Papers by Hubertus Vrijhoef
Implementation of integrated geriatric care at a German hospital: a case study to understand when and why beneficial outcomes can be achieved
BMC health services research, Jan 7, 2017
Many health systems have implemented integrated care as an alternative approach to health care de... more Many health systems have implemented integrated care as an alternative approach to health care delivery that is more appropriate for patients with complex, long-term needs. The objective of this article was to analyse the implementation of integrated care at a German geriatric hospital and explore whether the use of a "context-mechanisms-outcomes"-based model provides insights into when and why beneficial outcomes can be achieved. We conducted 15 semi-structured interviews with health professionals employed at the hospital. The data were qualitatively analysed using a "context-mechanisms-outcomes"-based model. Specifically, mechanisms were defined as the different components of the integrated care intervention and categorised according to Wagner's Chronic Care Model (CCM). Context was understood as the setting in which the mechanisms are brought into practice and described by the barriers and facilitators encountered in the implementation process. These were ...
Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams
International journal of integrated care, Jan 8, 2016
Teamwork between healthcare providers is conditional for the delivery of integrated care. This st... more Teamwork between healthcare providers is conditional for the delivery of integrated care. This study aimed to assess the usefulness of the conceptual framework Integrated Team Effectiveness Model for developing and testing of the Integrated Team Effectiveness Instrument. Focus groups with healthcare providers in an integrated care setting for people with chronic obstructive pulmonary disease (COPD) were conducted to examine the recognisability of the conceptual framework and to explore critical success factors for collaborative COPD practice out of this framework. The resulting items were transposed into a pilot instrument. This was reviewed by expert opinion and completed 153 times by healthcare providers. The underlying structure and internal consistency of the instrument were verified by factor analysis and Cronbach's alpha. The conceptual framework turned out to be comprehensible for discussing teamwork effectiveness. The pilot instrument measures 25 relevant aspects of team...
Profiling Patients' Healthcare Needs to Support Integrated, Person-Centered Models for Long-Term Disease Management (Profile): Research Design
International journal of integrated care, Jan 29, 2016
This article presents the design of PROFILe, a study investigating which (bio)medical and non-(bi... more This article presents the design of PROFILe, a study investigating which (bio)medical and non-(bio)medical patient characteristics should guide more tailored chronic care. Based on this insight, the project aims to develop and validate 'patient profiles' that can be used in practice to determine optimal treatment strategies for subgroups of chronically ill with similar healthcare needs and preferences. PROFILe is a practice-based research comprising four phases. The project focuses on patients with type 2 diabetes. During the first study phase, patient profiles are drafted based on a systematic literature research, latent class growth modeling, and expert collaboration. In phase 2, the profiles are validated from a clinical, patient-related and statistical perspective. Phase 3 involves a discrete choice experiment to gain insight into the patient preferences that exist per profile. In phase 4, the results from all analyses are integrated and recommendations formulated on whi...
Context, mechanisms and outcomes of integrated care for diabetes mellitus type 2: a systematic review
BMC Health Services Research, 2015
Integrated care interventions for chronic conditions can lead to improved outcomes, but it is not... more Integrated care interventions for chronic conditions can lead to improved outcomes, but it is not clear when and why this is the case. This study aims to answer the following two research questions: First, what are the context, mechanisms and outcomes of integrated care for people with type 2 diabetes? Second, what are the relationships between context, mechanisms and outcomes of integrated care for people with type 2 diabetes? A systematic literature search was conducted for the period 2003-2013 in Cochrane and PubMed. Articles were included when they focussed on integrated care and type 2 diabetes, and concerned empirical research analysing the implementation of an intervention. Data extraction was performed using a common data extraction table. The quality of the studies was assessed with the Mixed Methods Appraisal Tool. The CMO model (context + mechanism = outcome) was used to study the relationship between context factors (described by the barriers and facilitators encountered in the implementation process and categorised at the six levels of the Implementation Model), mechanisms (defined as intervention types and described by their number of Chronic Care Model (sub-)components) and outcomes (the intentional and unintentional effects triggered by mechanism and context). Thirty-two studies met the inclusion criteria. Most reported barriers to the implementation process were found at the organisational context level and most facilitators at the social context level. Due to the low number of articles reporting comparable quantitative outcome measures or in-depth qualitative information, it was not possible to make statements about the relationship between context, mechanisms and outcomes. Efficient resource allocation should entail increased investments at the organisational context level where most barriers are expected to occur. It is likely that investments at the social context level will also help to decrease the development of barriers at the organisational context level, especially by increasing staff involvement and satisfaction. If future research is to adequately inform practice and policy regarding the impact of these efforts on health outcomes, focus on the actual relationships between context, mechanisms and outcomes should be actively incorporated into study designs.
Instruments Measuring Integrated Care: A Systematic Review of Measurement Properties
The Milbank Quarterly, 2016
Policy Points: Investigations on systematic methodologies for measuring integrated care should co... more Policy Points: Investigations on systematic methodologies for measuring integrated care should coincide with the growing interest in this field of research. A systematic review of instruments provides insights into integrated care measurement, including setting the research agenda for validating available instruments and informing the decision to develop new ones. This study is the first systematic review of instruments measuring integrated care with an evidence synthesis of the measurement properties. We found 209 index instruments measuring different constructs related to integrated care; the strength of evidence on the adequacy of the majority of their measurement properties remained largely unassessed. Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. Our systematic review aims to provide evidence on the state of the art in measuring integrated care. Our comprehensive systematic review framework builds on the Rainbow Model for Integrated Care (RMIC). We searched MEDLINE/PubMed for published articles on the measurement properties of instruments measuring integrated care and identified eligible articles using a standard set of selection criteria. We assessed the methodological quality of every validation study reported using the COSMIN checklist and extracted data on study and instrument characteristics. We also evaluated the measurement properties of each examined instrument per validation study and provided a best evidence synthesis on the adequacy of measurement properties of the index instruments. From the 300 eligible articles, we assessed the methodological quality of 379 validation studies from which we identified 209 index instruments measuring integrated care constructs. The majority of studies reported on instruments measuring constructs related to care integration (33%) and patient-centered care (49%); fewer studies measured care continuity/comprehensive care (15%) and care coordination/case management (3%). We mapped 84% of the measured constructs to the clinical integration domain of the RMIC, with fewer constructs related to the domains of professional (3.7%), organizational (3.4%), and functional (0.5%) integration. Only 8% of the instruments were mapped to a combination of domains; none were mapped exclusively to the system or normative integration domains. The majority of instruments were administered to either patients (60%) or health care providers (20%). Of the measurement properties, responsiveness (4%), measurement error (7%), and criterion (12%) and cross-cultural validity (14%) were less commonly reported. We found <50% of the validation studies to be of good or excellent quality for any of the measurement properties. Only a minority of index instruments showed strong evidence of positive findings for internal consistency (15%), content validity (19%), and structural validity (7%); with moderate evidence of positive findings for internal consistency (14%) and construct validity (14%). Our results suggest that the quality of measurement properties of instruments measuring integrated care is in need of improvement with the less-studied constructs and domains to become part of newly developed instruments.
A Prospective Validation Study of a Rainbow Model of Integrated Care Measurement Tool in Singapore
International journal of integrated care, Jan 8, 2016
The conceptual ambiguity of the integrated care concept precludes a full understanding of what co... more The conceptual ambiguity of the integrated care concept precludes a full understanding of what constitutes a well-integrated health system, posing a significant challenge in measuring the level of integrated care. Most available measures have been developed from a disease-specific perspective and only measure certain aspects of integrated care. Based on the Rainbow Model of Integrated Care, which provides a detailed description of the complex concept of integrated care, a measurement tool has been developed to assess integrated care within a care system as a whole gathered from healthcare providers' and managerial perspectives. This paper describes the methodology of a study seeking to validate the Rainbow Model of Integrated Care measurement tool within and across the Singapore Regional Health System. The Singapore Regional Health System is a recent national strategy developed to provide a better-integrated health system to deliver seamless and person-focused care to patients t...
Measurement of Integrated Care on the level of Regional Health System in Singapore
International Journal of Integrated Care, Dec 8, 2014
ABSTRACT In response to the rapidly aging population of Singapore and the increasing demands on h... more ABSTRACT In response to the rapidly aging population of Singapore and the increasing demands on healthcare, the Singapore healthcare system was reorganized into six regional health systems (RHS) according to geographic locations to provide a better integrated health system. In each of the RHS, an acute hospital works closely with the community hospital, nursing homes, homecare providers, general practitioners and polyclinics to deliver seamless and holistic care to patients. However, even with an increasing awareness of the needs to better integrate the health system, there is no universal definition and method of integrated care. Furthermore, the recent initiative of RHS has not been evaluated. Therefore, this study aims to (i) explore the concept of integrated care in the Singapore context (ii) validate an integrated care measure developed by Valentijn et a.l (iii) measure the nature and degree of integrated care within and across the RHS and (iv) provide recommendations to improve integrated care in Singapore. Focus group discussions will be conducted to gather opinions from healthcare users of the RHS about the concept of integrated care. Healthcare professionals from the RHS will be surveyed for validation of the integrated care instrument and measurement of the level of integrated care of the RHS. The degree of integrated care of the RHS will then be compared to the international community and recommendations will be made based on the triangulation of data collected from the healthcare users and professionals. Results of this study which will be presented during the conference will provide insights on the degree of integrated care within and across the RHS to provide recommendations for improvements of the RHS. Data collected from this study can also be used as a baseline reference for prospective follow up.
De zorg voor mensen met één of meerdere chronische aandoeningen is aan verandering onderhevig. De... more De zorg voor mensen met één of meerdere chronische aandoeningen is aan verandering onderhevig. Deze verandering wordt hier beschouwd aan de hand van het overheidsbeleid en de hedendaagse praktijk. Kernvraag hierbij is: in welke mate leidt de beoogde verandering tot verbetering?
Preparing Primary Care for the Future
The Patient Patient Centered Outcomes Research, Jun 1, 2011
Background: Health promotion has become an integral part of primary healthcare for patients with ... more Background: Health promotion has become an integral part of primary healthcare for patients with chronic illness. A practical instrument to identify patient needs in health promotion will support patient-centered health counseling. Objective: The objective of the study was to develop and pilot test the 'Health Promotion Diabetes' (HEPRODIA) instrument, which aims to identify the needs of patients with diabetes mellitus for health-promoting activities with regard to their preferred lifestyle behavior change. Methods: Scale development of the instrument was guided by existing insights and expert opinion. Questionnaire data were collected in a sample of patients (n = 221) from eight primary care practices in the southern part of the Netherlands.
Is Europe Putting Theory Into Practice?
Developing appropriate and effective care for people with chronic disease
Economic Impact of Integrated Care Models for Patients with Chronic Diseases: A Systematic Review
Value in Health, 2016
To assess the costs and potential financial benefits of integrated care models for patients with ... more To assess the costs and potential financial benefits of integrated care models for patients with chronic diseases, that is, type 2 diabetes mellitus, schizophrenia, and multiple sclerosis, respectively. A systematic search of the literature was performed using EMBASE, MEDLINE, and Web of Science. Studies that conducted a cost analysis, considered at least two components of the chronic care model, and compared integrated care with standard care were included. Out of 575 articles, 26 were included. Most studies examined integrated care models for type 2 diabetes mellitus (n = 18) and to a lesser extent for schizophrenia (n = 6) and multiple sclerosis (n = 2). Across the three disease groups, the incremental cost per patient per year ranged from - €3860 to + €613.91 (x¯ = - €533.61 ± €902.96). The incremental cost for type 2 diabetes mellitus ranged from - €1507.49 to + €299.20 (x¯ = - €518.22 ± + €604.75), for schizophrenia from - €3860 to + €613.91 (x¯ = - €677.21 ± + €1624.35), and for multiple sclerosis from - €822 to + €339.43 (x¯ = - €241.29 ± + €821.26). Most of the studies (22 of 26 [84.6%]) reported a positive economic impact of integrated care models: for type 2 diabetes mellitus (16 of 18 [88.9%]), schizophrenia (4 of 6 [66.7%]), and multiple sclerosis (1 of 2 [50%]). In this systematic literature review, predominantly positive economic impacts of integrated care models for patients with chronic diseases were found.
Telemonitoring positively influences some aspects of quality of life. Furthermore it reduces pati... more Telemonitoring positively influences some aspects of quality of life. Furthermore it reduces patients' depression and anxiety scores on the short run. The current article presents the results of a one year follow-up study regarding the impact of a first generation telemonitoring system on depression and Quality of Life scores in patients with heart failure.
Implementation of integrated care for type 2 diabetes: a protocol for mixed methods research
International Journal of Integrated Care, Dec 15, 2014
While integrated care for diabetes mellitus type 2 has achieved good results in terms of intermed... more While integrated care for diabetes mellitus type 2 has achieved good results in terms of intermediate clinical and process outcomes, the evidence-based knowledge on its implementation is scarce, and insights generalisable to other settings therefore remain limited. This study protocol provides a description of the design and methodology of a mixed methods study on the implementation of integrated care for type 2 diabetes. The aim of the proposed research is to investigate the mechanisms by which and the context in which integrated care for type 2 diabetes has been implemented, which outcomes have been achieved and how the context and mechanisms have affected the outcomes. This article describes a convergent parallel mixed methods research design, including a systematic literature review on the implementation of integrated care for type 2 diabetes as well as a case study on two Dutch best practices on integrated care for type 2 diabetes. The implementation of integrated care for diabetes type 2 is an under-researched area. Insights from this study could be applied to other settings as well as other chronic conditions to strengthen the evidence on the implementation of integrated care.
International Journal of Integrated Care, 2009
Purpose: One of the main barriers for further improving the quality of chronic care was the absen... more Purpose: One of the main barriers for further improving the quality of chronic care was the absence of performance-based financing. With the introduction of a Diagnosis-Based Costing method (DBC) within primary care, a new organisational model is implemented in the region Maastricht. This integrated care model includes all relevant stakeholders, such as GPs, district nurses, dieticians, nurse practitioners, practice assistants, physiotherapists and hospital-based specialists. Aim is to optimise the quality of fragmented primary care for chronically ill within the existing budget restraints or, if even possible, to diminish the present costs for chronic care.
International Journal of Integrated Care, 2014
Background: Designed to enhance the integration of services in a primary care (outpatient) settin... more Background: Designed to enhance the integration of services in a primary care (outpatient) setting, the Primary focus program funds 70 integrated care projects (ICP). Main objective of this study was to determine the patterns of integrated care among the ICP. An evaluation framework was developed to assess the focus (person vs. population), level (clinical, professional, organisational and system) and enablers (functional vs. normative) of integrated care among the ICP.
More black box to explore: How collaborative partnerships shape integrated care
International Journal of Integrated Care, 2014
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Papers by Hubertus Vrijhoef