Table 1
Primary care nurses. Proposals for improvement.
| Themes | Ranking | Coefficient of variation | Spontaneity |
|---|---|---|---|
| Shared health record | 5.00 | 0.0 | 5 |
| Team work between specialised care, primary care and social services (protocols, care, discussion, etc) | 5.00 | 0.0 | 7 |
| Motivation, commitment, and the taking on of responsibility among professionals | 5.00 | 0.0 | 4 |
| More resources | 4.67 | 0.11 | 4 |
| Efforts to improve communication with patients | 4.22 | 0.16 | 4 |
| More information for staff about the model and continuity of the model | 4.22 | 0.2 | 2 |
| Remote consultations between clinicians | 4.22 | 0.2 | 1 |
| Assigned clinicians | 3.89 | 0.24 | 3 |
| Project champion, to manage conflicts and resistance in the integrated health organization | 3.63 | 0.31 | 1 |
| Data on clinical outcomes by doctor’s list | 3.56 | 0.25 | 1 |
| Videoconferences | 3.11 | 0.41 | 1 |
Table 2
Hospital nurses. Proposals for improvement.
| Themes | Ranking | Coefficient of variation | Spontaneity |
|---|---|---|---|
| Internists to take on their role as case managers | 4.86 | 0.08 | 1 |
| Unification of criteria for action (establishment of protocols for actions, etc.) | 4.86 | 0.08 | 4 |
| Greater commitment from all levels of care | 4.86 | 0.08 | 3 |
| Reinstatement of the figures of the advanced practice nurse case manager and liaison nurse in primary care, or taking on of corresponding functions by a primary care nurse | 4.86 | 0.08 | 3 |
| More staff, to avoid work overload | 4.57 | 0.17 | 3 |
| Differentiation of the tasks of each professional | 4.57 | 0.12 | 2 |
| Information technology tools to simplify record-keeping | 4.00 | 0.14 | 2 |
| Simpler model, based on protocols, that cover more patients (beyond those with multiple health problems) | 3.86 | 0.31 | 1 |
| Grouping patients with multiple chronic health problems on specific doctor’s lists | 3.29 | 0.29 | 1 |
Table 3
General practitioners. Proposals for improvement.
| Themes | Ranking | Coefficient of variation | Spontaneity |
|---|---|---|---|
| Development of protocols and standardisation of healthcare with shared goals, deprescribing | 5.00 | 0.00 | 15 |
| Commitment of the internist: he/she should be a clinical leader and really want the role | 4.86 | 0.08 | 5 |
| Joint training – criteria for stability/instability Communication, communication and communication | 4.71 | 0.16 | 4 |
| Establishment of flexible mechanisms to facilitate communication across the organisation (setting aside time, regular meetings between levels of care, joint meetings) | 4.71 | 0.1 | 7 |
| Definition of tasks and roles | 4.57 | 0.12 | 9 |
| Strengthening the role of patients and their families within the programme for patients with multiple chronic diseases | 4.14 | 0.09 | 4 |
| Real development of information technology tools and electronic health records with automatic reminders and prompts | 4.14 | 0.17 | 2 |
| Development of the skills of primary care nurses for monitoring patients with multiple chronic diseases | 4.14 | 0.17 | 2 |
| Coordination with hospital-at-home services | 4.14 | 0.26 | 2 |
| Encouragement of a greater involvement of general practitioners in the project | 4.14 | 0.17 | 1 |
| Integration with social services | 4.00 | 0.14 | 1 |
| Minimisation of unnecessary hospitalisation at home | 3.86 | 0.23 | 1 |
| Up-to-date records of patients with multiple chronic diseases in the integrated health organisation, discharge criteria | 3.71 | 0.20 | 1 |
| Liaison nurse pursuing the goals of specialised and primary care | 3.71 | 0.20 | 1 |
| Management prioritisation of programs, so that they can be addressed properly | 3.57 | 0.15 | 1 |
| Access by primary care staff to records of hospital follow-up of patients with multiple chronic diseases | 3.14 | 0.29 | 1 |
Table 4
Internal medicine specialists. Proposals for improvement.
| Themes | Ranking | Coefficient of variation | Spontaneity |
|---|---|---|---|
| More resources tailored to needs | 4.25 | 0.24 | 5 |
| Listening to clinicians from the organisation at the planning stage | 4.00 | 0.27 | 2 |
| Definition of priorities [defining roles in a realistic way, distinguishing care of patients with multiple chronic diseases from routine practice) | 3.75 | 0.37 | 4 |
| Official recognition within the organisation of the model and the professionals involved | 3.75 | 0.31 | 1 |
| Implementation of equivalent models in all the integrated healthcare organisations | 3.75 | 0.24 | 1 |
| Strengthening the interaction between levels of care: joint sessions, communication | 3.25 | 0.14 | 1 |
| Sharing of data on the results of the project | 3.25 | 0.39 | 1 |
| Being realistic about the expected results | 3.00 | 0.36 | 1 |
| Greater commitment by “some” general practitioners | 2.88 | 0.29 | 1 |
| Inclusion of internists on the hospital-at-home team | 2.75 | 0.32 | 1 |
| Improvement in the provision of care in the emergency department and its relationship with the hospital-at-home service | 2.63 | 0.35 | 1 |
| Encouragement of remote consultations between clinicians | 2.50 | 0.37 | 1 |
| Prioritisation of programs: “everybody complies with a clear business plan” | 2.00 | 0.40 | 1 |