Implementing diabetes self-management support in a new organizational context: experiences within Dutch care groups

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Hanneke W. Drewes
Lidwien C. Lemmens
Mireille Helmers
Janneke T. de Jong
Caroline A. Baan
Jeroen N. Struijs


Rationale, aims and objectives:  Self-management support (SMS) is a crucial element in the treatment of diabetes and a key component of person-centered care. Widely introduced disease management programs are assumed to improve SMS. Hence, new organizations, such as care groups and accountable care organizations, are introduced to implement disease management programs successfully. This study aims to explore the status of SMS within Dutch care groups and to identify professionals’ preferences and barriers regarding SMS within this new organizational context.Methods: A sequential explanatory mixed method design was used. SMS is quantitatively assessed with the Assessment of Chronic Illness Care and subsequently used to explore SMS experiences, preferences and barriers during the interviews. Grol’s implementation framework was used to categorize barriers for improvement.Results: The level of SMS differed between and within care groups, but was on average basic to reasonably good. At least about half of the interviewees (range 56-100% per SMS element) preferred to improve SMS. Experienced barriers to improve SMS could be related to the organizational level (mainly time and inadequate IT), the professional and patient (mainly motivation and routines), economical and financial arrangements (uncertainty and ambiguity) and SMS elements itself (mainly limited insight in effectiveness).Conclusions: Care groups have not fully implemented SMS and most interviewees prefer improvement. Experienced barriers to improve SMS support, concerning IT, professionals’ and patients’ motivation and short-term of financial arrangements, still need to be encountered within this new organizational context. This could partly be facilitated by more insight in the question: how could SMS be effective for whom?

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Health Promotion


Wild, S., Roglic, G., Green, A., Sicree, R. & King, H. (2004). Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 27 (5) 1047-1053.

Baan, C.A., Schoemaker, C.G., Jacobs-van der Bruggen, M.A.M., Hamberg-van Reenen, H.H., Verkleij, H., Heus, S. & Melse, J.M. (2009). Diabetes to 2025: prevention and care connected. Bilthoven: National Institute for Public Health and the Environment. Report No.: 260322004.

IDF, International Diabetes Federation. (2011). Diabetes Atlas (Fifth ed). Brussels: IDF.

Bodenheimer, T., Wagner, E.H. & Grumbach, K. (2002). Improving primary care for patients with chronic illness. Journal of the American Medical Association 288 (14) 1775-1779.

Wagner, E.H., Austin, B.T. & Von Korff, M. (1996). Organizing care for patients with chronic illness. Milbank Quarterly 74 (4) 511-544.

Battersby, M., Von Korff, M., Schaefer, J., Davis, C., Ludman, E., Greene, S.M., Parkerton, M. & Wagner, E.H. (2010). Twelve evidence-based principles for implementing self-management support in primary care. Joint Commission Journal on Quality and Patient Safety 36 (12) 561-570.

Wagner, E.H., Bennett, S.M., Austin, B.T., Greene, S.M., Schaefer, J.K. & VonKorff, M. (2005). Finding common ground: patient-centeredness and evidence-based chronic illness care. Journal of Alternative and Complementary medicine 11 (Supplement 1) S7-15.

Bonomi, A.E., Wagner, E.H., Glasgow, R.E. & VonKorff, M. (2002). Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement. Health Services Research 37 (3) 791-820.

Glasgow, R.E., Davis, C.L., Funnell, M.M. & Beck, A. (2003). Implementing practical interventions to support chronic illness self-management. Joint Commission Journal on Quality and Patient Safety 29 (11) 563-574.

Bodenheimer, T., MacGregor, K. & Sharifi, C. (2005). Helping patients manage their chronic conditions. California HealthCare Institution.

Heisler, M., Piette, J.D., Spencer, M., Kieffer, E. & Vijan, S. (2005) The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management. Diabetes Care 28 (4) 816-822.

Lorig, K.R. & Holman, H. (2003). Self-management education: history, definition, outcomes, and mechanisms. Annals of Behavioral Medicine 26 (1) 1-7.

Parchman, M.L., Zeber, J.E. & Palmer, R.F. (2010). Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in type 2 diabetes: a STARNet study. Annals of Family Medicine 8 (5) 410-417.

de Bakker, D.H., Struijs, J.N., Baan, C.B., Raams, J., de Wildt, J.E., Vrijhoef, H.J. & Schut, F.T. (2012). Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Affairs (Millwood) 31 (2) 426-433.

Struijs, J.N. & Baan, C.A. (2011). Integrating care through bundled payments--lessons from The Netherlands. New England Journal of Medicine 364 (11) 990-991.

Luft, H.S. (2010). Becoming accountable-opportunities and obstacles for ACOs. New England Journal of Medicine 363 (15) 1389-1391.

Ham, C. & Zollinger-Read, P. (2012). What are the lessons from the USA for clinical commissioning groups in the English National Health Service? Lancet 379 (9811) 189-191.

Struijs, J.N., van Til, J.T. & Baan, C.A. (2010). Experimenting with a bundled payment system for diabetes care in the Netherlands : The first tangible effects. Bilthoven: National Institute for Public Health and the Environment. Report No.: 2600014001.

van Til, J.T., Struijs, J.N. & de Wildt, J.E. (2011). The organisation of care groups in 2010. Bilthoven: National Institute for Public Health and the Environment.

Dutch Ministry of Health, Welfare and Sport. (2008). A programmatic approach to chronic diseases. The Hague: Dutch Ministry of Health, Welfare and Sport.

Struijs, J.N., de Jong-van Til, J.T., Lemmens, L.C., Drewes, H.W., de Bruin, S.R. & Baan, C.A. (2012). Experimenting with a bundled payment system for diabetes care in the Netherlands : results after three years. Bilthoven: National Institute for Public Health and the Environment.

Ivankova, N.V., Creswell, J.W. & Stick, S.L. (2006). Using mixed-methods sequential explanatory design: from theory to practice. Field Methods 18 (1) 3-20.

Cramm, J.M., Strating, M.M., Tsiachristas, A. & Nieboer, A.P. (2011). Development and validation of a short version of the Assessment of Chronic Illness Care (ACIC) in Dutch disease management programs. Health and Quality of Life Outcomes 9, 49.

Grol, R. & Wensing, M. (2010). Improving patient care. The Implementation of change in clinical practice. Amsterdam: Elsevier.

Grol, R.& Wensing, M. (2004). What drives change? Barriers to and incentives for achieving evidence-based practice. Medical Journal of Australia 180 (Supplement 6) S57-60.

Sunaert, P., Bastiaens, H., Feyen, L., Snauwaert, B., Nobels, F., Wens, J., Vermeire, E., Van Royen, P., De Maeseneer, J., De Sutter, A. & Willems, S. (2009). Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience". BMC Health Services Research 9, 152.

Newman, S., Steed, L. & Mulligan, K. (2004). Self-management interventions for chronic illness. Lancet 364 (9444) 1523-1537.

Sarkar, U., Piette, J.D., Gonzales, R., Lessler, D., Chew, L.D., Reilly, B., Johnson, J., Brunt, M., Huang, J., Regenstein, M. & Schillinger, D. (2008). Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems. Patient Education and Counseling 70 (1) 102-110.

Matthias, M.S., Bair, M.J., Nyland, K.A., Huffman, M.A., Stubbs, D.L., Damush, T.M. & Kroenke, K. (2010). Self-management support and communication from nurse care managers compared with primary care physicians: a focus group study of patients with chronic musculoskeletal pain. Pain Management Nursing 11 (1) 26-34.