Inter-professional collaboration in Chronic Care Model and its effect on outcomes of care.

1. 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)

2. Background The implementation of CCM in Tuscany Region (Italy) Just started

3. 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

4. The study Health care professionals working together in multidisciplinary teams could improve both processes and outcomes of care of chronic diseases. (Wagner, 2000)

5. The research question Does Inter-professional collaboration influences clinical and behavioral outcomes?

6. 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 Questionnaires Computer Assisted Telephone Interviews Sampling

7. 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

8. Methods The Chronic Patient Experience Questionnaire (ChroPEQ) 8 sections 56 questions

9. Methods - Notes • Patient engaged in the pilot stage were included in the study • One unit withdrawn from the study, so the data refer to 55 units.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.

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

11. Analisys – Main outcomes - Health Benefits About 67.63% of patients got a benefit in terms of health. 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? p=0.000 length of illness

12. Analisys – Main outcomes - Empowerment About 63.98% of patients has got a benefit in terms of health. Range Yes: 71.3 – 56.5 Since you are incharged by the team of chronic diseases’ surgery, are you able to better manage your chronic disease at home? p=0.000 length of illness

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

14. Results – Inter-professional collaboration About 11.96% of patients sees the GP after nursing consultations to be sure or to get more information about what nurse has done. How would you rate GP and nurse working together? 86.0 90.5 p=0.001 After seeing nurse, did you see your GP to be sure or to ask more information about what nurse has done during consultation?

15. Analisys Multilevel models describing variability of outcome and inter-professional collaboration across units. Level 2: 55 SdI* units Unit1 Unit2 Unitn Level 1: patients in units (range 18-172) *Sanità di Iniziativa

16. Analysis – Multilevel Modelling • Model 1 • Dependent variable: • Health benefits • Explanatory variables: • Age • Gender • Education • Health status • Chronicdisease • Lenghtofchronicdisease • Information (monitoring, food, weight, …) • Procedures (bloodpressure,glycemia, …) • Trust in nurse • Team working • Model 2 • Dependent variable: • Team Working • Explanatory variables: • Age • Gender • Education • Health status • Chronicdisease • Lenghtofchronicdisease • Seeing doctor after nursing consultation • GP and nurse are informed about Specialist visit results • Discordant information from GP, nurse and specialist

17. Results – Multilevel Model1 to explain health benefits (I) °p<=0.05 *p<=0.01 +p<=0.001

18. Results – Multilevel Model1 to explain health benefits (II) °p<=0.05 *p<=0.01 +p<=0.001

19. Results – Multilevel Model1 to explain health benefits (III)

20. Results – Multilevel Model2 to explain team working(I) °p<=0.05 *p<=0.01 +p<=0.001

21. Results – Multilevel Model2 to explain team working (II) °p<=0.05 *p<=0.01 +p<=0.001

22. Analisys – Multilevel Model1 to explain team working (III)

23. 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

24. 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

25. Conclusions The patient’s confidence, compliance and empowerment will increase as quality, effectiveness and efficiency of management of chronic diseases will improve.

26. 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)