One focus group was conducted in June 2018 with six GPs. A second focus group took part in January 2019 with three GPs and one specialist. Since three doctors expressed their interest in being interviewed, but no common date for a focus group for all suitable could be found, the second wave was supplemented by individual face-to-face interviews with two GPs and one specialist. Both focus groups lasted about 90 minutes, and the face-to-face interviews lasted between 30 and 60 minutes. In all, the results are based on data of 13 physicians who have been physicians in residential practice for in average 20 years and who had implemented the new care model.
All participating doctors have used the service of the case management at the time of being interviewed. Some physicians were less active in delegating tasks and enrolling patients. The main categories “Compatibility”, “Intention to participate”, “(not) perceived advantages of the innovation” and “System-related challenges for implementation and transfer” include in total 22 subcategories relevant for the research question. A detailed description of the categories and their definitions is added additionally [see Additional file 2]. The personal values and their relation to the perception of advantages as well as the assessed success of the healthcare innovation were analysed by comparing statements that were assigned to the four categories mentioned above and their sub-categories.
3.1 Values determining the perception of advantage
All informants acknowledged the work done by the MoniKas, in particular the assumption of non-medical, but social management tasks. All interviewed doctors received positive feedback from patients and their relatives and emphasized their satisfaction with the visits of a MoniKa - for example, in terms of patients feeling better informed and better cared for socially. But also, the challenges of the transfer to standard care, such as the question of how to cover necessary resources, were addressed in all interviews. Even if these potentials and challenges are recognized by almost all interviewees, the evaluation of these according to the personally perceived advantages is different. Thus, we found that the desired relative advantage, as most relevant for implementing the healthcare innovation, were mainly determined by (a) patient-oriented values or (b) economic-oriented values - taking into account that people with stronger economic-oriented values can also be driven by patient-oriented values or vice versa. However, certain values have a greater priority than others, which then determines the mainly desired advantage. We also identified further values and factors influencing the intention to participate (e.g. social norms, former project experience), which, however, do not seem to determine the desired advantage, or not in a substantial way. We now present the characteristics of participants with patient-oriented and economic-oriented values.
(A) patient-oriented values
Doctors interviewed, who had strong patient-oriented values, emphasized the importance of holistic patient care (medical, emotional, social) and were very concerned about the care of elderly people living alone at home and experiencing poor social support.
“And indeed, there are many ways. It doesn't have to be Mambo. The main thing is that the patients are well cared for.” (Exp. 03)
They also felt that the new care model could be a solution to the challenges associated with the medical care of multimorbidity, such as reduced mobility, communication problems and low compliance of multimorbid patients.
“[...] cognitive impairment of the patients, which lead to the fact that they are not in compliance with instructions, as we wish as physicians. In addition, mobility is becoming increasingly limited, which makes communication with patients who otherwise regularly come to the practice more difficult. The decreasing support from the family, which does not exist in small families. The wife is there because children often move far away, if there are children at all.“ (FG 1. BB)
(B) economic-oriented values
We identified that the desired advantage of participants with stronger economic-oriented values was mainly based on monetary interests and interests to improve processes within their practice. The focus was on the cost-effectiveness of the new model, which was assessed by comparing the resources used to implement it with, for example, the reduction of workload or hospital stays of patients. Thus economic-oriented values could manifest not only in the form of personal cost-benefits but also in the interest of reducing social costs
“I might have to say again that all the non-medical task we do here, they don't get paid. Yes, we do it all for free. And who will do that in the future? I don't see that. And then what will the care landscape look like, so it is really urgently necessary to have something like this.” (FG1, GG)
“The second is, I believe, that it is very important that money flows into this area. If there is no economy, they can forget everything. That is daydreaming. We have that in masses behind us.” (FG1, DD)
Table 2 includes identified factors which determine patient-oriented and economic-oriented values.
Table 2: Conceptualisation of patient- and economic- oriented values
patient-oriented values
|
economic-oriented values
|
· social management
· drug management
· patient information
· patient satisfaction
· patient’s security
· continuous care
|
· cost reduction
· practice procedure
· social costs
|
3.2 Perceived advantages and evaluation of the project’s success
Participants with more patient-oriented valuesexperienced the benefit for the patient also as an immediate personal advantage.
“Well, that's what I meant in the first place. Seldom something like that is so well accepted. The patients call and are so happy that they are in the project. Such statements are made spontaneously. And I didn't hear anybody say, well, listen, that's nothing or something like that. Never. Not once. Well, in that respect, I can only say positive things, yes.” (Exp 01)
“And with such a positive tailwind, which they bring with them because, as I said, they feel that they are in good hands, things run easier. And safer.” (FG 2, AA)
These participants felt a work relief through the delegation of home visits, although most of the tasks undertaken by MoniKa were social-management rather than medical. They communicated a perceived advantage in terms of patient safety. On the one hand, they expressed that they have an advantage from the fact that their patients are safer at home when someone trained has taken a look at the home environment.
“I think this is useful for me, too, when I know that patients are at least safer at home. There is no longer the tripping hazard of the carpet, there is perhaps also a nursing classification that is now happening here. There's someone who looks to see if a severely disabled person's ID card is necessary or something else.” (FG1, BB)
On the other hand, they feel better when they know that their patients are being cared for safely, for example, during their practice holidays. By delegating tasks to MoniKa’s continuous care can also be ensured in that case.
“That there is a continuity of care when you are on holiday, that the patient does not have to go to the substitute doctor. The patient is overstrained with such a big thing.” (FG1, EE)
Furthermore, participants with strong patient-oriented values quickly perceived advantages, shortly after implementation. They were more optimistic about the success of the project and spoke very positively about the new care model as a whole. Also, they reported that the enrolment of patients also became more straightforward when a direct benefit was noticed.
“Basically, I specifically addressed those where I saw that they would directly benefit from it. And after I noticed that it actually works well, that it is actually a good offer, it was much easier.” (FG2, DD)
In contrast, participants with more economic-oriented values did not see a direct advantage for themselves from the patient benefits, and they experienced (only) little connection to the success of the project in general.
“Nope, so, a care level has now been classified in a case or one or the other care aid has been purchased. Well, these are then improvements for the patients in the care level. They could also pay someone or...that's something concrete, yeah. And beyond that I wouldn't know right now if something has changed.” (Exp. 2)
“So, for me the use of MamBo is very difficult to evaluate, because of course the problems remain in my memory, where something doesn't work. And when I have hired MamBo like MoniKa, I get a feedback and I think it’s very positive, but I don't notice a direct advantage for me“. (FG1, AA)
For example, one participant with strong economic interests did not see any relief in his work, although he recognized and positively mentioned the work of the MoniKas who conducted home visits. He explained this by the fact that so far too few patients of his practice are involved in MamBo and have received a Monika.
“Well, […] nothing worth mentioning has changed. Because we have two and a half thousand patients a quarter and from this 40 are, or, I don't know, maybe a little more, are in the Mambo project. Well, that is an amount that is not really worth mentioning. And the patients, for some of them the one or other advantage resulted from the visit of Monika, that was quite helpful.” (Exp. 2)
So far, no changes in daily practice or at the societal level have been noticed in the outcomes relevant to them. They were less convinced of the new care model and expressed scepticism, especially with regard to proof its cost-effectiveness within the limited study period. Figure 1 models the link between the desired advantage, depending on the personal value orientation, and the perceived project success. Furthermore, negative consequences, such as the current expenditure of resources were more present in the interview when participants represented more substantial economic interests.
“Well, for that, Mambo would have to prove that it's somehow cost effective. I think it's going to be very difficult. It's going to be hard, just because of the amount of staff involved. I can hardly imagine that it will be successful in the end. Or it is still way too early for that or there are still too few people included. Well, you really should be able to prevent a stay in hospital or perhaps improve the medication etc. somehow, so that people really get a better care and have to go to hospital less often. And I'm sceptical about whether that will succeed. We're all sceptical about that, I suppose.“ (Exp. 2)
“Nah, I don't see any relief. So what perhaps relieves me is that MoniKa now makes house calls and makes useful proposals, which I think is good. But I have more documentation and communication work to do.” (Exp. 2)
3.3 Relevance of a rapid perception of advantages on the implementation process
Based on our findings of the interviews with participating physicians and with reference to a theoretical learning approach, we assume that quickly noticeable advantages are promotive for a continuous as well as a sustainable implementation. Accordingly, relative advantages that only become noticeable after a more extended period, such as economic benefits, inhibit the perception of the project’s success and its continuous implementation. The approach of operant conditioning can be used to support our assumption. As long as a positive consequence is expected or occurs, it is more likely that the behaviour will be repeated. However, the shorter the time between the behaviour and its consequence, the stronger the effect on the repetition of the behaviour [22] [23].
Figure 2 shows the transfer of the approach to our study results. The behaviour “Implementation of MamBo” should be repeated, or in our case, continued. The perceived advantages, conceptualized by the respective outcome relevant for either patient-oriented or business-oriented participants, are the consequence of the behaviour.
Following this approach, MamBo participants with stronger patient-oriented values would be more likely to continue the adoption of the MamBo structures as the relevant advantages for them are quickly noticeable after implementation. Moreover, optimistic and convinced participation promotes communication and thus, the diffusion of innovation [13]. In contrast, it is less likely that economic-oriented participants will continue the implementation in its complete form. Since so far, no or only little advantages have been perceived, no desired consequences reinforces the behaviour.