Van protocollaire ketenzorg naar persoonsgerichte chronische zorg in de huisartsenpraktijk (COPILOT)

Aim: To develop a proactive person-centered care approach for persons with (multiple) chronic diseases in general practice, and to explore the impact on ‘Quadruple aims’: experiences of patients and professionals, patient outcomes and costs of resources use.

Background: The management of people with multiple chronic diseases challenges healthcare systems designed around single diseases. Patients with multimorbidity often receive highly fragmented care that may lead to inefficient, ineffective, and potentially harmful treatments and neglect of essential health needs. A more comprehensive, person-centered approach is advocated for persons with multiple morbidities. However, examples on how to provide more person-centered care and evidence of its impact are scarce. A group of Dutch general practitioners (GPs) took the initiative to develop such a care approach.

Methods/Design: Mixed methods with a development and pilot-testing phase. The proactive person-centered approach will be developed using an action-based research design consisting of multiple plan-act-observe-reflect-adjust-cycles. In each cycle experiences of patients and primary care professionals from 10 practices will be collected via interviews, observations and focus groups. Starting point for the first cycle is a ‘person-centered consultation’ of up to one hour in which the GP discusses the health status and health care needs of the patient. Furthermore, shared decisions between GP and patient are made on treatment goals and follow up. In the pilot-test phase a nested case cohort study allows to explore the impact of the new approach on ‘Quadruple aim’ outcomes comparing persons with and without exposure to the new care approach.

Discussion: This study will provide a proactive person-centered approach for persons with multimorbidity in primary care, and estimate its potential impact on quadruple outcomes.

Keywords: Chronic diseases, General Practice, multimorbidity, person-centered care, primary care, Quadruple aim, action-based research