Complex primary care for multimorbid patients in the Netherlands: Interprofessional perspectives within and beyond general practice.

Many consultations in general practice concern patients with multimorbidity, pressuring our healthcare systems with complex care needs. The number of people affected from multimorbidity is still increasing, as is the average number of co-occurring diseases per patient. The resulting complexity of care needs cannot be managed by health professionals from a single discipline, but requires interprofessional collaborative practice.

Adjusting advance care planning to older people's needs: results from focus groups and interviews.

Background: Advance care planning (ACP) is becoming increasingly important in medical care. Some suggest standardized approaches to initiate ACP with all older adults. However, the idea of patient-centered care suggests more nuanced approaches tailored to individual older adults' needs.

How to use experience-sampling technology to understand daily functioning: A practical guide for mental health professionals.

Satisfying daily life functioning is essential in mental healthcare. Standard assessments focus on symptoms and are designed to detect underlying vulnerabilities. However, they offer insufficient insight into patterns of contextual variability and resilience.

Seeing the patient as a person in interprofessional health professions education.

Increasing prevalence of chronic disease leads to an increased need for person-centered care. To prepare future health professionals for this need, educational institutions provide interprofessional education in which they actively involve patients (hereafter called experts by experience). The organization of inter-institutional, interprofessional education with the active involvement of experts by experience poses challenges.

Pre-Diagnostic Symptoms of Young-Onset Dementia in the General Practice up to Five Years Before Diagnosis.

Background: Young-onset dementia (YOD) has many underlying etiologies, leading to a large heterogeneity in first symptoms. This makes it difficult for general practitioners (GPs) to recognize YOD.

Objective: Identify early symptoms that are more common in the pre-diagnostic phase of YOD.

Reaching consensus on GP interprofessional competencies: a nominal group study.

Background: As the requirements for collaboration in primary care increase, effective interprofessional teamwork between GPs and other primary care professionals is crucial. The need for more training in interprofessional collaborative competencies is widely recognised. However, existing competency frameworks do not sufficiently specify interprofessional collaboration to guide interprofessional competency development.

Involving patients in undergraduate health professions education: What's in it for them?

Objectives: Patients have become more involved in research, policy, and health professions education. They are involved in teaching students competencies required for person-centred care, but patient benefits have not received proper attention. This exploratory study identifies how patient involvement in health professions education help patients to practice self-management and shared decision-making.

Factors That Influence the Use of Electronic Diaries in Health Care: Scoping Review.

Background: A large number of people suffer from psychosocial or physical problems. Adequate strategies to alleviate needs are scarce or lacking. Symptom variation can offer insights into personal profiles of coping and resilience (detailed functional analyses).

Patient involvement in interprofessional education: A qualitative study yielding recommendations on incorporating the patient's perspective.

Background: Patient involvement in interprofessional education (IPE) is a new approach in fostering person-centeredness and collaborative competencies in undergraduate students. We developed the Patient As a Person (PAP-)module to facilitate students in learning from experts by experience (EBEs) living with chronic conditions, in an interprofessional setting. This study aimed to explore the experiences of undergraduate students, EBEs and facilitators with the PAP-module and formulate recommendations on the design and organization of patient involvement in IPE.

Implementing Experience Sampling Technology for Functional Analysis in Family Medicine - A Design Thinking Approach.

Background: A paradigm shift in health care from illness to wellbeing requires new assessment technologies and intervention strategies. Self-monitoring tools based on the Experience Sampling Method (ESM) might provide a solution. They enable patients to monitor both vulnerability and resilience in daily life.

Suitability of a Programme for Improving Interprofessional Primary Care Team Meetings.

Introduction: Primary care is increasingly being confronted with complex health care demands stemming from both biomedical and psychosocial problems of people with chronic diseases. Interprofessional collaboration is needed to enhance person-centredness and coordinate care provision in an efficient manner, which should eventually result in high-quality and integrated care. In primary care, collaboration often occurs through periodic interprofessional team (IPT) meetings.

Development of a conversation approach for practice nurses aimed at making shared decisions on goals and action plans with primary care patients.

Background: Primary care nurses play a crucial role in setting personal goals and action plans together with chronically ill patients. This may be a challenge for practice nurses, who are often trained to adopt protocol-based work routines. The aim of this study was to systematically develop a conversation approach, and a corresponding training course, for practice nurses aimed at making shared decisions about goals and actions with their chronically ill patients.

[Timely consideration of future care; advance care planning for people with intellectual disabilities].

People with intellectual disabilities (IDs) are often unable to decide for themselves regarding complex medical decisions, and need assistance from representatives, often next-of-kin. People with IDs are often frail. This frailty is characterized on the one hand by health problems, on the other hand by significant limitations in both intellectual functioning and in adaptive behaviour.

Development of a Customizable Programme for Improving Interprofessional Team Meetings: An Action Research Approach.

Introduction: Interprofessional teamwork is increasingly necessary in primary care to meet the needs of people with complex care demands. Needs assessment shows that this requires efficient interprofessional team meetings, focusing on patients' personal goals. The aim of this study was to develop a programme to improve the efficiency and patient-centredness of such meetings.

What makes it so difficult for nurses to coach patients in shared decision making? A process evaluation.

Background: Primary care nurses play a crucial role in coaching patients in shared decision making about goals and actions. This presents a challenge to practice nurses, who are frequently used to protocol-based working routines. Therefore, an approach was developed to support nurses to coach patients in shared decision making.

Disentangling self-management goal setting and action planning: A scoping review.

Introduction: The ongoing rise in the numbers of chronically ill people necessitates efforts for effective self-management. Goal setting and action planning are frequently used, as they are thought to support patients in changing their behavior. However, it remains unclear how goal setting and action planning in the context of self-management are defined in the scientific literature.

Interprofessional primary care team meetings: a qualitative approach comparing observations with personal opinions.

Background: The number of people with multiple chronic conditions requiring primary care services increases. Professionals from different disciplines collaborate and coordinate care to deal with the complex health care needs. There is lack of information on current practices regarding interprofessional team (IPT) meetings.

"They Are Talking About Me, but Not with Me": A Focus Group Study to Explore the Patient Perspective on Interprofessional Team Meetings in Primary Care.

Background: The number of people with multiple chronic conditions receiving primary care services is growing. To deal with their increasingly complex health care demands, professionals from different disciplines need to collaborate. Interprofessional team (IPT) meetings are becoming more popular.

Sustainable interprofessional teamwork needs a team-friendly healthcare system: Experiences from a collaborative Dutch programme.

The significance of effective interprofessional teamwork to improve the quality of care has been widely recognised. Effective interprofessional teamwork calls on good collaboration between professionals and patients, coordination between professionals, and the development of teamwork over time. Effective development of teams also requires support from the wider organisational context.

Successful participation of patients in interprofessional team meetings: A qualitative study.

Background: The number of people with multiple chronic conditions increases as a result of ageing. To deal with the complex health-care needs of these patients, it is important that health-care professionals collaborate in interprofessional teams. To deliver patient-centred care, it is often recommended to include the patient as a member of the team.

Developing interprofessional care plans in chronic care: a scoping review.

Background: The number of people suffering from one or more chronic conditions is rising, resulting in an increase in patients with complex health care demands. Interprofessional collaboration and the use of shared care plans support the management of complex health care demands of patients with chronic illnesses. This study aims to get an overview of the scientific literature on developing interprofessional shared care plans.

Patients' readiness to receive psychosocial care during nurse-led routine diabetes consultations in primary care: A mixed methods study.

Background: Patients with type 2 diabetes mellitus face several emotional and social consequences of their chronic illness in their everyday life. Symptoms of distress and depression are prevalent. For providing psychosocial self-management support, nurses in primary care were trained to identify patients with psychosocial problems during routine medically-shaped diabetes consultations.

What does it take to set goals for self-management in primary care? A qualitative study.

Background: There is an increasing number of patients with a chronic illness demanding primary care services. This demands for effective self-management support, including collaborative goal setting. Despite the fact that primary care professionals seem to have difficulties implementing goal setting, little information is available about the factors influencing the complexity of this process in primary care.

Interprofessional collaboration regarding patients' care plans in primary care: a focus group study into influential factors.

Background: The number of people with multiple chronic conditions demanding primary care services is increasing. To deal with the complex health care demands of these people, professionals from different disciplines collaborate. This study aims to explore influential factors regarding interprofessional collaboration related to care plan development in primary care.

Lessons learnt from a cluster-randomised trial evaluating the effectiveness of Self-Management Support (SMS) delivered by practice nurses in routine diabetes care.

Objective: To evaluate the effectiveness of biopsychosocial Self-Management Support (SMS) delivered by practice nurses in routine diabetes care.

Design: A pragmatic cluster-randomised controlled trial within a hybrid effectiveness-implementation study design. Practice nurses were cluster-randomised.