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

3. 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)

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. 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

7. 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

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

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 Patient engaged in the pilot stage were included in the study One unit withdrawn from the study, so the data refer to 55 units.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

10. Indicators Items Outcomes Health benefits Since you are incharged by the team of chronic diseases’ surgery, do you think to have benefits in terms of health? (Yes/No) Empowe rment Since you are incharged by the team of chronic diseases’ surgery, are you able to better manage your chronic disease at home? (Yes/No) A descriptive analysis of main results in terms of outcome and inter-professional collaboration Analisys

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

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

13. Indicator Item Inter- professional collaboration Team working How would you rate GP and nurse working together? A descriptive analysis of main results in terms of outcome and inter-professional collaboration Analisys

14. Results – Inter-professional collaboration 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

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

16. 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 Analysis – Multilevel Modelling 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

17. health benefits (odds ratio) Fixed Part – Patient level Cons0.089 Age0.996 Gender (male vs female)1.082 Education (secondary school vs primary school)1.008 Education (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) 0.978 Lenght of chronic disease0.980 + Results – Multilevel Model1 to explain health benefits (I) °p<=0.05*p<=0.01 + p<=0.001

18. 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 nurse1.782° 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: σ 2 u.099 °p<=0.05*p<=0.01 + p<=0.001 Results – Multilevel Model1 to explain health benefits (II)

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

20. Team working (odds ratio) Fixed Part – Patient level Cons Age0.992 Gender (male vs female)1.014 Education (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)1.202 Health status (good vs poor)1.169 Chronic disease ( heart failure vs diabetes) 1.012 Lenght of chronic disease0.993 °p<=0.05*p<=0.01 + p<=0.001 Results – Multilevel Model2 to explain team working(I)

21. PECIndicator Fixed Part – Patient level Seeing doctor after nursing consultation0.556 + GP and nurse are informed about Specialist visit results1.422 + Discordant information from GP, nurse and specialist0.529* Hospital level: σ 2 u 0.151 °p<=0.05*p<=0.01 + p<=0.001 Results – Multilevel Model2 to explain team working (II)

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)