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Poster Abstracts

Assessment of patient's and health professional's experience of integrated care: preliminary results from a pilot survey in Veneto Region-Italy


Silvia Netti Tiozzo ,

Pietro Gallina,

Francesco Avossa,

Natalia Alba,

Elena Schievano,

Lorena Marta Guerra,

Anna Zambon,

Elisa Boscolo,

Maria Chiara Corti


Introduction: Population ageing is associated with an increased co-prevalence of chronic diseases. For persons with multimorbidity, care fragmentation may lead to adverse outcomes and patient dissatisfaction while care management programs can improve quality of care. Veneto Region is conducting a pilot experience on integrated care involving persons with Congestive Heart Failure (CHF) and multimorbidity in a primary care setting. The purposes of the present pilot survey were to assess experience of integrated care among patients, general practitioners (GPs) and nurses involved in the project.

Methods: Veneto Region Health-Care System is administered through 21 Local Health-Care Authorities (LHAs) which provide Government funded health care granting universal coverage with a per-capita financing system delivering preventive, primary and hospital care. In 2015, Veneto Region started an integrated care-program in the whole region, involving older persons with Congestive Heart Failure (CHF) and multimorbidity. 42 Nurses and 42 GPs received specific training on Care Management using a collaborative team—based approach. The eligibility criteria of patients' selection were “being registered with the participating GPs”, "age 65 years or older" and "with CHF". To target the patients with CHF, co-morbidities and complexity we used the case-finding tool of the Adjusted Clinical Groups (ACG) System that generates high risk case management lists.

After obtaining informed consent, the care manager nurse assessed patient needs and preferences, created with GP an evidence-based Care Plan and an Action Plan for patient and care-giver. The nurse then starts a proactive monitoring phase by telephone, in person in the office, or at home. During this contacts, the nurse promotes and supports patients’ self-management, uses motivational interviewing to help patients manage their condition and provides ongoing education resources and general information. The Care Plan is regularly updated by the nurse and the GP and shared with the patient’s other providers to help coordinate complex care.

To assess the "experience" of integrated care we developed a 10-items questionnaire focused on difficulties, utility and comprehension of the tools, and on communication, timing and self-satisfaction.

The first part of the questionnaire was general; the second part was specific for patient, nurse, GP. It was administered to patients and health professionals 2 months after the first home assessment.

Preliminary Results: The ACG System identified 525 eligible patients for the ongoing Veneto Region pilot on Integrated Care.

By July 1st 212 patients were approached and 164 were enrolled. We examined the experience of Integrated Care through the questionnaire in 74 patients (45,1%), 28 GPs (70,0%) and 29 nurses (72,5%).

While patients consider the Integrated Care program "very useful" (34%) or "useful" (28%), GPs and Nurses quoted it as "rather " (39%) or "quite useful"( 38%)

Patients report the tools used having an average utility (32,1%), being clear (32.1%) and having an appropriate length (34,2%); while the majority of GPs and nurses report that tools are too long and time-consuming.

Most patients (95%) would like to continue participating because they report being supported, protected, very satisfied with the time the nurse dedicated them (64%) and with the information received (76%);

82% of GPs would like to continue participating because they have improved their patients knowledge and 39% reports nurses’ information is useful; 47% are very satisfied with the time the nurse dedicated to them and think their relationship with the nurse has improved over time.

96.6 % of nurses would like to continue participating for the holistic vision they can achieve and 38% reports the information received by the GP is useful. Among nurses, 31% have an average satisfaction for the time the GP dedicated to them but 24% is quite unsatisfied of the relationship with GPs.

While the overall satisfaction of patients and nurses is “very high” and “high” and above 95%, it is negative for 11% and quite negative for the 18% of the GPs. In the free text comments some GPs stated that too much time was wasted in filling redundant forms being already overwhelmed by bureaucratic tasks, and they complained for lack of funding to program medical locums while they were engaged with the program. Nevertheless, 32 % of GPs think the Integrated Care program is very useful in taking care of this patients sub-population.

Conclusions: Preliminary results suggest that patient's and nurses experience of integrated care is very positive in areas such as communication, comprehension, utility and satisfaction. For GPs and nurses however, the assessment tool was considered not easy to use due to its length and complexity. A redesign of the assessment instruments used in the program is probably required. Integrated care can improve communication and satisfaction of health professionals too, but it is necessary to reduce the reporting burden and to provide GPs and nurses with additional team-building assets: increasing multidisciplinary group meetings is a way to facilitate integrated care and overcome barriers; furthermore actively involving GPs in the change process, sharing goals and objectives, would enhance their engagement in the program.

Information on the effects of Veneto Region’s program in terms of hospitalization, ER access and on mortality will be available after 12 months of follow-up.

How to Cite: Netti Tiozzo S, Gallina P, Avossa F, Alba N, Schievano E, Guerra LM, et al.. Assessment of patient's and health professional's experience of integrated care: preliminary results from a pilot survey in Veneto Region-Italy. International Journal of Integrated Care. 2016;16(6):A27. DOI:
Published on 16 Dec 2016.


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