding the effects of integrated care on informal caregiver satisfaction may not be realistic. However, the results must be seen in light of the small sample size and should therefore be considered as preliminary. Nonetheless, this study provides guidance for further research and integrated care interventions involving informal caregivers. Trial registration. Current Controlled Trials ISRCTN05748494. Date of registration: 14/03/2013.

Vier generaties zorgwerkers leveren straks ouderenzorg aan drie generaties zorgvragers. Het is hoog tijd voor generatiemanagement voor een toekomstbestendige ouderenzorg

__Abstract__ There is an 80% prevalence of two or more psychiatric symptoms in psychogeriatric patients. Multiple psychiatric symptoms (MPS) have many negative effects on quality of life of the patient as well as on caregiver burden and competence. Irrespective of the effectiveness of an intervention programme, it is important to take into account its economic aspects.

Background: Disease management programmes are increasingly used to improve the efficacy and effectiveness of chronic care delivery. But, disease management programme development and implementation is a complex undertaking that requires effective decision-making. Choices made in the earliest phases of programme development are crucial, as they ultimately impact costs, outcomes and sustainability. Methods: To increase our understanding of the choices that primary healthcare practices face when implementing such programmes and to stimulate successful implementation and sustainability, we compared the early implementation of eight cardiovascular disease management programmes initiated and managed by healthcare practices in various regions of the Netherlands. Using a mixed-methods design, we identified differences in and challenges to programme implementation in terms of context, patient characteristics, disease management level, healthcare utilisation costs, development costs and health-related quality of life. Results: Shifting to a multidisciplinary, patient-centred care pathway approach to disease management is demanding for organisations, professionals and patients, and is especially vulnerable when sustainable change is the goal. Funding is an important barrier to sustainable implementation of cardiovascular disease management programmes, although development costs of the individual programmes varied considerably in relation to the length of the development period. The large number of professionals involved in combination with duration of programme development was the largest cost drivers. While Information and Communication Technology systems to support the new care pathways did not directly contribute to higher costs, delays in implementation indirectly did. Conclusions: Developing and implementing cardiovascular disease management programmes is time-consuming and challenging. Multidisciplinary, patient-centred care demands multifaceted changes in routine care. A

Op donderdag 20 juni j l. hield ik mijn oratie als bijzonder hoogleraar Management en organisatie van de ouderenzorg. De hoofdtitei 'Hoe slaagt de MOL?' ontstond uit het besef dat, naast management en organisatie, leiderschap minstens zo belangrijk is. Deze drie termen creëerden als acroniem dat beestje. Kunnen Management, Organisatie en Leiderschap zorgen voor toekomstbestendige ouderenzorg?

Rede, in verkorte vorm uitgesproken bij de aanvaarding van het ambt van bijzonder hoogleraar Management en Organisatie van Ouderenzorg aan het instituut Beleid & Management Gezondheidszorg van de Faculteit der Geneeskunde en Gezondheidswetenschappen, Erasmus Universiteit Rotterdam, op donderdag 20 juni 2013

Het uitgangspunt van de Zorgverzekeringswet is helder: transparantie over de kwaliteit van de geleverde zorg. Het regeerakkoord Bruggen siaan onderstreept de urgentie: "We verplichten aanbieders van zorg am bij de declara tie ook inform a tie te geven die no dig is am vast te kunnen stellen dat kwaliteit geleverd is." Ontbreekt die informatie, dan kan de verzekerde (cliënt) niet kiezen en kunnen zorgverzekeraars hun inkooprol niet waarmaken.

__Abstract__ __Introduction:__ In order to face the challenges associated with an aging population, traditional health care models are increasingly being replaced with integrated care models [1]. However, while evidence exists that these models benefit older people, there is a lack of knowledge about how integrated care affects the informal caregiver [2]. In this study, effects of a new integrated model on the caregivers of frail elderly have been investigated. The model is characterized by an umbrella organizational structure involving case management, multidisciplinary teams, protocols, consultations, and patient files. The aim of this study was to investigate the effects of this model on caregivers in terms of perceived health, quality of life, objective and subjective burden. __Theory and Methods:__ A quasi-experimental design with before/after study and control group was used. Data was gathered using questionnaires (instruments: 2 items of the RAND-36 [3], short form objective burden informal care [4], SRB [5], CarerQoL [6] ,Cantril’s Ladder [7]). Analysis encompassed group comparison using paired and unpaired tests and regression analyses with baseline measurements, control variables (sex, age, relation to care-receiver, living together with care-receiver, income, education, having a life partner, employment, durance of care giving) and the intervention as independent variables. Additionally, analyses of subgroups and interaction effects will be performed. __Preliminary results:__ Within and between group differences were found and indicated significant reductions in health (P<0.1) and life ratings (P<0.1) and more financial problems (P<0.05) for the control group. Regression analysis revealed that caregivers in the intervention group were more likely to take on HDL type tasks (P<0.05) and experienced less financial problems (P<0.05). __Conclusion:__ The integrated care intervention increased the likelihood of caregivers performing HDL tasks and reduced their

Background: The development of integrated care is a complex and long term process. Previous research shows that this development process can be characterised by four phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase and the consolidation and transformation phase. In this article these four phases of the Development Model for Integrated Care (DMIC) are validated in practice for stroke services, acute myocardial infarct (AMI) services and dementia services in the Netherlands. Methods. Based on the pre-study about the DMIC, a survey was developed for integrated care coordinators. In total 32 stroke, 9 AMI and 43 dementia services in the Netherlands participated (response 83%). Data were collected on integrated care characteristics, planned and implemented integrated care elements, recognition of the DMIC phases and factors that influence development. Data analysis was done by descriptive statistics, Kappa tests and Pearson's correlation tests. Results: All services positioned their practice in one of the four phases and confirmed the phase descriptions. Of them 93% confirmed to have completed the previous phase. The percentage of implemented elements increased for every further development phase; the percentage of planned elements decreased for every further development phase. Pearson's correlation was.394 between implemented relevant elements and self-assessed phase, and up to.923 with the calculated phases (p <.001). Elements corresponding to the earlier phases of the model were on average older. Although the integrated care services differed on multiple characteristics, the DMIC phases were confirmed. Conclusions: Integrated care development is characterised by a changing focus over time, often starting with a large amount of plans which decrease over time when progress on implementation has been made. More awareness of this phase-wise development of integrated care, could facilitate integrated care coo

Background. Disease management programmes (DMPs) have been developed to improve effectiveness and economic efficiency within

Objective: To assess surgical team members' differences in perception of non-technical skills. Design: Questionnaire design. Setting: Operating theatres (OTs) at one university hospital, three teaching hospitals and

Background: Integrated care is considered as a strategy to improve the delivery, efficiency, client outcomes and satisfaction rates of health care. To integrate the care from multiple providers into a coherent client-focused service, a large number of activities and agreements have to be implemented like streamlining information flows and patient transfers. The Development Model for Integrated care (DMIC) describes nine clusters containing in total 89 elements that contribute to the integration of care. We have empirically validated this model in practice by assessing the relevance, implementation and plans of the elements in three integrated care service settings in The Netherlands: stroke, acute myocardial infarct (AMI), and dementia. Methods. Based on the DMIC, a survey was developed for integrated care coordinators. We invited all Dutch stroke and AMI-services, as well as the dementia care networks to participate, of which 84 did (response rate 83%). Data were collected on relevance, presence, and year of implementation of the 89 elements. The data analysis was done by means of descriptive statistics, Chi Square, ANOVA and Kruskal-Wallis H tests. Results: The results indicate that the integrated care practice organizations in all three care settings rated the nine clusters and 89 elements of the DMIC as highly relevant. The average number of elements implemented was 50 18, 42 13, and 45 22 for stroke, acute myocardial infarction, and dementia care services, respectively. Although the dementia networks were significantly younger, their numbers of implemented elements were comparable to those of the other services. The analyses of the implementation timelines showed that the older integrated care services had fewer plans for further implementation than the younger ones. Integrated care coordinators stated that the DMIC helped them to assess their integrated care development in practice and supported them in obtaining ideas for expanding their integrated care

Background. The CQ Index for the elderly, a quality-of-care questionnaire administered by conducting interviews, is used to assess clients' experiences in Dutch nursing homes and homes for the elderly. This article describes whether inter-interviewer differences influence the perceived quality of healthcare services reported by residents, the size of this interviewer effect and the influence of the interviewer characteristics on CQ Index dimensions for public reporting. Methods. Data from 4345 questionnaires was used. Correlations were calculated, reliability analyses were performed, and a multilevel analysis was used to calculate the degree of correlation between two interviewers within one health care institution. Five models were constructed and the Intra Class Correlation (ICC) was calculated. Healthcare institutions were given 1-5 stars on every quality dimensions (1 = worst and 5 = best), adjusted for resident and interviewer characteristics. The effect of these characteristics on the assignment of the stars was investigated. Results. In a multilevel approach, the ICC showed a significant amount of variance on five quality dimensions. Of the interviewer characteristics, only previous interviewing experience, the reason of interviewing and general knowledge of health care had a significant effect on the quality dimensions. Adjusting for interviewer characteristics did not affect the overall star assignment to the institutions regarding 7 of 12 quality dimensions. For the other five dimensions (Shared decision-making, Meals, Professional competency, Autonomy, and Availability of personnel) a minor effect was found. Conclusions. We have shown that training, the use of experienced interviewers, written instructions, supervision and educational meetings do not automatically prevent interviewer effects

Introduction: This study examined the short- and long-term effects of a quality improvement collaborative on patient outcomes, professional performance, and structural aspects of chronic care management of type 2 diabetes in an integrated care setting.Methods: Controlled pre- and post-intervention study assessing patient outcomes (hemoglobin A1c, cholesterol, blood pressure, weight, blood lipid levels, and smoking status), professional performance (guideline adherence), and structural aspects of chronic care management from baseline up to 24 months. Analyses were based on 1,861 patients with diabetes in six intervention and nine control regions representing 37 general practices and 13 outpatient clinics.Results: Modest but significant improvement was seen in mean systolic blood pressure (decrease by 4.0 mm Hg versus 1.6 mm Hg) and mean high density lipoprotein levels (increase by 0.12 versus 0.03 points) at two-year follow up. Positive but insignificant differences were found in hemoglobin A1c (0.3%), cholesterol, and blood lipid levels. The intervention group showed significant improvement in the percentage of patients receiving advice and instruction to examine feet, and smaller reductions in the percentage of patients receiving instruction to monitor blood glucose and visiting a dietician annually. Structural aspects of self-management and decision support also improved significantly.Conclusions: At a time of heightened national attention toward diabetes care, our results demonstrate a modest benefit of participation in a multi-institutional quality improvement collaborative focusing on integrated, patient-centered care. The effects persisted for at least 12 months after the intervention was completed.Trial number: http://clinicaltrials.gov Identifier: NCT 00160017.

Background: Disease management programmes are heterogeneous in nature and often lack a theoretical basis. An evaluation model has been developed in which theoretically driven inquiries link disease management interventions to outcomes. The aim of this study is to methodically evaluate the impact of a disease management programme for patients with chronic obstructive pulmonary disease (COPD) on process, intermediate and final outcomes of care in a general practice setting. Methods. A quasi-experimental research was performed with 12-months follow-up of 189 COPD patients in primary care in the Netherlands. The programme included patient education, protocolised as

Background. Multidisciplinary and interorganizational arrangements for the delivery of coherent integrated care are being developed in a large number of countries. Although there are many integrated care programs worldwide, the process of developing these programs and interorganizational collaboration is described in the literature only to a limited extent. The purpose of this study is to explore how local integrated care services are developed in the Netherlands, and to conceptualize and operationalize a development model of integrated care. Methods. The research is based on an expert panel study followed by a two-part questionnaire, designed to identify the development process of integrated care. Essential elements of integrated care, which were developed in a previous Delphi and Concept Mapping Study, were analyzed in relation to development process of integrated care. Results. Integrated care development can be characterized by four developmental phases: the initiative and design phase; the experimental and execution phase; the expansion and monitoring phase; and the consolidation and transformation phase. Different elements of integrated care have been identified in the various developmental phases. Conclusion. The findings provide a descriptive model of the development process that integrated care services can undergo in the Netherlands. The findings have important implications for integrated care services, which can use the model as an instrument to reflect on their current practices. The model can be used to help to identify improvement areas in practice. The model provides a framework for developing evaluation designs for integrated care arrangements. Further research is recommended to test the developed model in practice and to add international experiences.