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 Sanità
Istituto di Management
Scuola Superiore Sant’Anna - Pisa (Italy)
Background
The implementation of CCM in Tuscany Region (Italy)
Background
The implementation of CCM in Tuscany Region (Italy)
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 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?
Methods
The survey: The experience of chronic patients charged to the units
of “Sanità d’iniziativa” (Chronic Care Model).
Results
Interviews when
patient is at home
GPs and LHAs’ referents
List of patient
charged to the
GP's units
Sampling
Questionnaires
Computer Assisted
Telephone Interviews
Methods
Patient Experience Survey
About 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)
Methods - Notes
• 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• One unit withdrawn from the study, so the data refer to 55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.
Analisys
A descriptive analysis of main results in terms of outcome
and inter-professional collaboration
Indicators
Items
Outcomes
Since you are incharged by the team of chronic
Health
diseases’ surgery, do you think to have benefits
benefits
in terms of health? (Yes/No)
Since you are incharged by the team of chronic
Empowe
diseases’ surgery, are you able to better manage
rment
your chronic disease at home? (Yes/No)
Analisys – Main outcomes - Health Benefits
About 67.63% of patients got a benefit in terms of health.
60
74.0
62.5
62.0
37.5
38.0
69.1
20
40
percent
Since you are
incharged by the
team of chronic
diseases’ surgery, do
you think to have
benefits in terms of
health?
80
100
Range Yes: 74.0 – 62.0
0
26.0
30.9
less than 5
from 5 to 8 years
no
from 9 to 15 years more than 15 years
yes
p=0.000
length of illness
Analisys – Main outcomes - Empowerment
About 63.98% of patients has got a benefit in terms of health.
59.1
56.5
40.9
43.5
65.1
60
71.3
20
40
percent
Since you are
incharged by the
team of chronic
diseases’ surgery, are
you able to better
manage your chronic
disease at home?
80
100
Range Yes: 71.3 – 56.5
34.9
0
28.7
less than 5
from 5 to 8 years
no
from 9 to 15 years more than 15 years
yes
p=0.000
length of illness
Analisys
A descriptive analysis of main results in terms of outcome
and inter-professional collaboration
Indicator
Item
Interprofessional
collaboration
Team How would you rate GP and nurse working
working together?
Results – Inter-professional collaboration
60
percent
How would you rate
GP and nurse working
together?
80
100
About 11.96% of patients sees the GP after nursing consultations to be sure or
to get more information about what nurse has done.
86.0
90.5
86.0
20
40
90.5
0
p=0.001
11.9
7.7
1.8
2.1
no
yes
poor
medium
good
After seeing nurse, did you see your GP to be sure or to ask more
information about what nurse has done during consultation?
Analisys
Multilevel models describing variability of outcome and interprofessional collaboration across units.
Level 2: 55 SdI* units
Unit1
Unit2
Level 1: patients in units (range 18-172)
*Sanità di Iniziativa
Unitn
Analysis – Multilevel Modelling
Model 1
Dependent variable:
Health benefits
Explanatory 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
Model 2
Dependent variable:
Team Working
Explanatory 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
Results – Multilevel Model1 to explain health benefits (I)
health benefits
(odds ratio)
Fixed Part – Patient level
Cons
Age
Gender (male vs female)
Education (secondary school vs primary school)
Education (high school vs primary school)
Education (university vs primary school)
Health status (passable vs poor)
Health status (good vs poor)
Chronic disease (heart failure vs diabetes)
Lenght of chronic disease
°p<=0.05
*p<=0.01
0.089
0.996
1.082
1.008
0.812°
0.616°
1.839+
1.860+
0.978
0.980+
+p<=0.001
Results – Multilevel Model1 to explain health benefits (II)
health benefits
(odds ratio)
Fixed Part – Patient level
Information (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)
0.989
Team 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 (III)
1
2013
.5
3 15
10 54
18
4
6 8341214
5333427394511
19
40
50
1
41
24 512844
27
23 213629 4825
22
-.5
0
2
17 1637
31
32
43
52
38 464749
9 530553526
0
20
40
Rank of predicted unit random intercept
60
Results – Multilevel Model2 to explain team working(I)
Team working
(odds ratio)
Fixed Part – Patient level
Cons
Age
Gender (male vs female)
Education (secondary school vs primary school)
Education (high school vs primary school)
Education (university vs primary school)
Health status (passable vs poor)
Health status (good vs poor)
Chronic disease (heart failure vs diabetes)
Lenght of chronic disease
°p<=0.05
*p<=0.01
0.992
1.014
1.556+
1.257°
2.150+
1.202
1.169
1.012
0.993
+p<=0.001
Results – Multilevel Model2 to explain team working (II)
PECIndicator
Fixed Part – Patient level
Seeing doctor after nursing consultation
GP and nurse are informed about Specialist visit results
Discordant information from GP, nurse and specialist
0.556+
1.422+
0.529*
Hospital level: σ2u
0.151
°p<=0.05
*p<=0.01
+p<=0.001
1.5
Analisys – Multilevel Model1 to explain team working (III)
21
1
41 10
42
51
3836
16
40
-1
-.5
0
.5
9
19
6 15 5345
4
2 822 52
4443
14
24
55
20
1 7 4613 12
18
31 504854
2825 29 47
34
33
235 322711 26
173735
3 3949
30
0
20
40
Rank of predicted unit random intercept
60
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 Murante
a.murante@sssup.it
Laboratorio Management e Sanità
Istituto di Management
Scuola Superiore Sant’Anna di Pisa (Italy)