Assessing the Strengths and Weaknesses for Implementing a Place-Based Model of Care for Older People on the Central Coast, Australia: Results of a Pilot Project Using the Population Health Management Maturity Index (PHM-MI) Tool.

Introduction: Population health management is increasingly being used to support place-based models of care. This case study provides an account of the use of the Population Health Management - Maturity Index (PHM-MI) tool to inform the future development of a neighbourhood model of care for older people in the Central Coast region of Australia.

Description: The PHM-MI tool comprises a set of six evidence-informed elements known to be important in enabling PHM in practice.

Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care.

The rise in health care costs, caused by older and more complex patient populations, requires Population Health Management approaches including risk stratification. With risk stratification, patients are assigned individual risk scores based on medical records. These patient stratifications focus on future high costs and expensive care utilization such as hospitalization, for which different models exist.

Reforming healthcare in the Netherlands: practical population health management and the Plot model: A questionnaire survey and focus group study to assess the willingness and readiness of six regions in the Netherlands.

Objective: As in many other countries, the Netherlands is facing challenges in the provision of healthcare to its population. To ensure the population remains in good health in coming decades, an integrative approach to the many factors that influence health and health outcomes is needed. Population health management is gaining interest as a strategic framework for systems change in healthcare organisations.

A methodological framework for evaluating transitions in acute care services in the Netherlands to achieve Triple Aim.

Objective: The accessibility of acute care services is currently under pressure, and one way to improve services is better integration. Adequate methodology will be required to provide for a clear and accessible evaluation of the various intervention initiatives. The aim of this paper is to develop and propose a Population Health Management(PHM) methodology framework for evaluation of transitions in acute care services.

Identifying complex patients using Adjusted Clinical Groups risk stratification tool.

Objectives: To produce an efficient and practically implementable method, based on primary care data exclusively, to identify patients with complex care needs who have problems in several health domains and are experiencing a mismatch of care. The Johns Hopkins ACG System was explored as a tool for identification, using its Aggregated Diagnosis Group (ADG) categories.

Study Design: Retrospective cross-sectional study using general practitioners' electronic health records combined with hospital data.

The Value of Merging Medical Data from Ambulance Services and General Practice Cooperatives Using Triple Aim Outcomes.

Background: Acute care services are currently overstretched in many high income countries. Overcrowding also plays a major role in acute care in the Netherlands. In a region of the Netherlands, the general practice cooperative (GPC) and ambulance service have begun to integrate their care, and the rapid and complete transfer of information between these two care organisations is now the basis for delivering appropriate care.

A systematic review of risk stratification tools internationally used in primary care settings.

Background And Aims: In our current healthcare situation, burden on healthcare services is increasing, with higher costs and increased utilization. Structured population health management has been developed as an approach to balance quality with increasing costs. This approach identifies sub-populations with comparable health risks, to tailor interventions for those that will benefit the most.

Effect of COVID-19 on health system integration in the Netherlands: a mixed-methods study.

Objectives: Overcrowding in acute care services gives rise to major problems, such as reduced accessibility and delay in treatment. In order to be able to continue providing high-quality health care, it is important that organizations are well integrated at all organizational levels. The objective of this study was to to gain an understanding in which extent cooperation within an urban acute care network in the Netherlands (The Hague) improved because of the COVID-19 crisis.

Assessment of the Adjusted Clinical Groups system in Dutch primary care using electronic health records: a retrospective cross-sectional study.

Background: Within the Dutch health care system the focus is shifting from a disease oriented approach to a more population based approach. Since every inhabitant in the Netherlands is registered with one general practice, this offers a unique possibility to perform Population Health Management analyses based on general practitioners' (GP) registries. The Johns Hopkins Adjusted Clinical Groups (ACG) System is an internationally used method for predictive population analyses.

Understanding people who self-referred in an emergency department with primary care problems during office hours: a qualitative interview study at a Daytime General Practice Cooperative in two hospitals in The Hague, The Netherlands.

Objective: To provide insight into the motives for hospital self-referral during office hours and the barriers deterring general practitioner (GP) consultation with a primary care request.

Setting: People who self-referred at a Daytime General Practice Cooperative (GPC) in two hospitals in The Hague, The Netherlands.

Participants: A total of 44 people who self-referred were interviewed in two hospitals.

An Approach to measuring Integrated Care within a Maternity Care System: Experiences from the Maternity Care Network Study and the Dutch Birth Centre Study.

Introduction: Integrated care is considered to be a means to reduce costs, improve the quality of care and generate better patient outcomes. At present, little is known about integrated care in maternity care systems. We developed questionnaires to examine integrated care in two different settings, using the taxonomy of the Rainbow Model of Integrated Care.

Typology of birth centres in the Netherlands using the Rainbow model of integrated care: results of the Dutch Birth Centre Study.

Background: The goal of integrated care is to offer a continuum of care that crosses the boundaries of public health, primary, secondary, and tertiary care. Integrated care is increasingly promoted for people with complex needs and has also recently been promoted in maternity care systems to improve the quality of care. Especially when located near an obstetric unit, birth centres are considered to be ideal settings for the realization of integrated care.

Barriers and facilitators influencing self-management among COPD patients: a mixed methods exploration in primary and affiliated specialist care.

Self-management is becoming increasingly important in COPD health care although it remains difficult to embed self-management into routine clinical care. The implementation of self-management is understood as a complex interaction at the level of patient, health care provider (HCP), and health system. Nonetheless there is still a poor understanding of the barriers and effective facilitators.

Value-based integrated (renal) care: setting a development agenda for research and implementation strategies.

Background: Integrated care services are considered a vital strategy for improving the Triple Aim values for people with chronic kidney disease. However, a solid scholarly explanation of how to develop, implement and evaluate such value-based integrated renal care services is limited. The aim of this study was to develop a framework to identify the strategies and outcomes for the implementation of value-based integrated renal care.

Collaboration processes and perceived effectiveness of integrated care projects in primary care: a longitudinal mixed-methods study.

Background: Collaborative partnerships are considered an essential strategy for integrating local disjointed health and social services. Currently, little evidence is available on how integrated care arrangements between professionals and organisations are achieved through the evolution of collaboration processes over time. The first aim was to develop a typology of integrated care projects (ICPs) based on the final degree of integration as perceived by multiple stakeholders.

The Dutch Birth Centre Study: study design of a programmatic evaluation of the effect of birth centre care in the Netherlands.

Background: Birth centres are regarded as settings where women with uncomplicated pregnancies can give birth, assisted by a midwife and a maternity care assistant. In case of (threatening) complications referral to a maternity unit of a hospital is necessary. In the last decade up to 20 different birth centres have been instituted in the Netherlands.

Towards an international taxonomy of integrated primary care: a Delphi consensus approach.

Background: Developing integrated service models in a primary care setting is considered an essential strategy for establishing a sustainable and affordable health care system. The Rainbow Model of Integrated Care (RMIC) describes the theoretical foundations of integrated primary care. The aim of this study is to refine the RMIC by developing a consensus-based taxonomy of key features.

Towards a taxonomy for integrated care: a mixed-methods study.

Introduction: Building integrated services in a primary care setting is considered an essential important strategy for establishing a high-quality and affordable health care system. The theoretical foundations of such integrated service models are described by the Rainbow Model of Integrated Care, which distinguishes six integration dimensions (clinical, professional, organisational, system, functional and normative integration). The aim of the present study is to refine the Rainbow Model of Integrated Care by developing a taxonomy that specifies the underlying key features of the six dimensions.

Exploring the success of an integrated primary care partnership: a longitudinal study of collaboration processes.

Background: Forming partnerships is a prominent strategy used to promote integrated service delivery across health and social service systems. Evidence about the collaboration process upon which partnerships evolve has rarely been addressed in an integrated-care setting. This study explores the longitudinal relationship of the collaboration process and the influence on the final perceived success of a partnership in such a setting.

Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care.

Introduction: Primary care has a central role in integrating care within a health system. However, conceptual ambiguity regarding integrated care hampers a systematic understanding. This paper proposes a conceptual framework that combines the concepts of primary care and integrated care, in order to understand the complexity of integrated care.

Ethnic differences in antenatal care use in a large multi-ethnic urban population in the Netherlands.

Objective: to determine differences in antenatal care use between the native population and different ethnic minority groups in the Netherlands.

Design: the Generation R Study is a multi-ethnic population-based prospective cohort study.

Setting: seven midwife practices participating in the Generation R Study conducted in the city of Rotterdam.

Intensified preventive care to reduce cardiovascular risk in healthcare centres located in deprived neighbourhoods: a randomized controlled trial.

Background: We examined the effectiveness of a structured collaboration in general practice between a practice nurse, a peer health educator, the general practitioner (GP) and a GP assistant in providing intensified preventive care for patients at high risk of developing cardiovascular diseases.

Design: A randomized controlled trial in three healthcare centres (18 GPs) in deprived neighbourhoods of two major Dutch cities.

Methods: Two hundred seventy-five high-risk patients (30-70 years) from various ethnic groups were randomized to intervention (n=137) or usual care group (n=138).

Different distribution of cardiovascular risk factors according to ethnicity: a study in a high risk population.

This study compares the distribution of cardiovascular risk factors in different ethnic groups at high risk of developing cardiovascular diseases within general practices. A total of 430 patients (179 Dutch, 126 Turks, 50 Surinamese, 23 Moroccans, 23 Antilleans and 29 from other ethnic groups) were included in the study. Data collection consisted of questionnaires and physical and clinical examinations.

Process evaluation of an intensified preventive intervention to reduce cardiovascular risk in general practices in deprived neighbourhoods.

Background: A RCT, conducted to examine the effectiveness of a structured collaboration in general practice to provide intensified preventive care in patients at high cardiovascular risk yielded no effect in the total group but differences across healthcare centres and ethnic groups become apparent. We conducted a process evaluation to explain these differences.

Methods: We assessed the reach of the target group and whether key intervention components (individual educational sessions, structured team meetings, and risk assessments) were performed as planned (maximum score for protocol completion is 11).