Inter-professional collaboration in Chronic Care Model and its effect on outcomes of care. Findings from a patient experience survey.

Anna Maria Murante and Sabina Nuti, Laboratorio Management e SanitàIstituto di ManagementScuola Superiore Sant’Anna - Pisa (Italy)

Background

Just

sta

rted

The implementation of CCM in Tuscany Region (Italy)

Background

In 2011 the 1th extension stage was concluded, about 2 units were created in each community area and more than 30% of LHAs’ residents were engaged

In 2012 CEOs are expected to work in order to achieve the following objective: more than 40% of residents in charged by GPs involved in CCM units

The implementation of CCM in Tuscany Region (Italy)

The study

Health care professionals working

together in multidisciplinary teams

could improve both processes and

outcomes of care of chronic diseases.(Wagner, 2000)

The research question

Does Inter-professional collaboration influences clinical and behavioral outcomes?

List of patient charged to the GP's units

Computer Assisted Telephone Interviews

Results

Sampling

Interviews when patient is at

home GPs and LHAs’ referents

Questionnaires

The survey: The experience of chronic patients charged to the units of “Sanità d’iniziativa” (Chronic Care Model).

Methods

Patient Experience SurveyAbout 6.600 patients, charged to 56 GPs’ units in 11 Local Health Authorities in Tuscany Region have been interviewed in the period February-July 2012 .

The random sample (representative at unit level) was extracted among the patients’ list provided by GPs of SdI* units: patients with only diabetes or heart failure were included.

A CATI interview was administered by using The Chronic Patient Experience Questionnaire (ChroPEQ) developed by the MES Lab with the support of Managers of Tuscany Health System and national and international experts on CCM.

*Sanità di Iniziativa

Methods

The Chronic Patient Experience Questionnaire (ChroPEQ)

8 sect

ions

56 ques

tions

Methods

•Patient engaged in the pilot stage were included in the study

•One unit withdrawn from the study, so the data refer to 55 units.•Questionnaire was only filled by patients who said to be assisted by both nurse and GP.

Methods - Notes

A descriptive analysis of main results in terms of outcome and inter-professional collaboration

Analisys

Analisys – Main outcomes - Health Benefits

26.0

74.0

30.9

69.1

37.5

62.5

38.0

62.0

02

04

06

08

01

00p

erce

nt

less than 5 from 5 to 8 years from 9 to 15 years more than 15 years

no yes

Range Yes: 74.0 – 62.0

Since you are incharged by the team of chronic diseases’ surgery, do you think to have benefits in terms of health?

length of illnessp=0.000

About 67.63% of patients got a benefit in terms of health.

Analisys – Main outcomes - Empowerment

28.7

71.3

34.9

65.1

40.9

59.1

43.5

56.5

02

04

06

08

01

00p

erce

nt

less than 5 from 5 to 8 years from 9 to 15 years more than 15 years

no yes

Since you are incharged by the team of chronic diseases’ surgery, are you able to better manage your chronic disease at home?

length of illnessp=0.000

Range Yes: 71.3 – 56.5

About 63.98% of patients has got a benefit in terms of health.

A descriptive analysis of main results in terms of outcome and inter-professional collaboration

Analisys

Results – Inter-professional collaboration

1.8

7.7

90.5

2.1

11.9

86.0

02

04

06

08

01

00p

erce

nt

no yes

poor medium good

How would you rate GP and nurse working together?

After seeing nurse, did you see your GP to be sure or to ask more information about what nurse has done during consultation?

p=0.001

About 11.96% of patients sees the GP after nursing consultations to be sure or to get more information about what nurse has done.

90.5 86.0

Unitn

Level 2: 55 SdI* units

Level 1: patients in units (range 18-172)

Unit2

Unit1

*Sanità di Iniziativa

Multilevel models describing variability of outcome and inter-professional collaboration across units.

Analisys

Model 1Dependent variable:Health benefitsExplanatory variables:•Age•Gender•Education•Health status •Chronic disease•Lenght of chronic disease•Information (monitoring, food, weight, …)

•Procedures (blood

pressure,glycemia, …)•Trust in nurse•Team working

Analysis – Multilevel ModellingModel 2Dependent variable:Team WorkingExplanatory variables:•Age•Gender•Education•Health status •Chronic disease•Lenght of chronic disease•Seeing doctor after nursing consultation•GP and nurse are informed about Specialist visit results•Discordant information from GP, nurse and specialist

health benefits (odds ratio)

Fixed Part – Patient levelCons 0.089Age 0.996Gender (male vs female) 1.082Education (secondary school vs primary school) 1.008Education (high school vs primary school) 0.812°Education (university vs primary school) 0.616°Health status (passable vs poor) 1.839+

Health status (good vs poor) 1.860+

Chronic disease (heart failure vs diabetes) 0.978Lenght of chronic disease 0.980+

Results – Multilevel Model1 to explain health benefits (I)

°p<=0.05 *p<=0.01 +p<=0.001

health benefits (odds ratio)

Fixed Part – Patient levelInformation (monitoring, food, weight, physical exercises) 1.445+

Procedures (blood pressure,glycemia, foot control, weight and waistline) 1.581+

Trust in nurse 1.782°Team working (poor vs very poor rates) 0.989Team working (medium vs very poor rates) 5.537*Team working (good vs very poor rates) 7.804*Team working (very good vs very poor rates) 11.385+

Unit level: σ2u .099

°p<=0.05 *p<=0.01 +p<=0.001

Results – Multilevel Model1 to explain health benefits (II)

Results – Multilevel Model1 to explain health benefits (III)

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0 20 40 60Rank of predicted unit random intercept

Team working (odds ratio)

Fixed Part – Patient levelConsAge 0.992Gender (male vs female) 1.014Education (secondary school vs primary school) 1.556+

Education (high school vs primary school) 1.257°Education (university vs primary school) 2.150+

Health status (passable vs poor) 1.202Health status (good vs poor) 1.169Chronic disease (heart failure vs diabetes) 1.012Lenght of chronic disease 0.993°p<=0.05 *p<=0.01 +p<=0.001

Results – Multilevel Model2 to explain team working(I)

PECIndicator

Fixed Part – Patient levelSeeing doctor after nursing consultation 0.556+

GP and nurse are informed about Specialist visit results 1.422+

Discordant information from GP, nurse and specialist 0.529*

Hospital level: σ2u 0.151

°p<=0.05 *p<=0.01 +p<=0.001

Results – Multilevel Model2 to explain team working (II)

Analisys – Multilevel Model1 to explain team working (III)

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0 20 40 60Rank of predicted unit random intercept

Conclusions (I)

Results confirm that health benefits increase when:

•patients are completely informed about a correct style of life

•guidelines are applied in the follow up visits

•Patients trust nurse (!!!)

•GP and nurse work well together

Conclusions (II)

Results confirm that the patient’s perception of how GP and nurse work together is explained by the extent to which :

• patients trust nurse’s work

• informational continuity of care (Specialist -> GP and nurse)

• coordination

Conclusions

The patient’s confidence, compliance and empowerment will increase as quality,

effectiveness and efficiency of management of chronic diseases will improve.

Thanks for your attention!

Anna Maria Murantea.murante@sssup.itLaboratorio Management e SanitàIstituto di ManagementScuola Superiore Sant’Anna di Pisa (Italy)