Multi-morbiditeit (psychisch, sociaal en somatisch) Problems on multiple domains vulnerable persons.
Conditions
Interventions
The proactive integrated care intervention that will be used consists of five
steps:
1. Active invitation of the patient from the practice
2. Consult of 45 minutes with a trained Practice Nurse Menta
(2)
appointment of one care coordinator and (3) a structured follow up plan
(frequency and duration) of the progression of this patient*s problems.
4. Execution of the personalised care plan. The ca
Sponsors
Leids Universitair Medisch Centrum
Eligibility
Age
18 Years to 99 Years
Inclusion criteria
Inclusion criteria: -The patients are >= 18yrs -The patients are registered within one of the participating GP practices. -Patients with at least two acute care encounters in the past 12 months. Acute care encounter is defined as an encounter with out-of-hours GP service, emergency care or acute mental health care. -Patients have problems registered in the GP Information system on at least two out of three of the following domains: somatic, mental or social.
Exclusion criteria
Exclusion criteria: - The patient is terminal. - The patient is living in a residential home. - The patient has dementia or a disability that prevents them from communicating effectively. - The patients opt out for permission to use medical data - The patient already has experience with the positive health tool. - The patient is not competent to make decisions concerning their health. This wil be assessed by the patient*s own general practitioner.
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| The main study parameter is incremental cost-effectiveness. To measure this outcome data sources will be used and linked at the individual level. At the start of the study (t=0) and at the end (t=22) data on care usage and costs will be collected. These data will be translated into cost using standard cost prices from the Dutch guideline for economic evaluations. | — |
Secondary
| Measure | Time frame |
|---|---|
| 1.Patient experience of care The secondary study parameter is insight into the patient experience of care. To assess their experience focus groups will be organized. Four main topics will be discussed, namely: care before the new approach, the new approach, the collaboration between the professionals and the experienced effects of the new approach. Furthermore, information about self-efficacy (PAM-13 and SE+IN itemlist), proactive coping (UPCC), and quality of life (SF-12) will be collected using questionnaires 2.Process evaluation A process evaluation of this study will be done simultaneously, as a process evaluation can provide valuable insight on the practicalities of the intervention. Data on recruitment and reach of the population will be gathered during the inclusion of patiens in this study. Information on integration of care with the social domain and the mental domain will also be gathered. Additional questionnaires will be gathered about patient satisfaction with care, using a modified version of the NPS (Reichheld, 2003). The nature of the communication between care professional and patient, will be assessed using a HCCQ questionnaire (Jochems, Duivenvoorden, van der Feltz-Cornelis, & van Dam, 2014; Czajkowska, Wang, Hall, Sewitch, & Körner, 2017). Furthermore, a questionnaire will be used combining the assessment of the acceptability (Acceptability of Intervention Measure - AIM), appropriateness (Intervention Appropriateness Measure - IAM), feasibility (Feasibility of Intervention Measure - FIM), and perceived and experienced effectiveness of the intervention (Weiner, Lewis, & Stanick, 2017). | — |
Countries
Netherlands
Outcome results
None listed