EMBOSS: reach and Effect of a person-centred integrated-care approach for chronic diseases and MultimorBidity in patients of low sOcio- economic StatuS in general practice
In the Netherlands, chronic care programmes are organised through standardised protocols. While effective for many patients, this approach may result in overtreatment of stable patients and insufficient care for those with complex needs. Person-centred integrated care (PC-IC) in primary care offers a promising alternative to single-disease management for people with chronic conditions. Especially for patients with a low socioeconomic status (LSES) who face more complex (social) problems and need care that is tailored to their situation and abilities.
Aim
The EMBOSS project therefore developed a person-centred and integrated approach in collaboration with patients and healthcare providers.
Results
The EMBOSS project therefore developed a person-centred and integrated approach in collaboration with patients and healthcare providers. The approach included a visual conversation tool to help facilitate discussions about personal situations, needs and possibilities, as well as training for healthcare providers.
Although the effects on health outcomes remained limited over the course of a year, the experiences were positive. Patients felt more heard and appreciated, while healthcare providers gained more insight into the social context and found their work more meaningful. The approach makes it clear that cooperation and simple, understandable communication are essential. The recommendation is to use this form of care widely, so that patients in vulnerable situations in particular are reached , but others also benefit from clear and visual communication.
Recommendations
- EMBOSS emphasises that collaboration with the low socio-economic status (SES) target group is both essential and feasible, as only they can indicate what aligns with their needs, capacities, and skills. Co-development and creation with healthcare professionals is equally crucial, as they are best positioned to assess what is practically feasible within routine general practice. Within EMBOSS, this collaborative approach was successfully implemented, resulting in the joint development of person-centred care and an integrated approach.
- Within scientific research, patients with a low socio-economic status (SES) are often insufficiently reached and included, resulting in many healthcare outcomes that are not inclusive and therefore have limited applicability to this population. To reduce health inequalities, it is essential to address this issue from the outset, beginning with the design of the project plan, and to actively invest in the inclusion of this group in research. This requires the use of accessible communication and appropriate strategies in recruitment, measurement instruments, and research materials, in order to achieve the most inclusive possible study population.
- It is recommended to conduct an additional follow-up assessment after a longer period, as twelve months appears insufficient to detect effects on PROMs/PREMs, laboratory values, and BMI. Such a measurement could provide valuable insights into the longer-term effects of the intervention.
- In addition, it would be of considerable added value to implement the EMBOSS intervention while directly involving professionals from the social care domain. By collaborating from the outset and undertaking the training jointly, part of the integrated network would already be established, facilitating referral processes and enabling patients to access appropriate support at an earlier stage.
- Another recommendation is to apply the EMBOSS approach to all patients within integrated care pathways. Selective identification in routine practice (for example, determining which patients have difficulties with reading and writing or limited health literacy) is challenging. Applying the approach universally ensures that those who need it most are reached. Moreover, evidence suggests that other patients did not perceive the use of simplified materials negatively; on the contrary, they were often experienced as clear and helpful.
- Greater emphasis should be placed on behaviour change strategies for healthcare professionals to support more effective integration of the new approach into their daily routines, thereby embedding it as a standard component of routine practice.
- Additional time should be allocated to support general practices, both in recruitment and in applying the intervention, to prevent it from being overlooked in routine care.
- The application of the intervention in an interdisciplinary setting should be ensured from the outset through the involvement of professionals from both the medical and social care domains. Joint engagement in development, training, and implementation strengthens interprofessional collaboration and facilitates the sustainable implementation of the intervention
Products
Title: Patient experiences with person-centred and integrated chronic care, focusing on patients with low socioeconomic status: a qualitative study.
Author: van Bommel HE, Raaijmakers LH, van den Muijsenbergh ME, Schermer TR, Burgers JS, van Loenen T, Bischoff EW.
Magazine: Br J Gen Pract.
Author: van Bommel HE, Raaijmakers LH, van den Muijsenbergh ME, Schermer TR, Burgers JS, van Loenen T, Bischoff EW.
Magazine: Br J Gen Pract.
Title: Patient experiences with person-centred and integrated chronic care, focusing on patients with low
socioeconomic status: a qualitative study.
Author: van Bommel HE, Raaijmakers LH, van den Muijsenbergh ME, Schermer TR, Burgers JS, van Loenen T, Bischoff EW.
Magazine: Br J Gen Pract.
Author: van Bommel HE, Raaijmakers LH, van den Muijsenbergh ME, Schermer TR, Burgers JS, van Loenen T, Bischoff EW.
Magazine: Br J Gen Pract.
Title: Co-creating a person-centred approach in primary care for patients with low socioeconomic status and
chronic conditions: a participatory learning & action study.
Author: van Bommel HE, van den Muijsenbergh METC, Bergsma B, Burgers JS, Bischoff EWMA, van Loenen T.
Magazine: Prim Health Care Res Dev.
Author: van Bommel HE, van den Muijsenbergh METC, Bergsma B, Burgers JS, Bischoff EWMA, van Loenen T.
Magazine: Prim Health Care Res Dev.
Title: Co-creating a person-centred approach in primary care for patients with low socioeconomic status and chronic conditions: a participatory learning & action study.
Author: van Bommel HE, van den Muijsenbergh METC, Bergsma B, Burgers JS, Bischoff EWMA, van Loenen T.
Magazine: Prim Health Care Res Dev.
Author: van Bommel HE, van den Muijsenbergh METC, Bergsma B, Burgers JS, Bischoff EWMA, van Loenen T.
Magazine: Prim Health Care Res Dev.
Title: European Forum for Primary Care annual conference Barcelona (primary care). Titel presentatie
Person-centred integrated care for people of low socio-economic status with chronic diseases and multimorbidity.
Author: Hester van Bommel
Author: Hester van Bommel
Title: Masterclass Samenwerking in de wijk (Netwerk Gezondheidscentra Zuid Nederland) i.s.m. Regionale Huisartsenorganisatie HGE. Titel presentatie:
Persoonsgerichte en integrale zorg voor iedereen, werkwijze EMBOSS
Author: Hester van Bommel
Author: Hester van Bommel
Title: European General Practice Reseach Netwerk (EGPRN) annual conference Split 2023. Title presentation: Cocreating a person-centred integrated care for people of low socio-economic status.
Author: Hester van Bommel
Author: Hester van Bommel
Title: Webinar Week van de Gezondheidsverschillen, Pharos. Titel presentatie:
Inspiratie voor een integrale & persoonsgerichte aanpak in de eerste lijn
Author: Hester van Bommel
Author: Hester van Bommel
Title: Symposium ‘Iedereen telt: inclusieve zorg, onderwijs en onderzoek’. Radboudumc. Titel presentatie: Persoonsgerichte en integrale zorg voor iedereen: Lessen uit het EMBOSS project
Author: Hester van Bommel, Erik Bischoff, Rob Weijers.
Author: Hester van Bommel, Erik Bischoff, Rob Weijers.
Title: NHG Congres 2024. Workshop Persoonsgerichte zorg voor mensen met een chronische ziekte en lage SES.
Author: Hester van Bommel, Erik Bischoff en Rob Weijers
Author: Hester van Bommel, Erik Bischoff en Rob Weijers
Title: Handreiking Persoonsgerichte en integrale aanpak in de eerstelijnszorg met
brede gespreksvoering
Link: https://www.pharos.nl/kennisbank/persoonsgerichte-en-integrale-aanpak-in-de-eerstelijnszorg-met-brede-gespreksvoering/
Link: https://www.pharos.nl/kennisbank/persoonsgerichte-en-integrale-aanpak-in-de-eerstelijnszorg-met-brede-gespreksvoering/
Title: Handreiking Persoonsgerichte en integrale aanpak in de eerstelijnszorg met
brede gespreksvoering
Link: https://www.zonmw.nl
Link: https://www.zonmw.nl
Title: Gesprekskaart voor persoonsgerichte zorg en ondersteuning in de huisartspraktijk
Link: https://www.pharos.nl/kennisbank/in-gesprek-met-de-patient/
Link: https://www.pharos.nl/kennisbank/in-gesprek-met-de-patient/
Title: Model persoonsgerichte zorg en ondersteuning in de huisartspraktijk
Link: https://www.pharos.nl/kennisbank/model-persoonsgerichte-zorg-en-ondersteuning/
Link: https://www.pharos.nl/kennisbank/model-persoonsgerichte-zorg-en-ondersteuning/
Title: Model persoonsgerichte zorg en ondersteuning in de huisartspraktijk
Link: https://www.pharos.nl/kennisbank/model-persoonsgerichte-zorg-en-ondersteuning/
Link: https://www.pharos.nl/kennisbank/model-persoonsgerichte-zorg-en-ondersteuning/
Title: Gesprekskaart voor persoonsgerichte zorg en ondersteuning in de huisartspraktijk
Link: https://www.pharos.nl/kennisbank/in-gesprek-met-de-patient/
Link: https://www.pharos.nl/kennisbank/in-gesprek-met-de-patient/
Features
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Project number:
10060022010002
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- Duration: 100%
Duration: 100 %20212025 - Part of programme:
- Related funding round:
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Project lead and secretary:
dr. M. Perry MD PhD
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Responsible organisation:
Radboudumc
Addressing knowledge questions form general practice
To support daily general practice in providing appropriate care and assistance to patients, we invest in research addressing prioritized questions from the National Research Agenda for General Practice. Learn more about the projects.
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