Improved patient care and increased job satisfaction among GPs
The TARGET integrated care programme
General practice must change. There is no doubt about it among general practitioners (GPs) in Drenthe, the Netherlands. “The population is ageing rapidly, healthcare worker shortages are increasing, and GP workload continues to grow”, explains associate professor and researcher Arianne Elissen. “We can improve the situation in general practice through an innovative data tool for gaining insight into the patient population; person-centred conversations to find out what is really going on with patients; and follow-up actions to address the real problems”, says Rowan Smeets, who recently obtained her PhD on this topic.
In 2016, the primary care group Dokter Drenthe joined forces with the health insurance company Zilveren Kruis and Maastricht University to future-proof general practice in the Dutch province of Drenthe. They wanted to organise care for patients with less complex care needs as efficiently as possible, leaving more room for patients with complex care needs. The TARGET project explored how general practices can go about this.
- Start project: 2016
- This project has received funding from: Zilveren Kruis
- Project website: https://www.dokterdrenthe.nl/zorgverlener/zorg/zorg-op-maat/target
Insight into the patient population
Rowan: “The first step is to distinguish patients with less complex care needs from patients with more complex care needs. This requires insight into the patient population. We began by identifying and analysing patient data – such as care use data and demographic, socioeconomic, and biomedical characteristics – to determine which patients make the most use of GP services. We found that these are mainly people with multiple chronic conditions and additional challenges, such as low income. Our study focused on this group of ‘frequent attenders’.”
A personal and positive conversation
Arianne: “GPs then have in-depth, person-centred conversations with these patients to find out what is really going on with them. What is the root of the problem? Is the question the patient came in with the real question, or is there more ¬– or something else – going on? Only when this is clear can a real solution be found. It may turn out that general practice can’t solve the problem, but social care or other primary care services can. The GP will then refer the patient to get the right care in the right place.” “A person-centred conversation takes much more time than a regular consultation”, adds Rowan. “But we believe it’s an investment that really pays off. This year, we will initiate a study to measure the long-term effects of the approach. The conversations are based on the concept of positive health. They don’t focus on the patient’s illness, but on what is going well and what the patient can still do. It gives a much more complete picture of the patient and their environment. The conversations are stimulating and positive, and have proved energising for both patients and GPs. Sometimes they help patients realise that their situation isn’t as bad as it seemed, or that there are still a lot of things they can do. Some patients take up an old hobby again and take great pleasure in it. GPs have said that they enjoy connecting with patients on a deeper level. There are subjects that don’t come up in regular consultations because there simply isn’t enough time. Being able to discuss these things significantly increased their job satisfaction and made their work feel more meaningful.”
The TARGET movement is growing
“In 2020, we launched a small-scale pilot study in which seven general practices participated”, says Arianne. “Today, we have 50 participants. The TARGET programme is an experiment that was made possible by the financial support of Dokter Drenthe and healthcare insurance company Zilveren Kruis of Stichting Achmea Gezondheidszorg. Its success can partly be attributed to its flexibility; GPs can organise care in a way that suits their patient population, their own ideas, and their preferred way of working. The guidelines also leave room for general practices to decide what patient information is worth registering. The system doesn’t dictate their every move – they’re the ones at the wheel.” Rowan: “We support general practices in implementing this new way of working. For example, we provide person-centred conversational skills training. We also instruct GPs on how to use a tool (De Zorgzwaartetool) developed by Niels Hameleers, a data scientist at Maastricht University. They can use this tool to download an up-to-date overview of their patient population each month, grouping patients by low, moderate, and high care use. The dashboard also has other filters. This insight enables GPs to respond proactively to changes in their patient population.”
And what about patients with less complex care needs? Rowan: “Less complex care can be organised more efficiently, for example by making more use of e-health solutions such as video calling or by streamlining the healthcare process.” Essentially, says Arianne, this new approach to general practice means a culture change. “It’s a long-term process. That said, the positive results we have achieved so far make us feel very confident about the future. The province of Drenthe has taken the lead in this, and it hasn’t gone unnoticed. TARGET has attracted a great deal of interest from regions and organisations across the Netherlands. Our research so far has mainly focused on its short-term effects. The upcoming follow-up study will focus more on its long-term effects and creating a network of health services in the region. The existence of such a network partly determines the success of this person-centred, integrated approach to health care.”
Text: Margo van Vlierden
Target in a nutshell (in Dutch)
- Arianne Elissen, PhD, Associate Professor, Department of Health Services Research
- Niels Hameleers, Data scientist, Department of Health Services Research.
- Dorijn Hertroijs, PhD, Assistent Professor, Department of Health Services Research
- Prof.dr. Dirk Ruwaard, Professor of Public Health and Health Care Innovation
- Rowan Smeets, PhD, postdoctoral researcher
In the media
- NOS Radio 1 Journaal, January 2023. Interview Rowan Smeets
Our most important scientific output
- Rowan Smeets (2023). Hitting the TARGET in primary care: working towards integrated and person-centred care.
Articles in scientific journals
- Smeets RGM, Hertroijs DFL, Mukumbang FC, Kroese MEAL, Ruwaard D, Elissen AMJ. First things first: How to elicit the initial program theory for a realist evaluation of complex integrated care programs. Milbank Q. 2022;100(1):151-189.
- Smeets RGM, Hertroijs DFL, Kroese MEAL, Hameleers N, Ruwaard D, Elissen AMJ. The Patient Centered Assessment Method (PCAM) for Action-Based Biopsychosocial Evaluation of Patient Needs: Validation and Perceived Value of the Dutch Translation. Int J Environ Res Public Health. 2021;18(22).
- Smeets RGM, Kroese MEAL, Ruwaard D, Hameleers N, Elissen AMJ. Person-centred and efficient care delivery for high-need, high-cost patients: primary care professionals’ experiences. BMC Family Practice. 2020;21(1):1-9.
- Smeets RGM, Elissen AMJ, Kroese MEAL, Hameleers N, Ruwaard D. Identifying subgroups of high-need, high-cost, chronically ill patients in primary care: A latent class analysis. PloS one. 2020;15(1):e0228103.
Presentations (conferences, invited lectures)
- Smeets RGM, Elissen AMJ, Spoorenberg SLW. Country practice example II: the Netherlands Coordination of chronic care management via care groups (networks in primary care). Seminar on skill-mix innovations by The European Observatory on Health Systems and Policies and l’Assurance Maladie, 16 September 2022 (invited lecture).
- Hertroijs DFL, Smeets RGM, Spoorenberg SLW, Ruwaard D, Elissen AMJ. Towards a focus on the person behind the patient: Is the TARGET integrated care program feasible and acceptable for general practice? International Conference on Integrated Care, 23-35 May 2022, Odense, Denmark (oral presentation).
- Smeets, RGM, Hertroijs DFL, Mukumbang FC, Kroese MEAL, Ruwaard D, Elissen AMJ. Learning how integrated primary care works: first steps towards a realist evaluation of the Dutch TARGET program. WONCA Europe Conference, 6-10 July 2021 (oral presentation).
- Smeets RGM, Kroese MEAL, Ruwaard D, Hameleers N, Elissen AMJ. Primary care professionals’ experiences with care delivery to high-need, high-cost, patients: a qualitative study. EHMA Annual Conference, 17-19 November 2020 (oral presentation).
- Smeets RGM, Elissen AMJ, Kroese MEAL, Hameleers N, Ruwaard D. Identifying subgroups of high cost, high need chronically ill patients in primary care: a Latent Class Analysis. Annual Research Meeting Academy Health, 2-4 June 2019, Washington DC, US (poster presentation).
- Smeets RGM, Kroese MEAL, Ruwaard D, Hameleers N, Elissen AMJ. Experienced barriers and potential solutions with regards to care delivery to high-need, high-cost patients: a qualitative study in primary care. NHG-Wetenschapsdag, 5 & 11 February 2021 (oral presentation).
Our most important output for societal target groups
Reports, news articles
- Samen beslissen: onlosmakelijk onderdeel van persoonsgerichte zorg. InEen Magazine, September 2022.
- Frequente chronische patiënt vraagt om samenwerking. Skipr Quarterly Magazine, 2022.
- Nieuw zorgprogramma streeft naar toekomstbestendige huisartsenzorg. Transmuraal Treant, 2022.
- Verkiezingsmanifest 2021: Intensiveer de samenwerking in zorgnetwerken. Zilveren Kruis, 2021.
- Smeets RGM, Elissen AMJ, Kroese MEAL, Wissink R, Ruwaard D. Chronische zorg over een andere boeg. De Eerstelijns. 2020.
- Hameleers N, Elissen A, Kroese M, Ruwaard D. Op weg naar een integraal programma chronische zorg: resultaten deelonderzoek in de zorggroep Huisartsenzorg Drenthe. Maastricht: Maastricht University; 2017.
- Smeets RGM, Elissen AMJ, Spoorenberg SLW. Presentatie target - resultaten tot zover. InEen themabijeenkomst: Integrale en persoonsgerichte zorg, 7 April 2022, Utrecht (oral presentation).
- Smeets RGM, Elissen AMJ, Spoorenberg SLW. Aan de slag met zorgzwaartemodellen. InEen themabijeenkomst: Integrale en persoonsgerichte zorg, 7 April 2022, Utrecht (workshop).
- Smeets RGM, Kroese MEAL, Ruwaard D. Integratie van chronische zorgprogramma’s: een andere kijk op de populatie. InEen conferentie ‘De ketenzorg voorbij?’, 11 February 2019, Soesterberg (workshop).
- Ruwaard D, Smeets RGM, Elissen AMJ, Kroese MEAL, Hameleers N. Integraal Programma Chronische Zorg: op weg naar een implementatie en evaluatie in co-creatie met de praktijk. Sandwichcursus HZD, november 2019, Dalfsen (oral presentation).
- Smeets RGM, Elissen AMJ, Weuring II. ‘Doelgroepbepaling en scope van het geïntegreerde zorgprogramma’. InEen themabijeenkomst: Integratie chronische zorgprogramma’s, 8 oktober 2019, Baarn, (workshop).
- Ruwaard D, Smeets RGM, Elissen AMJ, Kroese MEAL, Hameleers N. Op weg naar een Integraal Programma Chronische Zorg: Identificatie zorgzwaartemodel – voorlopige resultaten. Sandwichcursus HZD, november 2018, Dalfsen (oral presentation).
- Smeets RGM, Elissen AMJ, Kroese MEAL, Hameleers N, Ruwaard D. Op weg naar een Integraal Programma Chronische Zorg. Masterclass Eerstelijns Bestuurders, september 2018, Amersfoort (oral presentation).