2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
THEME 3
Team context: Organisation of care
delivery and interprofessional
collaboration
Poor interaction among healthcare professionals from various occupational backgrounds often
compromises the delivery of PCC. Inadequate communication among professionals leads to lack of
respect and assignment of blame, reinforcing fragmentation of care instead of interdisciplinary
collaboration. Interdisciplinary collaboration characterized by coordination and communication among
diverse professionals is needed to improve quality of care and enhance PCCD, which is known to
depend largely on the existence of prepared, proactive multidisciplinary teams. During this lecture
attention will be given to the relationships between interprofessional collaboration, relational
coordination among team members, team climate and quality of care delivery and/or PCCD in various
healthcare settings. Besides theories (such as relational coordination) and conceptual models (such as
the Chronic Care Model) empirical findings are discussed. The shift from acute to chronic care will be
discussed and how this leads to changing demands of patients, changing roles and expectation of
patients (e.g. having a more active role, self-care and self-management) and that this requires different
interaction between professionals and patients, and a different approach in the organization of care
delivery to improve PCCD.
__________________________________________________________________________________________________________________
Targets for theme #:
Students can analyze and apply theories, concepts, instruments and models from the literature to
explain how organization of care delivery and interprofessional collaboration contribute to PCCD;
Students can explain why (complex) system changes are needed instead of incremental changes in the
delivery of care only;
Students understand (potential) underlying mechanisms explaining (lack of) effectiveness of complex
care programs;
Students can analyze a complex issue in PCCD using several organizational concepts, such as relational
coordination, leadership, workplace structure and culture.…
1
,2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
Inhoud
Knowledge clips................................................................................................................................................3
1. Part A: The importance of system changes in care delivery..................................................................3
2. Part B: The importance of interprofessional collaboration...................................................................8
Lecture 3. Team context 15 sept.....................................................................................................................11
Chronic Care Model................................................................................................................................12
What is the CCM like in practice?............................................................................................................14
Relational coordination...............................................................................................................................16
Workgroup meeting........................................................................................................................................18
Homework assignment...............................................................................................................................18
Case study on the FFF approach.................................................................................................................21
Case study on ‘Someplace Medical Center’................................................................................................23
2
, 2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
Knowledge clips
1. Part A: The importance of system changes in care delivery
Focus on shift of acute to more chronic care delivery.
This shift in health care practice leads to changing
demands, roles and expectations of patients (e.g. a more
active role in the care process, an increased focus on
self-care and self-management). This shift also requires
different interactions between healthcare professionals
and patients, and also a different approach in the
organization of care.
Chronic illness = any condition that requires ongoing activity of the patient and the healthcare system.
Most healthcare delivery is reactive: care and support is provided when patients already experience health
problems. So there is less attention for prevention and early detection.
This traditional system of healthcare is inadequate for patient with chronic conditions. The fragmentation of
health services, a lack of coordination and discontinuities may result in the delivery of inadequate and
inefficient care. This in turn, may reduce the quality of care and life of patients with complex needs.
Chronic conditions place a different demand on patients and their relatives. Compared to acute conditions,
chronic illnesses differ e.g. in the severity, the time course, and the long-term follow-up by healthcare
professionals. They also involve continuous decision making about treatments and support, and the
adjustment of the daily life of patients. So this requires a very different way of organizing care and support
for this patient group.
The longer time frame of chronic conditions also
changes the kind of relationship that is needed
between care professionals and patients.
In acute care: the professional is seen as the expert
who selects and conducts the therapy.
In chronic care: the life of the patients are changed, and
the length of it is indefinite. People with chronic
conditions are basically their own caregivers, because
of the impact of the chronic condition on their own
daily life. Professionals should then play more of a
supporting role in the care process. So patients need to
be made full partners in their own care process. For the
patient, self-management essential, because effective
self-managers are better equipped to control chronic
conditions and positively influence their outcomes. Self-
management support by a healthcare professional is an
important strategy to reduce the burden of chronic
disease. Shared expertise: professionals are experts
3
THEME 3
Team context: Organisation of care
delivery and interprofessional
collaboration
Poor interaction among healthcare professionals from various occupational backgrounds often
compromises the delivery of PCC. Inadequate communication among professionals leads to lack of
respect and assignment of blame, reinforcing fragmentation of care instead of interdisciplinary
collaboration. Interdisciplinary collaboration characterized by coordination and communication among
diverse professionals is needed to improve quality of care and enhance PCCD, which is known to
depend largely on the existence of prepared, proactive multidisciplinary teams. During this lecture
attention will be given to the relationships between interprofessional collaboration, relational
coordination among team members, team climate and quality of care delivery and/or PCCD in various
healthcare settings. Besides theories (such as relational coordination) and conceptual models (such as
the Chronic Care Model) empirical findings are discussed. The shift from acute to chronic care will be
discussed and how this leads to changing demands of patients, changing roles and expectation of
patients (e.g. having a more active role, self-care and self-management) and that this requires different
interaction between professionals and patients, and a different approach in the organization of care
delivery to improve PCCD.
__________________________________________________________________________________________________________________
Targets for theme #:
Students can analyze and apply theories, concepts, instruments and models from the literature to
explain how organization of care delivery and interprofessional collaboration contribute to PCCD;
Students can explain why (complex) system changes are needed instead of incremental changes in the
delivery of care only;
Students understand (potential) underlying mechanisms explaining (lack of) effectiveness of complex
care programs;
Students can analyze a complex issue in PCCD using several organizational concepts, such as relational
coordination, leadership, workplace structure and culture.…
1
,2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
Inhoud
Knowledge clips................................................................................................................................................3
1. Part A: The importance of system changes in care delivery..................................................................3
2. Part B: The importance of interprofessional collaboration...................................................................8
Lecture 3. Team context 15 sept.....................................................................................................................11
Chronic Care Model................................................................................................................................12
What is the CCM like in practice?............................................................................................................14
Relational coordination...............................................................................................................................16
Workgroup meeting........................................................................................................................................18
Homework assignment...............................................................................................................................18
Case study on the FFF approach.................................................................................................................21
Case study on ‘Someplace Medical Center’................................................................................................23
2
, 2023-2024, Block 1 GW4002MV. Patient Centered Care Delivery
Knowledge clips
1. Part A: The importance of system changes in care delivery
Focus on shift of acute to more chronic care delivery.
This shift in health care practice leads to changing
demands, roles and expectations of patients (e.g. a more
active role in the care process, an increased focus on
self-care and self-management). This shift also requires
different interactions between healthcare professionals
and patients, and also a different approach in the
organization of care.
Chronic illness = any condition that requires ongoing activity of the patient and the healthcare system.
Most healthcare delivery is reactive: care and support is provided when patients already experience health
problems. So there is less attention for prevention and early detection.
This traditional system of healthcare is inadequate for patient with chronic conditions. The fragmentation of
health services, a lack of coordination and discontinuities may result in the delivery of inadequate and
inefficient care. This in turn, may reduce the quality of care and life of patients with complex needs.
Chronic conditions place a different demand on patients and their relatives. Compared to acute conditions,
chronic illnesses differ e.g. in the severity, the time course, and the long-term follow-up by healthcare
professionals. They also involve continuous decision making about treatments and support, and the
adjustment of the daily life of patients. So this requires a very different way of organizing care and support
for this patient group.
The longer time frame of chronic conditions also
changes the kind of relationship that is needed
between care professionals and patients.
In acute care: the professional is seen as the expert
who selects and conducts the therapy.
In chronic care: the life of the patients are changed, and
the length of it is indefinite. People with chronic
conditions are basically their own caregivers, because
of the impact of the chronic condition on their own
daily life. Professionals should then play more of a
supporting role in the care process. So patients need to
be made full partners in their own care process. For the
patient, self-management essential, because effective
self-managers are better equipped to control chronic
conditions and positively influence their outcomes. Self-
management support by a healthcare professional is an
important strategy to reduce the burden of chronic
disease. Shared expertise: professionals are experts
3
