Use of regional transmural agreements to support the right care in the right place for patients with chronic heart failure—a qualitative study

Abstract

Background Chronic heart failure (CHF) poses a major challenge for healthcare systems. As these patients’ needs vary over time in intensity and complexity, the coordination of care between primary and secondary care is critical for them to receive the right care in the right place. To support the continuum of care needed, Dutch regional transmural agreements (RTAs) between healthcare providers have been developed. However, little is known about how the stakeholders have experienced the development and use of these RTAs. The aim of this study was to gain insight into how stakeholders have experienced the development and use of RTAs for CHF and explore which factors affected this. Methods We interviewed 25 stakeholders from 9 Dutch regions based on the Measurement Instrument for Determinants of Innovations framework. Interview recordings were transcribed verbatim and analysed through open thematic coding. Results In most cases, the RTA development was considered relatively easy. However, the participants noted that sustainable use of the RTAs faced different complexities and influencing factors. These barriers concerned the following themes: education of primary care providers, referral process, patients’ willingness, relationships between healthcare providers, reimbursement by health insurance companies, electronic health record (EHR) systems and outcomes. Conclusion Some complexities, such as reimbursement and EHR systems, are likely to benefit from specialised support or a national approach. On a regional level, interregional learning can improve stakeholders’ experiences. Future research should focus on quantitative effects of RTAs on outcomes and potential financing models for projects that aim to transition care from one setting to another.

Sustainable adoption of noninvasive telemonitoring for chronic heart failure: A qualitative study in the Netherlands

“… 43 , 44 For example, referral of stable patients to primary care differs across regions. 25 Stakeholders should be aware that these factors can induce severe uncertainty. Study designs that are better equipped to take these considerations into account are realist evaluation, 45 RCTs with process evaluation, 46 platform trials, 47 and action-based research.…”

“…Many regions within the Netherlands have developed Regional Transmural Agreements (RTAs) to facilitate such transmural collaboration. 25 These RTAs are highly heterogenous for HF between regions, which may affect the feasibility and efficiency of different levels of centralization of telemonitoring programs. Future studies should explore the potential synergies and pitfalls of integration of telemonitoring within transmural collaborations and how these relate to the question of centralization.…”

“… 22 , 23 More recently, a national program was developed to support transmural collaboration throughout patient journeys and referral to the general practitioner when the patient is clinically stable. 24 , 25 …”

The effect of regional transmural agreements on the information transfer of frail older patients

“…It is well known that a new protocol can be hard to implement and is therefore not always successful [ 23 ]. In a recent article by Auener et al [ 13 ] the possible barriers in implementing an RTA in the field of chronic heart failure was investigated. Through interviews it became apparent that the development of an RTA was relatively easy, which is an experience we share.…”

“…To improve care for older patients a multidisciplinary transmural project was started to make guidelines with regards to the information transfer of frail older patients before admittance and after discharge from the hospital. Regional transmural agreements (RTA) [ 12 ] can be a way to formalize agreements among different healthcare providers to provide a continuum of care [ 13 ]. RTA’s are a model that is increasingly used in the Netherlands, in many different fields of medicine such as chronic heart failure, wound care and palliative care, and has been evaluated before.…”