Healthcare utilization patterns of individuals with depression after national policy to increase the mental health workforce in primary care: a data linkage study.

BACKGROUND: The deployment of the mental health nurse, an additional healthcare provider for individuals in need of mental healthcare in Dutch general practices, was expected to substitute treatments from general practitioners and providers in basic and specialized mental healthcare (psychologists, psychotherapists, psychiatrists, etc.). The goal of this study was to investigate the extent to which the degree of mental health nurse deployment in general practices is associated with healthcare utilization patterns of individuals with depression. METHODS: We combined national health insurers' claims data with electronic health records from general practices. Healthcare utilization patterns of individuals with depression between 2014 and 2019 (N = 31,873) were analysed. The changes in the proportion of individuals treated after depression onset were assessed in association with the degree of mental health nurse deployment in general practices. RESULTS: The proportion of individuals with depression treated by the GP, in basic and specialized mental healthcare was lower in individuals in practices with high mental health nurse deployment. While the association between mental health nurse deployment and consultation in basic mental healthcare was smaller for individuals who depleted their deductibles, the association was still significant. Treatment volume of general practitioners was also lower in practices with higher levels of mental health nurse deployment. CONCLUSION: Individuals receiving care at a general practice with a higher degree of mental health nurse deployment have lower odds of being treated by mental healthcare providers in other healthcare settings. More research is needed to evaluate to what extent substitution of care from specialized mental healthcare towards general practices might be associated with waiting times for specialized mental healthcare.

Healthcare utilization patterns for knee and hip osteoarthritis before and after changes in national health insurance coverage: a data linkage study from the Netherlands.

INTRODUCTION: Medical guidelines aim to stimulate stepped care for knee and hip osteoarthritis, redirecting treatments from hospitals to primary care. In the Netherlands, this development was supported by changing health insurance coverage for physio/exercise therapy. The aim of this study was to evaluate healthcare utilization patterns before and after health changes in health insurance coverage. METHOD: We analyzed electronic health records and claims data from patients with osteoarthritis in the knee (N = 32,091) and hip (N = 16,313). Changes between 2013 and 2019 in the proportion of patients treated by the general practitioner, physio/exercise therapist or orthopedic surgeon within 6 months after onset were assessed. RESULTS: Joint replacement surgeries decreased for knee (OR 0.47 [0.41-0.54]) and hip (OR 0.81 [0.71-0.93]) osteoarthritis between 2013-2019. The use of physio/exercise therapy increased (knee: OR 1.38 [1.24-1.53], hip: OR 1.26 [1.08-1.47]). However, the proportion treated by a physio/exercise therapist decreased for patients that had not depleted their annual deductibles (knee: OR 0.86 [0.79 - 0.94], hip: OR 0.90 [0.79 - 1.02]). This might be affected by the inclusion of physio/exercise therapy in basic health insurance in 2018. CONCLUSION: We have found a shift from hospitals to primary care in knee and hip osteoarthritis care. However, the use of physio/exercise therapy declined after changes in insurance coverage for patients that had not depleted their deductibles.

The never-ending patient journey of chronically ill patients: A qualitative case study on touchpoints in relation to patient-centered care.

BACKGROUND: Healthcare professionals caring for chronically ill patients increasingly want to provide patient-centered care (PCC). By understanding each individual patient journey, they can significantly improve the quality of PCC. A patient journey consists of patient interactions, so-called touchpoints, with healthcare professionals distributed over three periods: pre-service, service, and post-service period. The aim of this study was to ascertain chronically ill patients' needs for digital alternatives for touchpoints. Specifically, we aimed to explore which digital alternatives patients would like to see implemented into their patient journey to help healthcare professionals providing PCC. METHODS: Eight semi-structured interviews were conducted either face-to-face or via Zoom. Participants were included if they had visited the department of internal medicine and had received treatment for either arteriosclerosis, diabetes, HIV, or kidney failure. The interviews were analyzed utilizing a thematic analysis approach. RESULTS: The results suggest that the patient journey of chronically ill patients is a continuous cycle. Furthermore, the results showed that chronically ill patients would like to see digital alternatives for touchpoints implemented into their patient journey. These digital alternatives consisted of video calls, digitally checking in before a physical appointment, digitally self-monitoring one's medical condition and personally uploading monitoring results into the patient portal, and viewing their own medical status in a digital format. Particularly, patients who were familiar with their healthcare professional(s) and were in a stable condition mostly opted for digital alternatives. CONCLUSION: In the cyclical patient journey, digitalization can help put the wishes and needs of the chronically ill patients at the center of care. It is recommended that healthcare professionals implement digital alternatives for touchpoints. Most chronically ill patients consider digital alternatives to lead to more efficient interactions with their healthcare professionals. Furthermore, digital alternatives support patients to be better informed about the progress of their chronical illness.

Interdisciplinary collaboration in the treatment of alcohol use disorders in a general hospital department: a mixed-method study.

BACKGROUND: Interdisciplinary collaborations (i.e., where various disciplines work coordinated and interdependently toward shared goals) are stated to yield higher team effectiveness than multidisciplinary approaches (i.e., where various disciplines work in parallel within their professional boundaries) in somatic health care settings. Nevertheless, research is lacking on interdisciplinary approaches for alcohol use disorder (AUD) treatment of hospitalized patients as these types of approaches are still uncommon. This study aims to evaluate an innovative interdisciplinary AUD treatment initiative at a general hospital department by 1) identifying which and to what extent network partners are involved and 2) to explore how network partners experienced the interdisciplinary collaboration. METHODS: A mixed-method study was conducted, using 1) measures of contact frequency and closeness in a social network analysis and 2) semi-structured interviews, which were analyzed thematically. Respondents were network partners of an interdisciplinary collaboration in a general hospital department, initially recruited by the collaborations' project leader. RESULTS: The social network analysis identified 16 network partners, including a 'core' network with five central network partners from both inside and outside the hospital. The project leader played an important central role in the network and the resident gastroenterologist seemed to have a vulnerable connection within the network. Closeness between network partners was experienced regardless of frequency of contact, although this was especially true for the 'core' group that (almost) always consisted of the same network partners that were present at biweekly meetings. Interview data showed that presence of the 'core' network partners was reported crucial for an efficient collaboration. Respondents desired knowledge about the collaborations' effectiveness, and one structured protocol with working procedures, division of responsibilities and agreements on information sharing and feedback. CONCLUSIONS: The design of this interdisciplinary collaboration has potential in improving the treatment of hospital patients with AUD and was evaluated positively by the involved network partners. Interdisciplinary collaborations may offer a critical solution to increase treatment rates of patients with AUD and should be adopted in hospitals on a larger scale. Research towards the effectiveness of interdisciplinary collaborations in the treatment of hospitalized patients with AUD is needed.

Destination unknown: Parents and healthcare professionals' perspectives on transition from paediatric to adult care in Down syndrome.

BACKGROUND: Transitioning from paediatric medical care to adult care is a challenging process for children, parents and healthcare professionals. The aim of this study was to explore the experiences, concerns and needs of parents of children with Down syndrome and of professionals regarding this transition. METHOD: A qualitative study was performed using semi-structured interviews with 20 parents of children with Down syndrome and six healthcare professionals. RESULTS: We showed that parents and professionals have concerns during each of the three distinct phases of transition (preparation, transfer and integration). Data disclose specific concerns regarding communication, continuity of care and rebuilding trust. We propose a framework for the transition to adult care. CONCLUSIONS: The transition in medical care for children with Down syndrome should be flexible, patient-centred and coordinated together with patients and parents. Only in ensuring continuity of care will individuals with Down syndrome not get lost in transition.

Improving Customisation in Clinical Pathways by Using a Modular Perspective.

A standardised system of clinical pathways often conflicts with providing patient-centred heterogeneous care. Mental health care organisations are searching for new methods to become responsive towards unique treatment needs. Modularity is a method increasingly suggested to reconcile standardisation and customisation. The aim is to investigate the extent to which modularity can be applied to make clinical pathways in specialist mental health care more flexible in order to stimulate shared decision making (SDM) and thereby customise care processes to patient contexts while maintaining evidence-based standards. Methods consist of literature research and a theory-based case study including document analysis and semi-structured interviews, which were performed at a Dutch specialist mental health care organisation. The results show that in current literature two modularity-based structures are proposed that support flexibility and customisation, i.e., 'Prototype' and 'Menu-based'. This study reveals that departments tend to use the prototype method if they have predictable patient needs, evidence-based methods are available and there is sequency in treatment components. The menu-based method is preferred if there are unpredictable needs, or the evidence needed to create interconnectedness in treatment is lacking. In conclusion, prototype or menu-based methods are both suitable for applying SDM and reaching customisation in practice. The choice is determined by three characteristics: predictability of needs, availability of evidence and the interconnectedness of treatment components.

Providing person-centered care for patients with complex healthcare needs: A qualitative study.

BACKGROUND: People with chronic conditions have complex healthcare needs that lead to challenges for adequate healthcare provision. Current healthcare services do not always respond adequately to their needs. A modular perspective, in particular providing visualization of the modular service architecture, is promising for improving the responsiveness of healthcare services to the complex healthcare needs of people with chronic conditions. The modular service architecture provides a comprehensive representation of the components and modules of healthcare provision. In this study, we explore this further in a qualitative multiple case study on healthcare provision for children with Down syndrome in the Netherlands. METHODS: Data collection for four cases involved 53 semi-structured interviews with healthcare professionals and 21 semi-structured interviews with patients (the parents of children with Down syndrome as proxy). In addition, we gathered data by means of practice observations and analysis of relevant documents. The interviews were audio-recorded, transcribed verbatim and analyzed utilizing the Miles and Huberman approach. RESULTS: Our study shows that the perspectives on healthcare provision of professionals and patients differ substantially. The visualization of the modular service architecture that was based on the healthcare professionals' perspective provided a complete representation of (para)medical outcomes relevant to the professionals' own discipline. In contrast, the modular service architecture based on the patients' perspective, which we define as a person-centered modular service architecture, provided a representation of the healthcare service that was primarily based on functional outcomes and the overall wellbeing of the patients. CONCLUSION: Our study shows that visualization of the modular service architecture can be a useful tool to better address the complex needs and requirements of people with a chronic condition. We suggest that a person-centered modular service architecture that focuses on functional outcomes and overall wellbeing, enables increased responsiveness of healthcare services to people with complex healthcare needs and provision of truly person-centered care.

Role of lean leadership in the lean maturity-second-order problem-solving relationship: a mixed methods study.

OBJECTIVES: To investigate the relationship between lean adoption and problem-solving behaviour in nursing teams, and to explore the practices of lean leaders on nursing wards to reveal how they can stimulate second-order problem-solving within their teams. DESIGN: A mixed-methods retrospective multiple case study using semistructured interviews. Interview data were used to assess the level of lean maturity (based on a customised validated instrument) and the level of second-order problem-solving (based on scenarios). Within-case and cross-case analyses were employed to identify lean leadership practices. SETTING: 14 nursing teams, with different levels of lean maturity, in a Dutch hospital. PARTICIPANTS: Three members of each nursing team were interviewed: the team leader, one nurse from the ward's core team for the lean-based quality improvement programme and one nurse outside the core team. INTERVENTIONS: The nursing teams were in various phases of a lean-based quality improvement programme: 'The Productive Ward - Releasing Time to Care'. RESULTS: A strongly significant positive relationship between lean maturity and second-order problem-solving was found: ß=0.68, R2=0.46, p<0.001. Further, the results indicated a potential strengthening effect of lean leadership on this relationship. Seven lean leadership practices emerged from the data collected in a nursing ward setting: (1) convincing and setting an example; (2) unlocking individual and team potential; (3) solving problems systematically; (4) enthusing, actively participating and visualising; (5) developing self-managing teams; (6) sensing, as orchestrator, what is needed for change; and (7) listening, sharing information and appreciating. These practices have a strong link with transformational leadership. CONCLUSIONS: As lean matures, nursing teams reach a higher level of second-order problem-solving. In later stages, lean leaders increasingly relinquish responsibility by developing self-managing teams.

Problem-solving behaviour of nurses in a lean environment.

AIM: To investigate how the extensiveness of a lean implementation-that is, the extent to which lean as a new practice is adopted across nursing departments-relates to second-order problem solving behaviour of nurses. BACKGROUND: Lean implementation is expected to stimulate nurses' second-order problem-solving behaviour. METHOD: We used a vignette-based survey to look for differences in second-order problem-solving behaviour in early-adopter and late-adopter departments at two hospitals with differing degrees of extensiveness of lean implementation. RESULTS: At the hospital with an extensive lean implementation, nurses at the early-adopter department showed 71 second-order problem-solving responses from 50 problem scenarios, as compared with 39 responses from 37 scenarios in the late-adopter department. At the hospital with a less extensive lean implementation, these numbers were 16 from 23 compared with 18 from 19. CONCLUSIONS: The nurses in the hospital with an extensive lean implementation show more second-order problem-solving behaviour than those in the hospital with a stand-alone approach in a single department. IMPLICATIONS FOR NURSING MANAGEMENT: Extensive lean implementation where management clearly shows its belief in lean is a more favourable environment for changing the problem-solving behaviour of nurses.

The role of hospitals in bridging the care continuum: a systematic review of coordination of care and follow-up for adults with chronic conditions.

BACKGROUND: Multiple studies have investigated the outcome of integrated care programs for chronically ill patients. However, few studies have addressed the specific role hospitals can play in the downstream collaboration for chronic disease management. Our objective here is to provide a comprehensive overview of the role of the hospitals by synthesizing the advantages and disadvantages of hospital interference in the chronic discourse for chronically ill patients found in published empirical studies. METHOD: Systematic literature review. Two reviewers independently investigated relevant studies using a standardized search strategy. RESULTS: Thirty-two articles were included in the systematic review. Overall, the quality of the included studies is high. Four important themes were identified: the impact of transitional care interventions initiated from the hospital's side, the role of specialized care settings, the comparison of inpatient and outpatient care, and the effect of chronic care coordination on the experience of patients. CONCLUSION: Our results show that hospitals can play an important role in transitional care interventions and the coordination of chronic care with better outcomes for the patients by taking a leading role in integrated care programs. Above that, the patient experiences are positively influenced by the coordinating role of a specialist. Specialized care settings, as components of the hospital, facilitate the coordination of the care processes. In the future, specialized care centers and primary care could play a more extensive role in care for chronic patients by collaborating.

The effect of trends in health and longevity on health services use by older adults.

BACKGROUND: The effect of population aging on future health services use depends on the relationship between longevity gains and health. Whether further gains in life expectancy will be paired by improvements in health is uncertain. We therefore analyze the effect of population ageing on health services use under different health scenarios. We focus on the possibly diverging trends between different dimensions of health and their effect on health services use. METHODS: Using longitudinal data on health and health services use, a latent Markov model has been estimated that includes different dimensions of health. We use this model to perform a simulation study and analyze the health dynamics that drive the effect of population aging. We simulate three health scenarios on the relationship between longevity and health (expansion of morbidity, compression of morbidity, and the dynamic equilibrium scenario). We use the scenarios to predict costs of health services use in the Netherlands between 2010 and 2050. RESULTS: Hospital use is predicted to decline after 2040, whereas long-term care will continue to rise up to 2050. Considerable differences in expenditure growth rates between scenarios with the same life expectancy but different trends in health are found. Compression of morbidity generally leads to the lowest growth. The effect of additional life expectancy gains within the same health scenario is relatively small for hospital care, but considerable for long-term care. CONCLUSIONS: By comparing different health scenarios resulting in the same life expectancy, we show that health improvements do contain costs when they decrease morbidity but not mortality. This suggests that investing in healthy aging can contribute to containing health expenditure growth.

Incorporating shared savings programs into primary care: from theory to practice.

BACKGROUND: In several countries, health care policies gear toward strengthening the position of primary care physicians. Primary care physicians are increasingly expected to take accountability for overall spending and quality. Yet traditional models of paying physicians do not provide adequate incentives for taking on this new role. Under a so-called shared savings program physicians are instead incentivized to take accountability for spending and quality, as the program lets them share in cost savings when quality targets are met. We provide a structured approach to designing a shared savings program for primary care, and apply this approach to the design of a shared savings program for a Dutch chain of primary care providers, which is currently being piloted. METHODS: Based on the literature, we defined five building blocks of shared savings models that encompass the definition of the scope of the program, the calculation of health care expenditures, the construction of a savings benchmark, the assessment of savings and the rules and conditions under which savings are shared. We apply insights from a variety of literatures to assess the relative merits of alternative design choices within these building blocks. The shared savings program uses an econometric model of provider expenditures as an input to calculating a casemix-corrected benchmark. RESULTS: The minimization of risk and uncertainty for both payer and provider is pertinent to the design of a shared savings program. In that respect, the primary care setting provides a number of unique opportunities for achieving cost and quality targets. Accountability can more readily be assumed due to the relatively long-lasting relationships between primary care physicians and patients. A stable population furthermore improves the confidence with which savings can be attributed to changes in population management. Challenges arise from the institutional context. The Dutch health care system has a fragmented structure and providers are typically small in size. CONCLUSION: Shared savings programs fit the concept of enhanced primary care. Incorporating a shared savings program into existing payment models could therefore contribute to the financial sustainability of this organizational form.

'It is a completely new world you step into.' How older clients and their representatives experience the operational access to Dutch long-term institutional care.

PURPOSE OF THE STUDY: The access process is an important first step in the long-term institutional care for older people. Access can be seen as a concept consisting of three closely related dimensions: availability, affordability and acceptability (three A's). This study takes a new perspective by investigating how older clients experience the access process. DESIGN AND METHODS: Data were gathered through interviews with representatives of clients that were recently admitted in a long-term care facility, or if possible with clients themselves. A total of 33 respondents from 4 organizations that provide long-term institutional care were interviewed. RESULTS: The first contact with the long-term care provider was made in several different ways. Finding a location nearby family was a common aim, which in urgent situations was not always feasible. Most respondents were satisfied about the process and felt taken care of personally. Yet, many respondents mention the lack of practical information and 'guidance' in the complexity of elder care. For acceptability, having a dedicated liaison in the organization was relevant. IMPLICATIONS: The study revealed that the 3A model can be used to understand how older clients or their representatives experience the operational access process to long-term care. Especially the dimensions' availability and acceptability seemed to shape their experience.

The 3 A's of the access process to long-term care for elderly: providers experiences in a multiple case study in the Netherlands.

The access process is an important step in the care provision to independently living elderly. Still, little attention has been given to the process of access to long-term care for older clients. Access can be described by three dimensions: availability, affordability and acceptability (three A's). In this paper we address the following question: How do care providers take the three dimensions of access into account for the access process to their care and related service provision to independently living elderly? To answer this question we performed a qualitative study. We used data gathered in a multiple case study in the Netherlands. This study provides insight in the way long-term care organizations organize their access process. Not all dimensions were equally present or acknowledged by the case organizations. The dimension acceptability seems an important dimension in the access process, as shown by the efforts done in building a relationship with their clients, mainly through a strong personal relationship between client and care advisor. In that respect it is remarkable that the case organizations do not structurally evaluate their access process. Availability is compromised by practical issues and organizational choices. Affordability hardly seems an issue. Further research can reveal the underlying factors that influence the three A dimensions.

Modular health services: a single case study approach to the applicability of modularity to residential mental healthcare.

BACKGROUND: The Dutch mental healthcare sector has to decrease costs by reducing intramural capacity with one third by 2020 and treating more patients in outpatient care. This transition necessitates enabling patients to become as self-supporting as possible, by customising the residential care they receive to their needs for self-development. Theoretically, modularity might help mental healthcare institutions with this. Modularity entails the decomposition of a healthcare service in parts that can be mixed-and-matched in a variety of ways, and combined form a functional whole. It brings about easier and better configuration, increased transparency and more variety without increasing costs. AIM: this study aims to explore the applicability of the modularity concept to the residential care provided in Assisted Living Facilities (ALFs) of Dutch mental healthcare institutions. METHODS: A single case study is carried out at the centre for psychosis in Etten-Leur, part of the GGz Breburg IMPACT care group. The design enables in-depth analysis of a case in a specific context. This is considered appropriate since theory concerning healthcare modularity is in an early stage of development. The present study can be considered a pilot case. Data were gathered by means of interviews, observations and documentary analysis. RESULTS: At the centre for psychosis, the majority of the residential care can be decomposed in modules, which can be grouped in service bundles and sub-bundles; the service customisation process is sufficiently fit to apply modular thinking; and interfaces for most of the categories are present. Hence, the prerequisites for modular residential care offerings are already largely fulfilled. For not yet fulfilled aspects of these prerequisites, remedies are available. CONCLUSION: The modularity concept seems applicable to the residential care offered by the ALF of the mental healthcare institution under study. For a successful implementation of modularity however, some steps should be taken by the ALF, such as developing a catalogue of modules and a method for the personnel to work with this catalogue in application of the modules. Whether implementation of modular residential care might facilitate the transition from intramural residential care to outpatient care should be the subject of future research.

Front-office/back-office configurations and operational performance in complex health services.

BACKGROUND: Acquired brain injury (ABI) occurs from various causes at different ages and leads to many different types of healthcare needs. Several Dutch ABI-networks installed a local co-ordination and contact point (CCP) which functions as a central and easily accessible service for people to consult when they have questions related to ABI. GOALS: To explore the relationship between front/back office design and operational performance by investigating the particular enquiry service provided by different CCPs for people affected by an ABI. METHODS: In-depth interviews with 14 FO/BO employees from three case organizations, complemented with information from desk research and three one-day field visits. RESULTS: The CCPs applied different FO/BO configurations in terms of customer contact and in terms of grouping of front and/or back office activities into tasks for one employee. DISCUSSION: It is the complexity of the enquiry that determines which approach is more appropriate. For complex enquiries, the level of decoupling is high in all CCPs. This allows multiple experts to be involved in the process. For regular enquiries, CCPs have a choice: either working in the same way as in the complex enquiries or coupling FO/BO activities to be able to serve clients faster and without handovers.

Accountable Care Organizations: how to dress for success.

Accountable Care Organizations (ACOs) need to reconsider their provider configuration and make it capable of managing clinical and financial risk. To that aim, their management must decide which medical procedures are done by the ACO itself, and which are contracted out to market providers. Making this decision requires a balanced treatment of market and firm organization, recognizing that each has properties that can turn into relative strengths. Such a balanced treatment is lacking in the ACO debate. Using the transaction cost theory, we provide such a balanced treatment of market and firm organization, and discuss implications for the design of ACOs and accountable care initiatives in general.

Modeling the relationship between health and health care expenditures using a latent Markov model.

We investigate the dynamic relationship between several dimensions of health and health care expenditures for older individuals. Health data from the Longitudinal Aging Survey Amsterdam is combined with data on hospital and long term care use. We estimate a latent variable based jointly on observed health indicators and expenditures. Annual transition probabilities between states of the latent variable are estimated using a Markov model. States associated with good current health and low annual health care expenditures are not associated with lower cumulative health care expenditures over remaining lifetime. We conclude that, although the direct health care cost saving effect is limited, the considerable gain in healthy lifeyears can make investing in the improvement of health of the older population worthwhile.