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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.
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).
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.
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.
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.
Current health care systems are not optimally designed to meet the needs of our aging populations [
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) [
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 [
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 [
Overview of the intervention mapping process.
Steps | Methods | Results |
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 ( |
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. |
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 [
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).
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.
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.
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.
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.
An overview of the results of the needs assessment for self-management of frail older people is provided in the logic model shown in
All Dutch citizens are registered with their own family physician, usually over an extended period of time. This family physician functions as a gatekeeper; hospital care and specialist care (except for emergency care) can only be accessed with a referral by a family physician.
When patients need other health care or welfare services (eg, home care, physiotherapy, or occupational therapy), they can generally choose between many providers offering these services.
Funding of the Dutch health care system is organized by means of a compulsory social health insurance scheme.
Logic model for self-management of frail older people.
Logic model for collaboration among professionals.
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 [
Important contributing behaviors of professionals were (1) not providing the frail older person with adequate information for self-management [
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 [
Based on our needs assessment, we defined performance objectives for both program objectives and for each target population involved (
Social cognitive theory [
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.
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
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.
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 [
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 [
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 [
Further, the program benefitted from the involvement of the target populations because they brought up a wide range of knowledge and perspectives [
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.
Performance objectives for each target population related to self-management.
Performance objectives for each target population related to collaboration.
Section of matrix of change objectives on enhancing collaboration of professionals.
electronic health record
personal health record
Health and Welfare Information Portal
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.
None declared.