Triple aim improvement for individuals, services and society in dementia care : The DementiaNet collaborative care approach

DementiaNet facilitates a sustainable transition toward integrated primary dementia care: A long-term evaluation

INTRODUCTION

Care integration is a promising strategy to achieve sustainable health-care systems. With DementiaNet, a 2-year program, we facilitated collaboration between primary health-care professionals. We studied changes in primary dementia care integration during and after DementiaNet participation.

METHODS

A longitudinal follow-up study was performed. Networks started between 2015 and 2020; follow-up ended in 2021. Quantitative and quantitative data were collected annually to assess quality of care, network collaboration, and number of crisis admissions. Growth modeling was used to identify changes over time.

RESULTS

Thirty-five primary care networks participated. Network collaboration and quality of care of newly formed networks increased significantly in the first 2 years (respectively, 0.35/year, P < .001; 0.29/year, P < .001) and thereafter stabilized.

CONCLUSION

Primary care networks improved their collaboration and quality of care during DementiaNet participation, which persisted after the program ended. This indicates that DementiaNet facilitated a sustainable transition toward integrated primary dementia care.

Effects of DementiaNet's Community Care Network Approach on Admission Rates and Healthcare Costs: A Longitudinal Cohort Analysis

BACKGROUND

People with dementia are increasingly living at home, relying on primary care providers for most healthcare needs. Suboptimal collaboration and communication between providers could cause inefficiencies and worse patient outcomes. Innovative strategies are needed to address this growing disease burden and rising healthcare costs. The DementiaNet programme, a community care network approach targeted at patients with dementia in the Netherlands, has been shown to improve patient's quality of care. However, very little is known about the impact of DementiaNet on admission risks and healthcare costs. This study addresses this knowledge gap.

METHODS

A longitudinal cohort analysis was performed, using medical and long-term care claims data from 38 525 patients between 2015-2019. The primary outcomes were risk of hospital admission and annual total healthcare costs. Mixed-model regression analyses were used to identify changes in outcomes.

RESULTS

Patients who received care from a DementiaNet community care network showed a general trend in lower risk of admission for all types of admissions studied (ie, hospital, emergency ward, intensive care, crisis, and nursing home). Also, the intervention group showed a significant reduction of 12% in nursing days (relative risk [RR] 0.88; 95% CI: 0.77- 0.96). No significant differences were found for total healthcare costs. However, we found effects in two sub-elements of total healthcare costs, being a decrease of 19.7% (95% CI: 7.7%-30.2%) in annual hospital costs and an increase of 10.2% (95% CI: 2.3%-18.6%) in annual primary care costs.

CONCLUSION

Our study indicates that DementiaNet's community care network approach may reduce admission risks for patients with dementia over a long-term period of five years. This is accompanied by a decrease in nursing days and savings in hospital care that exceed increased primary care costs. This improvement in integrated dementia care supports wider scale implementation and evaluation of these networks.

Specifics of and training needs in the inter-professional home care ofpeople with dementia

Introduction: Successful home care for people living with dementia (PLwD) allows them to live in their own home environment for as long as possible. Current findings indicate a need for further development of medical and nursing knowledge and skills in evidence-based collaborative care for these patients. Aim: To identify specifics of inter-professional care for PLwD and training needs of home care nurses and general practitioners involved in care. Method: A multi-perspective qualitative study was conducted, comprising focus groups as well as individual interviews. Focus groups and interviews followed a semi-structured topic guide. Interview data was digitally recorded and transcribed verbatim, followed by a thematic framework analysis. Results: The sample consisted of nine nurses, one medical assistant, three general practitioners and nine family caregivers of PLwD. Five themes related to inter-professional home care were inductively developed: challenges in outpatient dementia care, challenges in collaboration, insufficient healthcare infrastructure, competencies needed in dementia care, and training requirements. Challenges were a lacking flow of information as well as continuity and organization of care. Home care nurses and family caregivers complained about missing communication skills in health professionals involved in the care of PLwD. Conclusions: The interviews revealed heterogeneous training needs of home care nursing staff and general practitioners that can be addressed by an inter-professional training course.

Clinical leadership training in integrated primary care networks: a qualitative evaluation

Objective

To explore how a clinical leadership training programme contributes to successful implementation of integrated dementia care in local primary care networks.

Methods and analysis

A qualitative design was used in local primary care networks in the Netherlands. Twenty-six primary care professionals, nurses (n=22), general practitioners (n=2) and occupational therapists (n=2) followed a 2-year practice-based educational programme including individual coaching and interactive group training. Embedded leadership training created opportunities for direct application of acquired leadership skills. Reports of coaching sessions and transcripts of semi-structured interviews with 20 leadership trainees, 8 network members and a focus group interview with 9 leadership trainees were thematically analysed.

Results

They identified 50 learning goals, mostly associated with personal leadership competences. These professionals perceived some improvement in their leadership behaviour and preferred a duo-network leadership arrangement. Individual coaching sessions and group training sessions were perceived as fruitful support. Coaching sessions were found to facilitate learning processes regarding personal competencies, collaboration issues and role clarification. Group meetings were appreciated for exercises on transformational leadership behaviour and exchange of experiences. Network leaders and members observed improved quality of care and mentioned continuity of leadership, perseverance of leaders and a sufficient time period to bring about change as important facilitating factors.

Conclusion

Clinical leadership training to stimulate integrated primary care is promising as it was positively valued and contributed to improved perceived leadership competencies. Network leaders and members experienced improved quality of care when at least continuity in leadership was warranted.

Implementation of interprofessional digital communication tools in primary care for frail older adults: An interview study

Communication and coordination between primary healthcare professionals and informal caregivers involved in the care for frail older adults is suboptimal and could benefit from interprofessional digital communication tools. Implementation in daily practice however frequently fails. We aim to identify generic barriers and facilitators experienced by healthcare professionals and informal caregivers during implementation of interprofessional communication tools to improve their long-term use. Qualitative content analysis using individual semi-structured interviews was used for evaluating three different digital communication tools used by interprofessional primary care networks for frail older adults by 28 professionals and 10 caregivers. After transcription and open coding, categories and themes were identified. Barriers and facilitators were related to: tool characteristics, context of use, involvement of professionals and caregivers. The tool improved availability, approachability and users' involvement. The large number of digital systems professionals simultaneously use, and different work agreements hampered tool use. The tools facilitated care coordination, and professionals declared to be better informed about patients' current situations. Overall, interprofessional digital communication tools can facilitate communication in networks for primary elderly care. However, integration between digital systems is needed to reduce the number of tools. Organizations and policy makers have an important role in realizing the tools' long-term use.

Care Integration in Primary Dementia Care Networks: A Longitudinal Mixed-Methods Study

Introduction:

Currently, care integration for community-dwelling persons with dementia is poor and knowledge on how to effectively facilitate development of integrated dementia care is lacking. The DementiaNet program aims to overcome this with a focus on interprofessional collaboration. The objective of this study is to investigate how care integration in interprofessional primary dementia care networks matures and to identify factors associated with (un)successfully maturation.

Theory and methods:

A longitudinal mixed-methods study, including 17 primary care networks participating in the DementiaNet study, was performed. Semi-structured interviews based on the Rainbow Model of Integrated Care were conducted at start, at 12- and 24 months. Network maturity scores (range 1–4) were derived from the interviews and qualitative data was used to explain the observed patterns.

Results:

Networks consisted on average of 9 professionals (range 4–22) covering medical, care and social disciplines. Network maturity yearly increased with 0.29 (95%-CI: 0.20–0.38). Important factors for improvement included getting to know each other’s expertise, having a capable network leader(s), stable network composition and participation of a general practitioner.

Conclusions:

The DementiaNet approach enables a transition towards more mature networks. Identified success factors provide better understanding of how network maturity can be achieved and gives guidance to future care integration strategies.

Development and pilot testing of quality improvement indicators for integrated primary dementia care

Background

Implementation of integrated primary care is considered an important strategy to overcome fragmentation and improve quality of dementia care. However, current quality indicator (QI) sets, to assess and improve quality of care, do not address the interprofessional context. The aim of this research was to construct a feasible and content-wise valid minimum dataset (MDS) to measure the quality of integrated primary dementia care.

Methods

A modified Delphi method in four rounds was performed. Stakeholders (n=15) (1) developed a preliminary QI set and (2) assessed relevance and feasibility of QIs via a survey (n=84); thereafter, (3) results were discussed for content validity during a stakeholder and (4) expert consensus meeting (n=8 and n=7, respectively). The stakeholders were professionals, informal caregivers, and care organisation managers or policy officers; the experts were professionals and researchers. The final set was pilot-tested for feasibility by multidisciplinary dementia care networks.

Results

The preliminary set consisted of 40 QIs. In the survey, mean scores for relevance ranged from 5.8 (SD=2.7) to 8.5 (SD=0.7) on a 9-point Likert scale, and 25% of all QIs were considered feasible to collect. Consensus panels reduced the set to 15 QIs to be used for pilot testing: 5 quality of care, 3 well-being, 4 network-based care, and 3 cost-efficiency QIs. During pilot testing, all QIs were fully completed, except for well-being QIs.

Conclusion

A valid and feasible MDS of QIs for primary dementia care was developed, containing innovative QIs on well-being, network-based care and cost-efficiency, in addition to quality of care QIs. Application of the MDS may contribute to development and implementation of integrated care service delivery for primary dementia care.

Emerging Collaborative Care Models for Dementia Care in the Primary Care Setting: A Narrative Review

The rapidly increasing population living with dementia presents a unique economic and public health challenge. However, primary care physicians, despite their position as first-line providers, often lack the time, support, and training to systematically screen for, diagnose, and treat dementia, as well as provide adequate psychosocial support to unpaid caregivers. Models of collaborative care, which have found success in reducing symptom severity and increasing quality of life for other chronic illnesses, have been studied for feasibility, efficacy, and cost effectiveness in treating individuals with dementia and supporting caregivers. A review of initial data from several models suggests that enrollment in a collaborative care program for dementia is associated with benefits such as reduction in behavioral symptoms of dementia, improved functioning and quality of life, less frequent utilization of acute medical services, and decrease in caregiver burden. These evidence-based models, if implemented widely, stand to facilitate delivery of highly effective dementia care while reducing associated total medical expense. In this narrative review, we examine the key components of collaborative care teams, summarize outcomes of prior studies and discuss barriers and opportunities for wider dissemination of collaborative care models that are partnered with and/or based within primary care settings.

Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study

BACKGROUND

Persons with dementia use emergency department services at rates greater than other older adults. Despite risks associated with emergency department use, persons with dementia and their caregivers often seek emergency services to address needs and symptoms that could be managed within primary care settings. As emergency departments (EDs) are typically sub-optimal environments for addressing dementia-related health issues, facilitating effective primary care provision is critical to reduce the need for, or decision to seek, emergency services. The aim of this study is to explore how features of primary care practice influence care-seeking decisions by community-dwelling persons with dementia and familial caregivers.

METHODS

Semi-structured qualitative interviews were conducted with 27 key dementia-care stakeholders (10 primary care/geriatrics providers, 5 caregivers, 4 emergency medicine physicians, 5 aging service providers, and 3 community paramedics) from multiple health systems. Transcripts from audio recordings were analyzed using a thematic analysis framework to iteratively code and develop emergent themes. Features of primary care were also synthesized into lists of tangible factors leading to emergency care-seeking and those that help prevent (or decrease the need for) ED use.

FINDINGS

Stakeholders identified eight categories of features of primary care encompassing the clinical environment and provision of care. These collapsed into four major themes: (1) clinic and organizational features-including clinic structure and care team staffing; (2) emphasizing proactive approaches to anticipate needs and avoid acute problems-including establishing goals of care, preparing for the future, developing provider-patient/provider-caregiver relationships, and providing caregiver support, education, and resources to help prevent emergencies; (3) health care provider skills and knowledge of dementia-including training and diagnostic capabilities; and (4) engaging appropriate community services/resources to address evolving needs.

CONCLUSIONS

Features of primary care practice influence decisions to seek emergency department care at the system, organizational/clinic, medical, and interpersonal levels, particularly regarding proactive and reactive approaches to addressing dementia-related needs. Interventions for improving primary care for persons with dementia and their caregivers should consider incorporating features that facilitate proactive family-centered dementia care across the four identified themes, and minimize those leading to caregiver decisions to utilize emergency services.

Knowledge, attitudes, and qualification needs of primary health care professionals in the care of dementia

ABSTRACT Objective: To identify the knowledge and attitudes of doctors and nurses in tracking, diagnosing, treating, and monitoring dementias and their educational needs in this area. Method: Cross-sectional study, carried out among 195 doctors and 274 nurses working in teams of the Family Health Strategy (FHS) in the city of São Paulo. The instrument used was Health Care for Dementia: the Primary Care perspective. The data were submitted for descriptive statistics. Results: Among physicians, 64.1% reported routinely diagnosing dementia, but only 23.1% in the mild phase; 89.2% mentioned difficulties in identifying cases of the disease; 94.9%, difficulties in the treatment and monitoring of patients, including the needs to support the caregiver (28.2%); 84.6% of doctors and 79.2% of nurses reported difficulties in monitoring severe cases of the disease. Conclusion: Gaps in knowledge were identified regarding the tracking and diagnosis of dementia, patient monitoring, diagnostic information, and support for the caregiver.

Professional education on dementias in Primary Health Care: an integrative review

OBJECTIVE

To investigate the most commonly used educational approaches in dementia training for primary health care professionals.

METHOD

Integrative literature review, conducted between April and June of 2018, in PubMed, LILACS and IBECS databases. The descriptors used were: Training, Health Personnel, Dementia, Primary Health Care for PubMed; and the MeSH terms, Training Programs, Health Personnel, Dementia, and Primary Health Care for LILACS and IBECS.

RESULTS

The sample consisted of 13 articles; eight were published in the last five years (62%); seven articles with a quantitative approach (54%); seven articles produced on the European continent (54%), followed by five published on the North American continent (38%). All journals were from the health area (100%).

CONCLUSION

Educational strategies were combined and used for education. Significant improvements in knowledge, skills, and attitudes of the teams with regard to professional management of dementias were evidenced.

Identification of influencing factors and strategies to improve communication between general practitioners and community nurses: a qualitative focus group study

BACKGROUND

As the number of patients with complex healthcare needs grows, inter-professional collaboration between primary care professionals must be constantly optimized. General practitioners (GPs) and community nurses (CNs) are key professions in primary care; however, poor GP-CN communication is common, and research into the factors influencing its quality is limited.

OBJECTIVE

To explore patient-related GP-CN communication and facilitating and hindering factors, and to identify strategies to enhance this communication.

METHOD

A qualitative focus group design was used to identify the facilitating and hindering factors and strategies for improvement. In a Dutch primary care setting, 6 mono-professional focus group interviews (3 meetings of 13 GPs; 3 meetings of 18 CNs) were organized between June 2015 and April 2016, recorded and transcribed verbatim. Two independent researchers performed the coding of these interviews, identifying their categories and themes.

RESULTS

Results show that, despite the regular contact between GPs and CNs, communication was generally perceived as poor in effectiveness and efficiency by both professions. Mutual trust was considered the most important facilitating factor for effective communication. Profession-specific factors (e.g. differences in responsibility and profession-specific language) and organizational factors (e.g. lack of shared care plans, no in-person communication, lack of time) may be of influence on communication. Participants' suggestions for improvement included organizing well-structured and reimbursed team meetings and facilitating face-to-face contact.

CONCLUSION

GP-CN patient-related communication benefits most from trusting inter-personal relationships. Inter-professional training programmes should address both professional and organizational factors and should be evaluated for their effect on quality of care.

Longitudinal multiple case study on effectiveness of network-based dementia care towards more integration, quality of care, and collaboration in primary care

INTRODUCTION

This study aimed to provide insight into the merits of DementiaNet, a network-based primary care innovation for community-dwelling dementia patients.

METHODS

Longitudinal mixed methods multiple case study including 13 networks of primary care professionals as cases. Data collection comprised continuously-kept logs; yearly network maturity score (range 0-24), yearly quality of care assessment (quality indicators, 0-100), and in-depth interviews.

RESULTS

Networks consisted of median nine professionals (range 5-22) covering medical, care and welfare disciplines. Their follow-up was 1-2 years. Average yearly increase was 2.03 (95%-CI:1.20-2.96) on network maturity and 8.45 (95%-CI:2.80-14.69) on quality indicator score. High primary care practice involvement and strong leadership proved essential in the transition towards more mature networks with better quality of care.

DISCUSSION

Progress towards more mature networks favored quality of care improvements. DementiaNet appeared to be effective to realize transition towards network-based care, enhance multidisciplinary collaboration, and improve quality of dementia care.

Evaluation of DementiaNet, a network-based primary care innovation for community-dwelling patients with dementia: protocol for a longitudinal mixed methods multiple case study

INTRODUCTION

Primary healthcare professionals will increasingly be required to manage and optimise their treatment for patients with dementia. With DementiaNet, we aim to reduce the burden of dementia on healthcare services and society through implementation and facilitation of integrated network-based care with increased dementia expertise. DementiaNet is designed as a stepwise approach including clinical leadership, quality improvement cycles and interprofessional training, which are tailor-made to the local context. For example, the composition of the network and improvement goals are tailored to the local context and availability. Here, we describe the linked evaluation study which aims to provide insight in effectiveness, process and mechanism of the DementiaNet approach through an innovative evaluation design.

METHODS AND ANALYSIS

We designed a longitudinal, mixed methods, multiple case study. Study population consists of two levels: (i) local DementiaNet networks of primary care professionals and (ii) patients and informal caregivers who receive care from these networks. At the start and after 12 and 24 months, quantitative data are collected for each network on: level of network maturity, quality of care indicators and outcomes reported by informal caregivers of dementia patients. We assess changes in networks over time and the association with quality of care and informal caregiver-reported outcomes. Throughout the study, logs about each network are registered. Additionally, semi-structured interviews with network members and informal caregivers will provide insight in experiences and opinions regarding effects and mechanisms through which changes in quantitative outcomes are effectuated. Rich narratives will be constructed about the development of the local networks using collected data.

ETHICS AND DISSEMINATION

The study protocol was reviewed by the local medical ethics committee; formal judgement was not required (protocol number: 2015-2053). The findings of this study will be disseminated through peer-reviewed publications, conference presentations and presentations for healthcare professionals where appropriate.