Published on 19.09.12 in Vol 1, No 2 (2012): Jul-Dec
Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/1945, first published Sep 26, 2011.
Filling the Gaps in a Fragmented Health Care System: Development of the Health and Welfare Information Portal (ZWIP)
Background: Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated.
Objective: To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR).
Methods: We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups.
Results: We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program.
Conclusions: This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.
JMIR Res Protoc 2012;1(2):e10
- cooperative behavior;
- interdisciplinary communication;
- electronic health records;
- frail elderly
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Current health care systems are not optimally designed to meet the needs of our aging populations . First, they are characterized by fragmentation, which leads to inefficiency and can make health care efforts less effective [ , ]. Second, they do not facilitate the incorporation of patient perspectives in care decisions because they are designed according to a medical model that relies on care decisions being made by professionals with limited patient involvement [ ].
Yet, the roles of patients and informal caregivers in our health care system are changing. Patients are now increasingly encouraged to become involved. There are several reasons for this. First, patients are involved in their care because it is they who make daily decisions about how they manage their disease (eg, they decide whether they take their medication or follow the lifestyle advice provided by professionals) . Second, patient involvement is valued for moral and ethical reasons and considered a patient’s right [ ]. Third, research has shown that increased patient involvement can have favorable effects, such as improved health outcomes and improved adherence [ - ]. Therefore, increasing the involvement of patients in their own care by enabling them to participate in decision making and by supporting them to manage their disease to the best of their ability is highly recommended.
However, increased patient involvement may be difficult to achieve in a health care system that suffers from fragmentation because both patients and professionals may already be struggling to meet the complex demands placed on them by such a health care system. In a fragmented health care system, care for a single patient, especially care for a frail older patient (an older patient suffering from a range of problems in the physical, psychological, and social domain), is often provided by multiple professionals who work in a variety of settings [, , ]. As a consequence, continuity of care (the degree to which a series of discrete health care events is experienced as coherent, connected, and consistent with the patient’s medical needs and personal context [ ]), is limited. This undermines the quality of care provided [ , ]. Consequently, coordination of care across settings and services, by the sharing of accurate information between professionals and by the effective collaboration of professionals, patients, and informal caregivers, is badly needed [ , , ].
Therefore, we developed a program aimed at: (1) facilitating self-management and shared decision making by frail older people, and (2) reducing fragmentation of care by enhancing collaboration among professionals involved in the care of frail older people through a multidisciplinary shared electronic health record (EHR) and personal health record (PHR). This paper describes the development of this program.
The program, the Health and Welfare Information Portal (ZWIP), was initiated by ZOWEL NN, a collaborative of stakeholders in health care and welfare services, located in the city of Nijmegen, the Netherlands. The two main objectives for the program were: (1) to facilitate self-management and shared decision making by frail older people and their informal caregivers, and (2) to improve collaboration among professionals by enhancing and facilitating information sharing through a multidisciplinary shared EHR and PHR. Intervention mapping, a stepwise approach for the systematic development of theory- and evidence-informed interventions , was chosen as the method for developing the program. In the following sections, we will discuss the steps taken in this process. An overview is provided in .
|1. Needs assessment||Problems analysis based on literature search; semi-structured interviews with frail older people and informal caregivers (n = 22); 2 meetings of working group of professionals (n = 15); and 1 meeting of working group of older people and informal caregivers (n = 4).||Logic model for self-management () and interprofessional collaboration ( ).|
|2. Preparing matrices of performance objectives and determinants||Building matrices of performance objectives, determinants and change objectives based on the needs assessment.||Matrices of performance objectives and determinants for frail older people and informal caregivers, professionals, and the organizations of professionals (- ).|
|3. Selecting theory-informed intervention methods and practical strategies||Literature search for theories and methods and their effectiveness for the target populations; selection of theories and methods.||Theories used for the program: social cognitive theory (main theory), goal-setting theory, and elements of theories of organizational change.|
|Methods and strategies used for professionals: modeling, active learning, direct experience, and creating facilitating conditions.|
|Methods and strategies used for frail older people and informal caregivers: tailoring, modeling, guided practice, collaborative goal setting, and action planning.|
|4. Producing program components and materials||Requirements for Health and Welfare Information Portal (ZWIP) were defined in 3 additional meetings of working group of professionals (n = 15) and one additional meeting of working group of older people and informal caregivers (n = 4).||Main program component: the ZWIP.|
|Subsequently, development of ZWIP in parallel with reviewing by working groups: 4 meetings of working group of professionals (n = 6); 3 meetings with two working groups of frail older people (n = 4).||Target population: frail older people ≥ 70 years, informal caregivers, and their professionals.|
|Small pilot study of the ZWIP.||Setting: primary care.|
|Materials: the ZWIP; bubble diagram and goal-setting forms; and personalized Internet-based and paper brochures with health promotion information concerning different domains of health, functioning, and well-being.|
|5. Planning program adoption, implementation, and sustainability||Program initiated by network of local stakeholders in health care and welfare services; future users involved extensively in development; necessity for health care system changes for frail older people felt at several levels (government, organizations, and professionals).||Implementation strategies for professionals: involvement in development; starting with early adopters; educational program (CME credits available) and e-learning; telephonic help desk available; coaching and e-coaching available; financial compensation; publicity and flyers; and incentives.|
|Implementation strategies for employing organizations: financial compensation and educational program for employees.|
|Implementation strategies for frail older people and informal caregivers: involvement in development, flyers, involvement of informal caregiver, involvement of family physician, Internet-based and paper version of the ZWIP, instruction in using the ZWIP by volunteer, and telephonic help desk available.|
|6. Planning for evaluation||Design of an evaluation plan.||Framework for process evaluation and evaluation of effects.|
Step 1: Needs Assessment
First, we assembled a planning group to develop the intervention. This planning group included the project manager, the project leader (RM), two researchers (SR and MHu), two family physicians, a geriatrician, a nurse scientist experienced in intervention mapping (MHe), an information technology consultant, and a long-term care facility physician.
This planning group analyzed the existing problems with self-management of frail older people and interprofessional collaboration in primary care. First, we performed a literature search for barriers to patient self-management and interprofessional collaboration. Second, we conducted semi-structured interviews at the homes of frail older people (n = 11) and informal caregivers (n = 11). They were invited to participate by their family physician or welfare organization and were purposively selected based on variation in living situation, socioeconomic position, and health and social problems. Interviewees were asked for their experiences with receiving information from health care and welfare professionals, informational continuity (ie, whether information concerning their health or well-being was exchanged between professionals), and interprofessional collaboration. Third, we established two working groups. The first group consisted of health care and welfare professionals (n = 15) who were involved in the care of frail older people. They were recruited through their employing organizations and were financially compensated for their time investments. Members included family physicians (n = 3), primary care nurses (n = 3), geriatricians (n = 2), municipality workers (n = 2), social workers (n = 2), a long-term care facility physician (n = 1), a pharmacist (n = 1), and a psychologist (n = 1). The second working group consisted of older people (n = 2) and informal caregivers (n = 2), who were asked to participate by older people participating in the user panel of ZOWEL NN. Both groups were asked to discuss the problems they experienced with self-management of frail older people and collaboration among professionals and they were asked to review and comment on the results from the literature search, semi-structured interviews, and the other working group.
Results of this needs assessment were integrated into a logic model. This model is derived from the Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation (PRECEDE) model [, ] that displays behaviors, its consequences, and its determinants in a structured manner. As the problems described for each topic (self-management and collaboration) were too distinct to be compiled into one single logic model, we constructed a separate logic model for each program objective.
Step 2: Preparing Matrices of Performance Objectives and Determinants
Based on the problem analysis, we defined performance objectives (ie, the behaviors required to achieve the program objectives) for each target population. These performance objectives were then crossed in matrices with those determinants of behavior that were known to have a major influence on behavior and were amenable to change. On the crossings of performance objectives and determinants, change objectives were formulated (ie, the highly specific outcomes the program should be aiming for). We designed these matrices for all target populations involved (ie, frail older people and their informal caregivers, professionals, and their employing organizations).
Step 3: Selecting Theory-Informed Intervention Methods and Practical Strategies
We searched the literature for theories that were proven to be effective in changing the identified determinants or that were successfully used to enhance patient self-management or to promote collaboration among professionals. From these theories, we selected methods and strategies for our program. In this selection, we aimed for an optimal balance between the expected advances toward our program objectives and the investments required from the target populations.
Step 4: Producing Program Components and Materials
Requirements for the program components were defined in additional meetings of the working groups of professionals and older people and informal caregivers. Subsequently, members of the planning group started development of program components. These components were reviewed by the working group of professionals and by two additional working groups of frail older people in an iterative process involving several rounds of reviewing by the working groups, the working groups making suggestions for improvement, and members of the planning group making adjustments. In this process, development and reviewing coincided, each working group being presented with the latest version of the components at the time of their meeting. Final versions of the program components were tested in a small pilot study involving two frail older people, two informal caregivers, and seven professionals.
Step 5: Planning Program Adoption, Implementation, and Sustainability
A prerequisite for adoption and implementation of the program was met by the extensive involvement of the target population in its development and the commitment of the local collaborative of stakeholders in health care and welfare services. Further, implementation was facilitated by selecting implementation strategies that were tailored to the needs of each target population. Planning for sustainability was started early in the development of the program by searching for funding for incorporation of the program in everyday practice.
Step 6: Planning for Evaluation
In this final step, we designed a plan for the evaluation of the program. This involved an evaluation of the effects of the program as well as a process evaluation.
Step 1: Results of the Needs Assessment
An overview of the results of the needs assessment for self-management of frail older people is provided in the logic model shown in[ , , , - ]. A second logic model representing collaboration among professionals is shown in [ , , , , , - , - ]. Each logic model describes the problem (the last two columns), the behavioral and environmental factors that contribute to the problem (the second column), and the determinants that influence those factors (the first column). We will briefly discuss the results of the needs assessment in the following section. Knowledge of the Dutch health care system may help the interpretation of the results of this needs assessment; therefore, a summary of its characteristics is provided in [ ].
Needs Assessment Concerning Frail Older People’s Involvement in Self-management
Frail older people, informal caregivers, professionals, and previous research reported problems with patient involvement in self-management. These problems related to frail older people and informal caregivers not performing the activities required, and professionals not encouraging or facilitating involvement.
Identified behaviors of frail older people and informal caregivers that contributed to these problems included: (1) not adequately informing professionals about their health situation nor asking sufficient questions [, ], and (2) not adhering to medications prescribed or advice given [ , , ]. These behaviors were influenced by many determinants such as attitude toward self-management because not all frail older people want to be involved extensively [ , ]; emotions such as fear of loss of independence [ , ]; self-efficacy for self-management [ , , , ]; knowledge about the disease, symptoms, and treatments [ , , ]; skills [ , ]; personal limitations (eg, cognitive problems) [ , , , ]; perceived social norms [ , ]; social support, such as advocacy [ , , , ]; financial constraints [ , , ]; and the high complexity of the health care system [ ].
Important contributing behaviors of professionals were (1) not providing the frail older person with adequate information for self-management [, , ], and (2) not being genuinely interested in the frail older person and not encouraging questions [ , , ]. Important determinants affecting these behaviors were attitude toward patient self-management [ , ], knowledge [ ], skills for self-management support [ , ], and determinants related to the health care system [ , ].
Needs Assessment Concerning Collaboration Among Professionals
Professionals, patients, informal caregivers, and the literature cited problems with collaboration among professionals. The main behaviors that contributed to these problems were a lack of communication or insufficient communication [, , ]; delays in the transfer of information or information not being transferred at all [ , ]; giving either insufficient information (eg, not giving the information required by a particular discipline) [ , ] or too extensive information that was not read by professionals with already demanding work schedules; and not involving the frail older person in the collaboration between professionals. Important determinants influencing these behaviors included attitudes toward collaboration [ , ], beliefs in the advantages of collaboration [ ], knowledge about the information needed by other disciplines [ ], communication skills [ , , ], and external factors such as time constraints [ ] and legal restrictions to the sharing of information [ ]. However, for professionals in the working groups, more practical determinants were the most important, such as not knowing which other professionals were involved in the care of the frail older person, not knowing them personally [ , , , ], and not being able to contact these professionals (eg, due to part-time work or busy telephone lines) [ , , ].
Step 2: Results on Matrices of Performance Objectives and Determinants
Based on our needs assessment, we defined performance objectives for both program objectives and for each target population involved (and 2). Also, we reviewed the determinants shown in [ , , , - ] and 2 [ , , , , , - , - ] in order to select those determinants of behavior that were considered both important to target and modifiable. For the first program objective, aimed at facilitating self-management, we developed two matrices: one for frail older people and informal caregivers and one for professionals. For frail older people and informal caregivers, targeted determinants were attitudes, skills and self-efficacy, knowledge, and social support. For professionals, targeted determinants were attitudes, knowledge, skills, and organization. For the second program objective, aimed at enhancing collaboration, we designed three matrices: one for professionals, one for their organizations, and one for frail older people and informal caregivers. For professionals, targeted determinants were attitudes and beliefs, knowledge, skills, and accessibility; for their organizations, the targeted determinant was organizational culture; and for frail older people and informal caregivers, targeted determinants were attitude, self-efficacy, knowledge, skills, social norms and social support, and accessibility. We then crossed the performance objectives with these determinants to design matrices of change objectives. For example, for the performance objective “professional communicates with other professionals involved” and the determinant “knowledge,” a change objective was “professional states that problems in communication lead to adverse outcomes for frail older people.” Therefore, we wanted our program to increase professionals’ knowledge about the effects of communication problems. provides an example of a matrix of change objectives.
Step 3: Selected Theories, Methods, and Strategies
Social cognitive theory  was selected as the main theory behind the program because it has been successfully used in the past for interventions aimed at improving patient self-management and in Internet-based interventions focusing on improving self-management [ - ]. A key concept of social cognitive theory is perceived self-efficacy: the beliefs people have about their capabilities to produce the effects they desire by their own actions [ ]. If self-efficacy is low, people are less likely to either act or to continue trying when facing difficulties [ ]. We included several methods and strategies derived from this theory in the program, based on their ability to change the targeted determinants of behavior. For professionals, we included active learning, direct experience, modeling, and facilitation. For frail older people and their informal caregivers, we included modeling, guided practice, and tailoring. Further, elements of goal-setting theory [ ] (ie, goal setting and action planning) [ ] were included in the program to assist frail older people and informal caregivers in describing what is most important to them, to help them to achieve their goals, and to increase their involvement in the care process. Goal-setting theory highlights the importance of setting specific, difficult goals because people who set such goals perform better that those who are merely asked to do their best [ ]. Last, we incorporated elements of several theories of organizational change into the program. Methods used from these theories were providing training and coaching, and creating facilitating conditions [ , ].
Step 4: Characteristics of ZWIP
Taking the former steps of the intervention mapping process into account, we developed the main component of the program: the ZWIP. The ZWIP is a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. It can be considered to be both a shared EHR and PHR. The ZWIP is aimed at frail older people identified through a specific screening method and includes: (1) a tool for multidisciplinary communication in a secure environment that enables communication through sending messages between the frail older person, informal caregiver, and the professionals involved; (2) an overview of health care and welfare professionals involved in the care of the frail older person and their contact information; (3) information about the frail older person’s health, functioning, and social situation as well as the care provided; (4) the goals and action plans of the frail older person and the informal caregiver, which are formulated with them during home visits by nurses or social workers by means of a goal-setting tool; and (5) tailored educational materials for the frail older person and informal caregiver. Fundamental to the ZWIP is the central position of the frail older person, who can view the information included and who decides which professionals are granted access to his personal ZWIP. As a rule, messages that are communicated within the ZWIP are visible for all professionals with access to the ZWIP as well as for the frail older person and informal caregiver. This allows everyone concerned to remain informed about the frail older person’s situation and enables everyone to bring up their own relevant observations in an ongoing conversation. However, at the request of frail older people and professionals, we also included the option of sending a private message to an individual person.
After development, as a final step before implementation, we conducted a small pilot study of the ZWIP. The most important lessons learned from this pilot were practical issues such as the need to communicate as unambiguously as possible.
Step 5: ZWIP Program Adoption and Implementation
Strategies used for the adoption and implementation of the program were tailored to the needs of each particular target population. We will describe the main strategies used in the next paragraphs; an overview of all strategies is provided in(step 5).
For health care and welfare professionals, our most important strategy was an interdisciplinary educational program for health care and welfare professionals involved in the care of frail older people. This program consisted of 3 three-hour meetings concerning the following subjects: (1) the concept of frailty and identification of frailty, as this was required to identify the frail older people who were the program’s target population; (2) providing self-management support to frail older people by thoroughly informing them and using collaborative goal setting; (3) interdisciplinary collaboration, including information about what each discipline has to offer in the care for frail older people; and (4) working with the ZWIP. Except for its educational content, the educational program also served as a method for identifying and bringing together local health care and welfare professionals involved in the care of frail older people because the program enabled professionals to get acquainted with each other. The educational meetings were held near local family practices and all local professionals working with frail older people were invited to participate. Another important strategy was that we aimed to ensure the participation of intrinsically motivated early adopters. Further, we tailored the implementation of the program to each setting by providing family medical practices with several options for implementation, which allowed them to choose the method that would best meet their local needs and circumstances. Also, we provided financial compensation for time invested in the program, gave coaching and e-coaching in using the ZWIP, and had a telephonic help desk available.
For frail older people and informal caregivers, we had two main strategies. First, we involved their family physician in the project, who actively promoted their participation. Second, we aimed to either facilitate the use of information technology or to make the use of information technology by frail older people redundant, as we were aware that they often have low computer literacy. Hence, we provided them with an Internet-based version of the ZWIP as well as a paper version of the ZWIP, which held all information that was included in the Internet-based ZWIP except for the communication; we offered them a home visit by a volunteer, who could either demonstrate the ZWIP to inform them about its possibilities or could train them in using the ZWIP themselves; and we had a telephonic help desk available during office hours.
Step 6: Preparing for Evaluation of the ZWIP
As a final step in the intervention mapping process, we planned the evaluation of the ZWIP. This evaluation will involve both a process evaluation and an effect evaluation. In the process evaluation, we will evaluate the implementation of the intervention, exposure of the target populations to the intervention, experiences of the target populations with the intervention, and barriers and facilitators to the use of the intervention. This will be studied using a combination of quantitative and qualitative data (ie, surveys, data about both the use of the ZWIP and exposure to its implementation strategies, and semi-structured interviews). The effects of the ZWIP program will be evaluated by means of a controlled clinical trial. Outcome measures will be the effects of the program on interprofessional collaboration, patient self-management and autonomy, patient outcomes such as functioning and quality of life, and use of care. Also, cost-effectiveness of the ZWIP will be evaluated. Last, as we consider the interprofessional educational program an important part of the implementation, the effects of this program on interprofessional collaboration will be evaluated separately. This will be done in a before-and-after study using several validated questionnaires (ie, the Attitudes Toward Health Care Teams Scale , the Interprofessional Attitudes Questionnaire [ , ], and the Team Skills Scale [ ]) followed by semi-structured interviews with purposively selected participants.
This paper describes the successful development of a program aimed at facilitating self-management and shared decision making by frail older people and their informal caregivers and at reducing fragmentation of care through improving collaboration among professionals. For this development, the intervention mapping framework was used and future users were involved extensively. In the past, this framework has also been successfully used for the development of health promotion programs aimed at such diverse topics as leg ulcers , physical activity of employees in sedentary occupations [ ], sexually transmitted disease, pregnancy and human immunodeficiency virus prevention [ ], and asthma self-management [ ]. To our knowledge, this is the first time that intervention mapping was successfully used to develop an intervention that specifically targets collaboration between professionals.
A major advantage of the use of intervention mapping was that it facilitated the systematic incorporation of the needs and preferences of the target population as well as evidence from previous research. We can exemplify this with our first program objective, which concerned self-management and shared decision making. Previous research has shown that most older people prefer a less active role in medical decision making , but they do want to be informed, and they want their concerns and wishes to be taken into account when decisions are made [ ]. Still, there is enormous variation in the extent to which older people wish to participate in decision making [ ]. Therefore, we designed our program to meet the basic level of involvement wanted by most older patients (eg, by providing information about their health and customized educational materials; by including goal setting to gain knowledge of their goals and preferences; and by educating professionals in self-management support), yet made the program flexible to more extensive patient involvement in decision making (eg, by incorporating action planning for patients willing to engage in it and by facilitating patients’ communication with professionals).
Further, the program benefitted from the involvement of the target populations because they brought up a wide range of knowledge and perspectives . Moreover, the target populations were able to specify which problems found in the literature were considered most pressing by members of their own population because they were highly knowledgeable of their characteristics and circumstances. For example, although we initially assumed that lack of continuity of information was an important barrier to collaboration, the involvement of the working group of professionals demonstrated that more basic obstacles to collaboration existed (ie, practical problems concerning communication, such as not knowing which other professionals are involved or not being able to contact them due to differing working hours). Therefore, we decided to shift focus of the program to include facilitation of communication as well. This enabled designing a program that was tailored to meet their needs, thereby increasing the chances of an effective intervention and a successful implementation.
Although involvement of the target population was considered important, it also presented a challenge. First, involving frail older people proved to be difficult. For the limited number of frail participants in the working groups, problems such as not being able to attend the meetings due to health problems limited their ability to participate. Therefore, we also invited older people who were not frail to join the working groups. Also, for some of the frail older people participating in the semi-structured interviews, cognitive problems made it difficult for them to express their views about the rather abstract interview topics. Therefore, although frail older people were involved in the development process, their involvement was less than we would have preferred. Second, the evidence gathered from previous research and the different working groups did not always point in the same direction. An example was the discussion about whether or not all messages should be visible to everyone with access to the ZWIP. The working group of professionals was hesitant at first to make all messages visible, and the working groups of frail older people were divided. In the end, both groups mentioned that there were instances in which they felt a private message was absolutely required. In such cases, the planning group made a final decision. These decisions were made based on a thorough deliberation on all the arguments available from the literature and the working groups as well as arguments concerning feasibility.
Although the ZWIP is a systematically developed evidence-informed intervention, its future success depends highly on its successful implementation and its use by professionals in everyday practice. Implementation and use will be monitored and adaptations will be made whenever required. Further, future use of the ZWIP in everyday practice will have to establish the added value of the communication tool of ZWIP in relation to already existing communication methods.
In summary, this article describes the successful development of the ZWIP, a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. We expect that the ZWIP will be able to increase the involvement of frail older people and informal caregivers in their care and will improve collaboration among professionals. Therefore, we expect that the ZWIP will contribute to filling the gaps in our fragmented health care systems.
This project was funded by grant 60-61900-98-129 of the Dutch National Care for the Elderly Program, coordinated and sponsored by ZonMw, The Netherlands, an organization for health research and development. The sponsor was not involved in study design, analysis of data, writing of the report, or in the decision to submit the paper for publication.
We would like to thank Wilma Derksen-Driessen, Emile ter Horst, Leontien van Nieuwenhuijzen, and Marieke Perry for their assistance in the development of the program.
The ZOWEL NN Study Group consists of (in alphabetical order): MJM. Adriaansen (Faculty of Health and Social Sciences, HAN University of Applied Sciences); C Benraad (Pro Persona, Nijmegen); GF Borm (Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen); IJHM Cox (ZZG Health care organization, Nijmegen); D Dingemans (ZOWEL NN user forum); MM Heinen (Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen); ME Hoogsteen-Ossewaarde (Department of Geriatric Medicine, Alzheimer Centre Nijmegen, Radboud University Nijmegen Medical Centre, Nijmegen); E ter Horst (Informatics Communication Academy, HAN University of Applied Sciences); R Koopmans (Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Nijmegen Medical Centre, Nijmegen); RJF Melis (Department of Geriatric Medicine, Alzheimer Centre Nijmegen, Radboud University Nijmegen Medical Centre, Nijmegen); GRM Molleman (Municipal Health Service Nijmegen (GGD Nijmegen), Academic Collaborative Centre AMPHI, Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Nijmegen Medical Centre, Nijmegen); M Nieuwboer (Shared Service Centre, Advisory Process Improvement and Innovation, Radboud University Nijmegen Medical Centre, Nijmegen); MGM Olde Rikkert (Department of Geriatric Medicine, Alzheimer Centre Nijmegen, Radboud University Nijmegen Medical Centre, Nijmegen); MCH Pepels (Foundation for the well-being of senior citizens, Nijmegen); A Persoon (Department of Geriatric Medicine, Alzheimer Centre Nijmegen, Radboud University Nijmegen Medical Centre, Nijmegen); PSHM Peters (De Waalboog Foundation, Nijmegen); H Schers (Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Nijmegen Medical Centre, Nijmegen); Y Schoon (Department of Geriatric Medicine, Alzheimer Centre Nijmegen, Radboud University Nijmegen Medical Centre, Nijmegen); T Van Achterberg (Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen); S Zuidema (Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Nijmegen Medical Centre, Nijmegen), The Netherlands.
Concept and design: SR, MHe, and RM; analysis of the data: SR, MHe, and RM; drafting of the article: SR; and critical revision of the article: MHu, TvA, SZ, MOR, HS, MHe, and RM.
Conflicts of Interest
Multimedia Appendix 1
Performance objectives for each target population related to self-management.PDF File (Adobe PDF File), 50KB
Multimedia Appendix 2
Performance objectives for each target population related to collaboration.PDF File (Adobe PDF File), 48KB
Multimedia Appendix 3
Section of matrix of change objectives on enhancing collaboration of professionals.PDF File (Adobe PDF File), 38KB
- Weiner M, Callahan CM, Tierney WM, Overhage JM, Mamlin B, Dexter PR, et al. Using information technology to improve the health care of older adults. Ann Intern Med 2003 Sep 2;139(5 Pt 2):430-436. [Medline]
- Holman H, Lorig K. Patient self-management: a key to effectiveness and efficiency in care of chronic disease. Public Health Rep 2004 May;119(3):239-243. [CrossRef] [Medline]
- Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med 2009 Mar;7(2):100-103 [FREE Full text] [CrossRef] [Medline]
- Johnson P, Wistow G, Schulz R, Hardy B. Interagency and interprofessional collaboration in community care: the interdependence of structures and values. J Interprof Care 2003 Feb;17(1):69-83. [Medline]
- Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002 Nov 20;288(19):2469-2475. [Medline]
- de Haes H. Dilemmas in patient centeredness and shared decision making: a case for vulnerability. Patient Educ Couns 2006 Sep;62(3):291-298. [CrossRef] [Medline]
- Bastiaens H, Van Royen P, Pavlic DR, Raposo V, Baker R. Older people's preferences for involvement in their own care: a qualitative study in primary health care in 11 European countries. Patient Educ Couns 2007 Sep;68(1):33-42. [CrossRef] [Medline]
- Edwards A, Elwyn G, Hood K, Atwell C, Robling M, Houston H, Study Steering Group. Patient-based outcome results from a cluster randomized trial of shared decision making skill development and use of risk communication aids in general practice. Fam Pract 2004 Aug;21(4):347-354 [FREE Full text] [CrossRef] [Medline]
- Griffin SJ, Kinmonth AL, Veltman MW, Gillard S, Grant J, Stewart M. Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med 2004 Nov;2(6):595-608 [FREE Full text] [CrossRef] [Medline]
- Bodenheimer T. Coordinating care--a perilous journey through the health care system. N Engl J Med 2008 Mar 6;358(10):1064-1071. [CrossRef] [Medline]
- Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ 2003 Nov 22;327(7425):1219-1221. [CrossRef] [Medline]
- van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract 2010 Oct;16(5):947-956. [CrossRef] [Medline]
- Schoen C, Osborn R, Huynh PT, Doty M, Davis K, Zapert K, et al. Primary care and health system performance: adults' experiences in five countries. Health Aff (Millwood) 2004 Jul;Suppl Web Exclusives:W4-487. [CrossRef] [Medline]
- Committee on Quality Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
- Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Ann Intern Med 2005 Apr 19;142(8):700-708. [Medline]
- Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning Health Promotion Programs: An Intervention Mapping Approach. San Francisco: Jossey-Bass; 2006.
- Green LW, Kreuter MW. Health Program Planning: An Educational and Ecological Approach. New York: McGraw-Hill; 2005.
- Bayliss EA, Steiner JF, Fernald DH, Crane LA, Main DS. Descriptions of barriers to self-care by persons with comorbid chronic diseases. Ann Fam Med 2003 May;1(1):15-21 [FREE Full text] [Medline]
- Bayliss EA, Ellis JL, Steiner JF. Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities. Ann Fam Med 2007;5(5):395-402 [FREE Full text] [CrossRef] [Medline]
- Bayliss EA, Bosworth HB, Noel PH, Wolff JL, Damush TM, Mciver L. Supporting self-management for patients with complex medical needs: recommendations of a working group. Chronic Illn 2007 Jun;3(2):167-175. [CrossRef] [Medline]
- Bentley J. Older people as health service consumers 4: disempowered or disinterested? Br J Community Nurs 2003 Apr;8(4):181-187. [Medline]
- Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ 2007 Jul 7;335(7609):24-27. [CrossRef] [Medline]
- DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004 Mar;42(3):200-209. [Medline]
- Horwitz RI, Viscoli CM, Berkman L, Donaldson RM, Horwitz SM, Murray CJ, et al. Treatment adherence and risk of death after a myocardial infarction. Lancet 1990 Sep 1;336(8714):542-545. [Medline]
- Jeon YH, Jowsey T, Yen L, Glasgow NJ, Essue B, Kljakovic M, et al. Achieving a balanced life in the face of chronic illness. Aust J Prim Health 2010;16(1):66-74. [Medline]
- Jerant AF, von Friederichs-Fitzwater MM, Moore M. Patients' perceived barriers to active self-management of chronic conditions. Patient Educ Couns 2005 Jun;57(3):300-307. [CrossRef] [Medline]
- Lorig K. Self-management education: more than a nice extra. Med Care 2003 Jun;41(6):699-701. [CrossRef] [Medline]
- Mancuso CA, Rincon M, McCulloch CE, Charlson ME. Self-efficacy, depressive symptoms, and patients' expectations predict outcomes in asthma. Med Care 2001 Dec;39(12):1326-1338. [Medline]
- Noël PH, Frueh BC, Larme AC, Pugh JA. Collaborative care needs and preferences of primary care patients with multimorbidity. Health Expect 2005 Mar;8(1):54-63. [CrossRef] [Medline]
- Rost K, Frankel R. The introduction of the older patient's problems in the medical visit. J Aging Health 1993 Aug;5(3):387-401. [Medline]
- Rotar-Pavlic D, Svab I, Wetzels R. How do older patients and their GPs evaluate shared decision-making in healthcare? BMC Geriatr 2008;8:9 [FREE Full text] [CrossRef] [Medline]
- Warwick M, Gallagher R, Chenoweth L, Stein-Parbury J. Self-management and symptom monitoring among older adults with chronic obstructive pulmonary disease. J Adv Nurs 2010 Apr;66(4):784-793. [CrossRef] [Medline]
- Wetzels R, Geest TA, Wensing M, Ferreira PL, Grol R, Baker R. GPs' views on involvement of older patients: an European qualitative study. Patient Educ Couns 2004 May;53(2):183-188. [CrossRef] [Medline]
- Yen L, Gillespie J, Rn YH, Kljakovic M, Anne Brien J, Jan S, et al. Health professionals, patients and chronic illness policy: a qualitative study. Health Expect 2011 Mar;14(1):10-20. [CrossRef] [Medline]
- Beaulieu MD, Samson L, Rocher G, Rioux M, Boucher L, Del Grande C. Investigating the barriers to teaching family physicians' and specialists' collaboration in the training environment: a qualitative study. BMC Med Educ 2009;9:31 [FREE Full text] [CrossRef] [Medline]
- Bradshaw PL. Service user involvement in the NHS in England: genuine user participation or a dogma-driven folly? J Nurs Manag 2008 Sep;16(6):673-681. [CrossRef] [Medline]
- Cook G, Klein B. Involvement of older people in care, service and policy planning. J Clin Nurs 2005 Mar;14 Suppl 1:43-47. [CrossRef] [Medline]
- Davies S, Laker S, Ellis L. Promoting autonomy and independence for older people within nursing practice: a literature review. J Adv Nurs 1997 Aug;26(2):408-417. [Medline]
- Fewster-Thuente L, Velsor-Friedrich B. Interdisciplinary collaboration for healthcare professionals. Nurs Adm Q 2008 Jan;32(1):40-48. [CrossRef] [Medline]
- Freeth D. Sustaining interprofessional collaboration. J Interprof Care 2001 Feb;15(1):37-46. [Medline]
- Gandhi TK, Sittig DF, Franklin M, Sussman AJ, Fairchild DG, Bates DW. Communication breakdown in the outpatient referral process. J Gen Intern Med 2000 Sep;15(9):626-631. [Medline]
- Gerardi D, Fontaine DK. True collaboration: envisioning new ways of working together. AACN Adv Crit Care 2007 Jan;18(1):10-14. [Medline]
- Horder J. Interprofessional collaboration and interprofessional education. Br J Gen Pract 2004 Apr;54(501):243-245. [Medline]
- Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007 Feb 28;297(8):831-841. [CrossRef] [Medline]
- San Martín-Rodríguez L, Beaulieu MD, D'Amour D, Ferrada-Videla M. The determinants of successful collaboration: a review of theoretical and empirical studies. J Interprof Care 2005 May;19 Suppl 1:132-147. [CrossRef] [Medline]
- Sargeant J, Loney E, Murphy G. Effective interprofessional teams: "contact is not enough" to build a team. J Contin Educ Health Prof 2008;28(4):228-234. [CrossRef] [Medline]
- Suter E, Arndt J, Arthur N, Parboosingh J, Taylor E, Deutschlander S. Role understanding and effective communication as core competencies for collaborative practice. J Interprof Care 2009 Jan;23(1):41-51. [CrossRef] [Medline]
- Xyrichis A, Lowton K. What fosters or prevents interprofessional teamworking in primary and community care? A literature review. Int J Nurs Stud 2008 Jan;45(1):140-153. [CrossRef] [Medline]
- Weller JM, Barrow M, Gasquoine S. Interprofessional collaboration among junior doctors and nurses in the hospital setting. Med Educ 2011 May;45(5):478-487. [CrossRef] [Medline]
- Schäfer W, Kroneman M, Boerma W, van den Berg M, Westert G, Devillé W, et al. The Netherlands: health system review. Health Syst Transit 2010;12(1):v-xxvii, 1 [FREE Full text] [Medline]
- Bandura A. Health promotion by social cognitive means. Health Educ Behav 2004 Apr;31(2):143-164. [CrossRef] [Medline]
- McAlister AL, Perry CL, Parcel GS. How individuals, environments, health behaviors interact: social cognitive theory. In: Health Behavior and Health Education: Theory, Research, and Practice. San Francisco: Jossey-Bass; 2008:169-188.
- Lorig KR, Ritter PL, Laurent DD, Plant K. Internet-based chronic disease self-management: a randomized trial. Med Care 2006 Nov;44(11):964-971. [CrossRef] [Medline]
- Lorig KR, Sobel DS, Stewart AL, Brown BW, Bandura A, Ritter P, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care 1999 Jan;37(1):5-14. [Medline]
- Bandura A. Self-efficacy. In: Ramachaudran VS, editor. Encyclopedia of Human Behavior. San Diego, CA: Academic Press; 1994:71-81.
- Locke EA, Latham GP. Building a practically useful theory of goal setting and task motivation. A 35-year odyssey. Am Psychol 2002 Sep;57(9):705-717. [Medline]
- Bodenheimer T, Handley MA. Goal-setting for behavior change in primary care: an exploration and status report. Patient Educ Couns 2009 Aug;76(2):174-180. [CrossRef] [Medline]
- Butterfoss F, Kegler M, Francisco VT. Mobilizing organizations for health promotion: theories of organizational change. In: Health Behavior and Health Education: Theory, Research, and Practice. San Francisco: Jossey-Bass; 2008:335-361.
- Heinemann GD, Schmitt MH, Farrell MP, Brallier SA. Development of an Attitudes Toward Health Care Teams Scale. Eval Health Prof 1999 Mar;22(1):123-142. [Medline]
- Carpenter J. Interprofessional education for medical and nursing students: evaluation of a programme. Med Educ 1995 Jul;29(4):265-272. [Medline]
- Carpenter J. Doctors and nurses: stereotypes and stereotype change in interprofessional education. Journal of Interprofessional Care 1995;9(2):151-161. [CrossRef]
- Hepburn K, Tsukuda RA, Fasser C. Team skills scale. In: Geriatric Interdisciplinary Team Training. New York: Springer Pub Co; 1998:264-265.
- Heinen MM, Bartholomew LK, Wensing M, van de Kerkhof P, van Achterberg T. Supporting adherence and healthy lifestyles in leg ulcer patients: systematic development of the Lively Legs program for dermatology outpatient clinics. Patient Educ Couns 2006 May;61(2):279-291. [CrossRef] [Medline]
- McEachan RR, Lawton RJ, Jackson C, Conner M, Lunt J. Evidence, theory and context: using intervention mapping to develop a worksite physical activity intervention. BMC Public Health 2008;8:326 [FREE Full text] [CrossRef] [Medline]
- Tortolero SR, Markham CM, Parcel GS, Peters RJ, Escobar-Chaves SL, Basen-Engquist K, et al. Using intervention mapping to adapt an effective HIV, sexually transmitted disease, and pregnancy prevention program for high-risk minority youth. Health Promot Pract 2005 Jul;6(3):286-298. [CrossRef] [Medline]
- Bartholomew LK, Shegog R, Parcel GS, Gold RS, Fernandez M, Czyzewski DI, et al. Watch, Discover, Think, and Act: a model for patient education program development. Patient Educ Couns 2000 Feb;39(2-3):253-268. [Medline]
- Say R, Murtagh M, Thomson R. Patients' preference for involvement in medical decision making: a narrative review. Patient Educ Couns 2006 Feb;60(2):102-114. [CrossRef] [Medline]
|EHR: electronic health record|
|PHR: personal health record|
|ZWIP: Health and Welfare Information Portal|
Edited by G Eysenbach; submitted 26.09.11; peer-reviewed by F Richy; comments to author 15.01.12; revised version received 28.02.12; accepted 26.06.12; published 19.09.12
©Sarah HM Robben, Mirjam Huisjes, Theo van Achterberg, Sytse U Zuidema, Marcel GM Olde Rikkert, Henk J Schers, Maud M Heinen, René JF Melis, For The ZOWEL NN Study Group. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 19.09.2012.
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