Insights from stakeholders, the stratification process and assessment.


  1. Different perceptions  

    Perceptions between managers, frontline staff and patients do not always match

    These differences were not as simple as one group being more positive than the other. There were notable differences in staff engagement in particular areas. Frontline staff have a good understanding of the benefits associated with the integrated care. This was underestimated by programme managers. Managers, however, have a more positive view on the impact of workforce development activities than frontline staff. For patients, their views and experiences were significantly influenced by the organisational setup. There is an increasing interest from patients to take more responsibility for their health.

Stakeholder Insights - Organisation

  1. Influence on patient experience and views

    Organisational set-up does influence the views and experiences of patients

    Patients are more likely to agree that participation improves their level of care. Especially if it includes: - What this demand of urgent care means?
    - Some form of self management.
    - Self care or patient empowerment.
    - Patient satisfaction with communication channels.
    - Shared decision making.

    - A committee that represents the views of patients and/or carers.

  2. Predicts outcomes

    Organisational set-up does predict outcomes in many instances

    Staff hold more positive views when training is tailored to their needs. Especially when their views are evaluated, and rewards are given for good service. Training and staff development is seen as positive. Although patients and trainers view some courses as time consuming and demanding. Cost saving and justifying business cases are sometimes at odds with the ethos of the healthcare organisation.

    As the future direction of their organisation, staff agree that their programme will bring long-term benefits. Particularly when the following elements are in place:

    - Implementation barriers identified.

    - Regular evaluation of staff awareness.

  3. Influence on manager and staff experience and views

    Organisational set-up does influence the views and experiences of programme managers and staff

    Programme managers have more positive views on organisational support, change, implementation and programme benefits. This suggests that healthcare organisations must do more to engage staff at all levels. Not just those in managerial positions. Managers think the programme fits in with the broader aims and objectives of their organisation.

Stakeholder Insights - Staff Engagement

  1. Staff engagement is key to patient adherence

    Successful patient adherence happens when staff are engaged

    According to the ACT project, patients appreciate a unique reference person to coordinate their healthcare. A dedicated contact person is considered both important and helpful. 

    Frontline staff need to be more aware of the strategies for promoting patient adherence. This also helps keep participants well informed about the primary goals of the programme. It also increases the probability that it will stabilise or improve their health. Now, and in the future.

    Successful promotion of patient engagement in the programmes requires more staff, and more staff time allocation.

  2. Staff engagement is not simply achieved

    There is no single intervention that will, on its own, ensure staff engagement

    The ACT project reveals that staff engagement is a complex element of change management. It is not reliant on one single intervention. A range of different interventions need to be put in place. This will ensure that staff feel engaged with the project. 

    ACT has reinforced findings from previous studies. These suggest staff engagement requires factors such as:
    - Comprehensive workforce development.
    - Clarity on project aim and benefits.
    - Regular 360° communications.
    - Have a single reference contact person for the programme.

    Feedback from qualitative and quantitative data reinforces the conclusion that staff engagement is complex. Findings from ACT suggest a holistic approach. This will ensure a high level of staff engagement. There is no ‘silver bullet’. The approach should encompass all key elements. Especially those identified as being important to staff engagement. These key factors have limited impact in isolation. When used as part of a package of techniques, they work in synergy to optimize benefits, including elements like workforce development, communication and staff involvement in programme design.

    There were no obvious patterns or drivers identified. Suggesting a more complex picture. Qualitative data from staff support this complexity, and their perception of engagement. Instead of one issue of importance, staff report a range of factors.

  3. Staff engagement varies significantly

    Levels of staff engagement vary significantly

    The ACT project revealed the need to identify and work out frequent mismatches in perception, between programme managers and staff, about levels of staff engagement.

    Variations in levels of staff engagement between programmes is expected. This is particularly true for the programmes analysed, which are of varying sizes, scopes and settings. They also utilise different modalities of care at separate stages of their development. Even so, the study suggests that the success of staff engagement varies across different programmes.

    There are different views between staff and managers on the level of staff engagement. This is shown by the significant level of variation identified through non-parametric testing. As the extreme differences show below, managers are more positive towards psychological ownership, workforce development and leadership; staff are more positive towards motivation and awareness, as shown in the next figure.

Stakeholder Insights - Patient Adherence

  1. Willingness to participate

    There is a willingness by patients to participate in healthcare programmes

    This willingness is associated with the following expectation:

    - Shared decision making.
    - Better self management.
    - Readily available communication channels to monitor patient satisfaction.

    Organisational structure does predict patient outcomes in a number of areas. There are many factors on why patients choose willingly to participate in their programme. These include employing shared decision making approaches, selfmanagement, self-care, and patient empowerment. Checking patient satisfaction with communication channels is another participation factor.

    Self-management and self-monitoring were also positively associated with patient beliefs surrounding the power to influence their health. Along with making and tracking their appointments themselves, and having access to their data.

    The responsibility for adherence should be shared between patients and healthcare providers.

    Awareness of the adherence concept is an important factor for its promotion. Several barriers and promoters to adherence are identified by the patient questionnaire and focus group (see figure 6). The adherence concept is clear to staff. What is not clear, is how to implement this strategy in practice.

    Transfer of knowledge is frequently employed to promote adherence. This strategy alone, however, is not sufficient. The results from focus groups confirm that patients need to be convinced of the benefits of a healthcare recommendation. Otherwise, the adherence level will not be stable. Routine daily circumstances will endanger or promote optimal adherence with healthcare recommendations.

  2. Patients overestimate their adherence

    Patients overestimate their level of knowledge and adherence behaviour

    Patients are often unaware of the impact of their own behaviour on their health. They assume that they understand their diagnosis or what they can do to improve their health. The focus group interview disclosed important uncertainties, misunderstandings and misconceptions in this regard.

    The level of education is an important positive predictor promoting whether a patient understands the impact of the disease or not. Health education needs to be tailored to individual patient´s needs. Essential for effective education, staff should help patients engage with the best suited communication channel, at the right moment, and with the right person.

    Support from family and friends, and feeling secure, are of prime importance to patients.

    These are common findings throughout all focus groups held at ACT. Good family support helps patients to cope with their disease. It also helps to maintain a positive attitude also in times of suffering.

    A single point of contact in the health care system, and telehealth solutions, improves the patient's feeling of being supported. Improving their the sense of security. Across most regions, feeling secure emerged as a pivotal factor. It influences the health behaviour of patients, and forms a basis for patient self-empowerment.

    Patients need to master the implementation of new health strategies. Those who feel supported are more likely to gain confidence.

  3. Simple patient questionnareis are useful

    A simple patient questionnaire can detect meaningful differences between predefined and project-specific characteristics

    The level of education is relevant for the beliefs of patients around their own healthcare behaviour. Age turns out to be another pivotal factor when explaining the benefits of medication and healthcare behaviour to elderly participants. They are less likely to understand their medication, and not so convinced that changing their behaviour will influence their health.

    A comprehensive assessment of adherence requires in-depth structured questioning.

    Uncovering the many facets of patient adherence has had limited success. Using a format similar to a Likert scale (allows user to agree or disagree with a statement), the patient questionnaire could only address simple questions.

    Adherence is a complex concept. Thus, one question alone in a face-to-face situation is also insufficient to describe the actual status of adherence. However, a reliable understanding of adherence can be achieved by serial, targeted, open questions. Focus group interviews allow employing interrogation techniques suitable to disclose valuable insights regarding the actual adherence level of the patient. These reveal relevant uncertainties and misunderstandings of patients. Such insights, however, are vital to improve patient adherence over time.

    To get the desired information, the interview technique is crucial. When asked superficial questions, most participants reported a high adherence level. They agreed to strive for full understanding of their health condition and diagnosis. In-depth questioning revealed important uncertainties, misunderstandings and misconceptions in sizeable proportions of participants. By contrast, only a small percentage of participants had admitted some limitations in this respect. Compared to the patient questionnaire, more limitations towards adherence were identified in the focus groups.

Stratification Details & Process

  1. Risk prediction modeling is a priority

    Risk prediction modelling is a priority for the implementation of integrated care at a European level

    One of the key challenges generated by large-scale deployment of integrated care services is the need for dynamic health risk assessment, both at population level and in the clinical scenario. This helps to feed adaptive case management strategies. Particularly those aimed at covering the evolving requirements of chronic patients over time.

    Summary of results

    All five ACT regions agree on the relevant role of population-based health risk assessment for regional deployment of integrated care. There is also consensus on the use of population health stratification and not clinical stratification. That is, health risk assessment tools generated from modelling the entire population of a given region (or geographical area) with a holistic approach.

    The evolution of risk prediction modelling tools allows proper quantification of sensitivity/specificity of the estimations.

    Regional risk prediction modelling tools

    Our observations show the use of diverse regional risk prediction modelling tools. Together with the criteria for health risk strata classifications, these limit comparability of risk pyramid distributions among ACT regions (Figures 5 and 6). Likewise, different problems associated with data management preclude appropriate comparisons of the recommended indicators.

    We also identified issues with license binding constraints, and insufficient transparency of some computational algorithms. These may limit transferability of population-based health-risk assessment among regions. These two factors might also prevent the adaptation of current risk prediction tools. Especially for the following evolving requirements:

    - Integration between healthcare and social services.
    - Implementation of synergies between population-based and clinical health risk prediction modelling.

    There are innovative strategies for individual health risk prediction models, which can be applied in different clinical scenarios. The ACT work has reported on the conceptual steps required to develop these strategies. Further studies are needed to evaluate their feasibility, added value and clinical applicability.

Assessment Insights

  1. Include resource usage  

    The ability to track the use of resources is a useful feature of a stratification strategy

    This shows why patients assigned to complex programmes (case management) are using more resources. Especially when compared to patients in disease management programmes of HF, COPD and DM.

    We have not been able to measure patient level data. Yet results at the population level confirm they are consistent with the stratification algorithms. They also show when resource allocation for patient needs has been adequately thought through.

  2. Evaluation data is not readily available

    Data availability and homogeneity are the biggest challenges when evaluating the performance of the programmes

    We collected a wealth of data during the ACT project. The collection is unique. It encompasses not only the outcomes, but also the full context of the deployment. Including stakeholder perceptions. The challenges we have identified during collection and analysis are data availability, comparability and ambiguity.
  3. Data is reported at different levels

    Complexity of the quantitative data collection

    Figure (7) depicts the size and quantitative complexity of the data collection process performed in ACT. Shown here after the interpretation and reorganisation of the collected data. Quantitative data are collected from national data, regional data, programme data, and programme instance data for 2012, 2013 and 2014 in more than 90 datasets. The data from surveys cover more than 2,500 responses that address the qualitative aspects of care coordination, workflow optimisation, staff engagement and patient adherence. The survey data was provided by different stakeholders (patients, staff and programme managers).

    The ACT framework was designed to be flexible in the processing of different data elements. The ACT Evaluation engine has the capacity to visualise this wealth of data in different dashboards.

  4. Data does not allow comparison at indicator level

    Despite the wealth of data, there is a limit on how the data can be compared at indicator level

    The data have been reported at different levels (national, regional, programme and programme instance level). Some indicators are missing in the reported data. This does not mean these indicators are not collected or available locally, but there is an issue to make the data available for evaluation and research purposes. Regions embarking in the endeavour of CC&TH deployment should not underestimate the effort of data collection.