DEMAND-DRIVEN SERVICES IN HEALTH CARE: A PATIENT-CENTERED TRANSITION ANALYSIS IN ELDERLY CARE

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DEMAND-DRIVEN SERVICES IN HEALTH CARE: A

PATIENT-CENTERED TRANSITION ANALYSIS IN

ELDERLY CARE

Master Thesis – MSc Supply Chain Management University of Groningen, Faculty of Economics and Business

July 25, 2013

LUCHINA PLAT

Student number: s1833650

Email: l.plat@student.rug.nl

Supervisor/ university Dr. H. Broekhuis Co-assessor/ university

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PREFACE

The paper in front of you is my master thesis for the master Business Administration, specialization Supply Chain Management. By finishing this research I will conclude my education at the University of Groningen. I performed research on the development of a demand-driven service supply chain that support the dynamic and complex health needs and preferences of elderly people. For the duration of this research, there have been many challenges and difficult moments, but I have learned a lot. However, I could not have reached my end goal without the help of a number of people.

First of all, I would like to thank my supervisor, dr. M. Broekhuis, for her support and providing me with useful insights and all the feedback I could need during my research. Second, I would like to thank my second assessor, M.R. Van der Laan, for providing insights and especially for helping me during my initial struggles with the dataset.

Next to my assessors, I would like to thank my family and friends for supporting me during this research, for helping whenever I needed and always providing useful comments and criticism. Especially my parents, who have been patient with me during the lesser moments of this research, for their continuous support, encouragement and for always believing in me. Finally, I would like to thank Linda Rietveld, for her mental support during the entire project. Luchina Plat

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ABSTRACT

Due to changes in current health care systems, the need for more patient-centered or demand-driven care services has become apparent. This especially the case in elderly care, where the population is very heterogenic, often has frequent changing needs and preferences over time and is growing in size. The goal of this research is to provide insights for management on organizing better service care chains that support the transitory behavior of elderly people, based on their changing needs and preferences over time. Meanwhile, reducing costs of elderly care and stimulating healthy ageing. By means of a need-based segmentation study, the health trajectories of elderly people, and the triggers that cause transitory behavior, are studied. The results showed that elderly people are mostly inclined to remain within their starting segment over a period of three years (largest shifts) or transition towards neighboring segments (second largest shifts). Currently, the best option found for organizing a demand-driven service supply chain to match the transitory behavior, based on the identified triggers for improving health states of the elderly, is linking existing basic chain care models. These chain care models, the Service-, Transfer- and Kluwen model, each fulfill certain identified needs of the elderly people.

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1. INTRODUCTION

In today’s society, health care users are increasingly expecting care services that fit their personal needs and preferences; they expect customized care. The needs and preferences of the individual are becoming more important in the health sector, resulting in the need for a different approach in the delivery of care, a more demand-driven service delivery. The goal of a demand-driven service approach is to deliver customized care by taking the needs of the care user into account when designing the service supply chain (Rijckmans, Garretsen, Van de Goor & Bongers, 2006). This leads to a major issue in health care today; the societal trend to place a bigger emphasis on patient-centeredness and to strengthen the position of the care user in the traditionally supply-driven system (Meijboom, Schmidt-Bakx & Westert, 2011). For many industrialized countries today, experimenting with patient-centered health care or demand-driven care, which are used interchangeably in this paper, has become very popular (Lako and Rosenau, 2008). Another issue in today’s society concerns the growing costs of health care services, especially of people with ages 65 and higher, and the need to lower those costs (Meijboom et al., 2011). An economically rational way for care providers to deliver customized care is to base the supply of care on the shared needs and preferences of the care user (Lillrank, Groop, & Malmström, 2010). This results in the discussion of placing the individual care user in a more central role while trying to find a better way to balance their health needs and consumption of supplies. But how can care providers organize their service supply chains around the changing needs and preferences of their care users and offer their service supply to match that demand? In this paper, the design of such a service supply chain will be investigated, focusing on elderly care.

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8 properly. The large variety of health related needs of elderly people combined with the aging of Western society implies that they are consuming a growing share of total scarce health care resources (LaFortune, Béland, Bergman & Ankri, 2009). Recently, many projects have been developed in order to seek a solution for improving the quality of life for elderly people, but many of these projects are too general and do not include a target population and their special needs and preferences (Marcelino and Pereira, 2009). However, one way to provide the appropriate care for a large heterogeneous group of care users is by applying a need-based segmentation. By means of a need-based segmentation, robust empirical groups of elderly people can be identified who share similar needs and preferences in health care. By using the identified needs and preferences of the elderly people as a starting point when designing care services, the service supply becomes patient-oriented or demand driven (Rijckmans et al., 2006).

Currently, the general approach to determining the health status of elderly people is to look at relationships among measures of, for example, cognition, frailty, chronic conditions and steps along the disablement pathway (Fried, Ferrucci, Darer, Williamson & Anderson, 2004; Hogan, MacKnight & Bergman, 2003). Although these measures will provide valid health state predictors, they relate differently to various dimensions of health status and take on a more medical or diagnostic point of view (LaFortune et al., 2009). Evidence provides that the trends in one specific domain are not evidence of health trends overall (Comijs, Dik, Aartsen, Deeg & Jonker, 2005). Using a purely medical or diagnostic point of view for determining health states and providing care for elderly people does not match the need for a more patient-centered perspective in health care.

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9 identified in the health trajectory of elderly people based on their changing needs and preferences for care services? and [2] how should a care service chain be organized, i.e. the characteristics, based on the identified transitions or developments in order for care providers to facilitate and support the dynamic and complex nature of elderly people as much as possible during their life’s course? The practical relevance of this research is to provide insight for care providers on how to organize their service supply chain so that it fits with the changing needs and preferences of elderly people. Although identifying the transitory behavior of elderly people has been studied before (LaFortune et al., 2009), the novelty of this research concerns linking the identified transition paths of elderly people to the development of a matching demand-driven service supply chain. The academic relevance results from applying a supply chain management perspective on service care chains and, consequently, by including all needs and preferences of the target population, not solely one specific health area as is currently done.

2. THEORETICAL BACKGROUND

In this section the theoretical foundation underlying this study will be described. First, a review on existing supply chain management (SCM) theory is provided, both general and in health care sector. Second, the concept of need-based segmentation in health care and especially in elderly care is addressed. Finally, the development of demand-driven care chains in general and its link to the needs and preferences of the elderly population is discussed.

2.1 SCM and the Health Care Sector

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10 the customer is not placed outside the value chain, but acts on the inside and can contribute to the process by means of various value-adding activities (Zhang and Chen, 2008). This leads to the most important change in supply chain thinking for services, being customer-supplier duality. Customer-supplier duality in services means that the production flow has turned bi-directional: the products not only flow from supplier to customer, but also from the customer to the supplier (Sampson, 2000). Overall, the customer plays a critical role inside service supply chains. According to Ford and Scanlon (2007), this is extremely the case in the healthcare sector, where the customer (i.e. care user) acts as a value co-creator in the entire service process.

Recent studies have shown that there are numerous other barriers that are slowing down the adoption of SCM practices in health care, including the lack of support from top management and also limited education in the field of SCM practices (Aronsson and Abrahamsson, 2011; McKone-Sweet, Hamilton & Willis, 2005). The fact that there is a lack of adopting SCM practices is very surprising, seeing as 30 up to 40 percent of total hospital expenses are logistics related. Adding to this, close to half of these costs can be eliminated by using supply chain practices (Poulin, 2003). Although there is well-documented evidence that SCM practices result in cost reduction and creates a competitive advantage, the healthcare industry has been extremely slow to embrace these practices. The main reason for the slow embrace is the fact that the patient flow in health care is more complex than in other service industries (McKone-Sweet et al. 2005). This complexity results from the increasing care users’ needs for more different care services on the one hand, and the ongoing specialization of care providers on the other hand. According to Rosendal, Ahaus, Huijsman & Raad (2009), care users are becoming increasingly more demanding in terms of (different) care services. At the same time, due to ongoing specialization, more and more different care providers need to be involved in the care supply chain of a single care user. As a result, care users often have to deal with multiple care providers during their entire care process and all those different care providers have to be inter-related in order to provide the right care for the care user.

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11 that the supply-driven approach is no longer sufficient and the need for a demand-driven approach increases. According to Vollmann et al. (2000) a demand-driven supply chain can be defined as a supply chain in which all actors involved are sensitive and responsive to demand information of the end customer and meet those varied and variable demands in a timely and cost-effective manner. This is specifically the case when the demand-driven aspect of care provision is highlighted, suggesting that the focus on that end of the supply chain should be articulated more clearly (Schary and Skjott-Larsen, 2001; Al-Mudimigh, Zairi & Ahmed, 2004). By focusing more on the needs and preferences of the care user, the design of the supply chain becomes demand-driven, starting at the bottom with the care user.

A form of demand-driven care services is called chain care: a coherent set of focused and planned activities and/or measures aimed at a specific category of care users, phased in time and patient-centered(Raad voor de Volksgezondheid en Zorg, 1998). As in SCM, the focus in chain care is on intensive coordination and integration between different links or parties in the care- or logistics chain in order to avoid sub-optimalization (Rosendal et al., 2009). This phenomenon is the result of years of development and search for more consistency and alignment in care services and does not only connect all professionals involved, but also makes new connections between the content, the organization and the financial side of care services (Kesteloot and Defever, 1998). Within chain care, there are basically two continuous developments: (1) the constant need to improve the quality of care and (2) the strive to control the continuously increasing costs of care and welfare (Rosendal et al. 2009). Although chain care is a step in the good direction in the development of supplying demand-driven care services, chain care is only a milestone on the way of achieving better quality of care and improving or maintaining quality of life for the care user.

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12 input of experts in the field (HKZ, INK, Kwaliteitskader ketenzorg). In other words, the main focus of disease management so far has not been on the total health state of care users, but on certain components of conditions and their integration (Rosendal et al., 2009). However, the fact that most disease management programs use the care user as a starting point is a good step towards more demand-driven chain care.

Although disease management adds to the development of patient-centered chain care, there are some challenges left for the future. These challenges mainly concern dealing with multi-morbidity (the presence of two or more chronic or acute conditions within one person) (Van Bussel, 2007). This is especially interesting seeing as the numbers of patients with multi-morbidity will increase in the future, partly due to an aging population, but also due to improved treatment of conditions (Donkers, Bras & Van Dingen, 2008). The expected increase of care users with multi-morbidity results in the need for more development in the area of chain care. Mainly the need for the creation of more demand-driven programs that include multiple conditions (Rosendal et al., 2009). In these types of programs, the GP’s and the geriatricians will fulfill an important coordination role. For these programs to develop, it is first important that agreements are reached on regional levels on the care trajectories for elderly people. Second, it is important that the GP is appointed as the primary focal point in order to adequately and effectively provide care for chronic and complex care users throughout their entire care process. Also, in order to provide the optimal care, multiple care providers will be involved in the process (RVZ, 2008).

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2.2 Need-based Segmentation and Transition Paths

This section will be split up in two separate sub-sections. First, need-based segmentation and the current studies in general and in the healthcare sector will be discussed. Second, current literature on transition paths in general and in health care will be addressed.

2.2.1 Segmentation studies

Oliver and Webber (1982) were two of the first authors that proposed a critical evaluation of trade-offs between manufacturing, production strategy and what the customer wants. However, the first explicit link between market requirements and manufacturing processes was made by Hill (1985), who introduced the concept of order winners and order qualifiers. After that, many authors came with different theories, but it was Chorn (1991) who first stated that a segmented supply chain strategy should be developed when one understands what the customer wants. It then makes sense that, when groups of customers exist with differentiated service requirements, to try to optimally match their expectations through some form of a differentiated supply chain (Godsell and Harrison, 2002). Adding to that, Gattorna, Chorn & Day (1991), proposed early on that the only way forward is behavioral segmentation of customers, based on their buying behavior. They believed that, based on the buying behavior of customers, supply chain strategies can be developed to meet the requirements of individual segments. The work by Gattorna (1998) has since become increasingly more applied in several industries.

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14 customization without increasing costs (De Blok et al., 2010). Adding to this, Marcelino and Pereira (2009), state that using an approach which includes accumulating the knowledge and experience of the care users themselves will lead to an increase in the quality of life and creates new services that will meet the community’s expectations.

In elderly care, where the care users are heterogeneous and have complex, dynamic and increasingly chronic needs for care, segmentation can be a very useful tool. Based on research by Van der Laan, Van Offenbeek, Broekhuis & Slaets (2013), these needs and preferences can be grouped: (1) experienced needs rather than an objectified needs assessment by health care professionals; (2) holistic health-related needs rather than disease-oriented needs; (3) and holistic referring to covering the entire scope of human functioning (physical, psychological, social, mobility, and cognition). They used this need-based assessment to come to the following five segments or sub-groups of elderly people: (1) vital; (2) psychosocial coping problems (PSC); (3) physical and mobility problems (PM); (4) problems in multiple domains (MD); and (5) extremely frail. The segmentation is based on calculating probabilities for each of the needs (physical, psychological, social, mobility, and cognition) and linking them to the five segments. The segment on which the elder has the highest probability is the segment in which he or is placed. Although an elder can belong to several segments, he or she is placed in one segment in its entirety. These five segments, from vital elderly until extremely frail elderly, are increasing in complexity of needs and preferences and decreasing in health state. The five segments of elderly people identified by Van der Laan et al. (2013) will be used in this study as a starting point for researching transitory behavior. Adding to their research, Slaets (2013) found that the costs of care for elderly people is relatively stable and low for the vital and the PSC segment, but the costs increase exponentially from the PM segment and up. Consequently, as it is the goal to keep elderly people healthy for as long as possible and also decrease costs of care, it becomes interesting to investigate how a service supply chain can be designed in order to keep elderly people in the vital segment or to ensure they again become part of it.

2.2.2 Transition paths

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15 people properly during their life’s course (LaFortune et al., 2009). Without the former, it is difficult to understand the dynamic of health status (LaFortune et al., 2009). Consequently, it becomes interesting to investigate how the health trajectories, or transition paths, of elderly people progress over time.

Research on transition paths in health care, specifically in elderly care, is scarce and little validated results could be obtained. However, seeing as the aim of identifying transition paths is to study segment membership of elderly people over longer periods of time, some general theory can be provided. When discussing transition paths in the health trajectory of elderly people, the focus is on the so-called trigger that changes their needs for certain care services. Among elderly people, this trigger can happen unexpectedly and also more frequently than among the population of younger adults. This is mainly due to the decreasing health status and frailty of elderly people (De Blok et al., 2010). Consequently, it becomes interesting to investigate what triggers occur in the health trajectory of elders and which transitory paths they follow.

Therefore, research question 1 (RQ1) is modified to: To what extent can we identify transition

paths in the needs of elderly people and also identify triggers that influence changes in their transitory behavior?

2.3 Demand-driven SCM in Health Care

The following section will first elaborate on the issue of linking need-based segmentation to the development of a matching service supply chain and, secondly, provide information on current demand driven care chain in the health care sector.

2.3.1 Need-based segmentation and the development of a SC

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16 From section 2.1 and 2.2 it becomes abundantly clear that the health care sector is too big and too diversified in order to be treated as one single industry with one perspective and one solution to operations management (Lillrank et al., 2010). According to Miller and Page, 2007), this problem can be approached by viewing all elements through a conceptual lens and this way revealing meaningful, even simple, patterns. It is in this light of decreasing complexity in the supply of care services, that health care should be segmented or classified into parts that are similar in certain aspects and are homogeneous enough to be managed. However, after dividing a population into sub-groups, what is the next step in eventually organizing a matching demand-driven supply chain? Unfortunately, literature on this topic could not be found, mainly due to the scarce amount of literature on need-based segmentation in general. However, a number of interesting findings can be provided concerning this topic. Even in demand-driven supply chains, it is important to note that knowing and understanding the demand of the target population is not enough. For example, in health care operations, the care users may not need what they want, or do not want what they need (a healthier lifestyle). Care users may expect what cannot be provided or may ignore what is available (Motwani, Klein & Harowitz, 1996). Basically, care users are often reluctant, scared, confused and have difficulty articulating their needs. Health care providers simply cannot answer every need and preference of their care users, so it is important to understand that there are supply restrictions.. Knowing what the target population wants does not guarantee that those services can be provided. Unfortunately, studying the supply chain restrictions of elderly care is outside the scope of the research. Therefore, existing basic chain care models for elderly care will be used as a starting point for organizing a service supply chain that will support the identified changing needs and preferences of the elderly people. This circumvents the issue of investigating supply chain restrictions in elderly care and also the need for developing a service supply chain from scratch.

2.3.2 Current basic care chain models

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17 the Service model; and (3) the Kluwen model. Donkers et al. (2008) indicate that the models are not yet suited for extremely complex care needs and that it is also not yet proven which of the three models has the most potential for innovation. The three basic chain care models are based on the characteristics of demand for care services and the organization of supplying them. These characteristics by Donkers et al. (2008) will first be discussed per model and are later on summarized in table 1.

In the first model, the Transfer model, the focus is on the recovery of the care user and regaining total independence. It mostly concerns care users with an acute condition who have an operation or have other temporary disturbances of their physical performance. The care user receives sequential care of decreasing intensity in order to regain independence. In these types of care chains, no care provider is primarily responsible, but the responsibility for total care as well as treatment responsibility is handed over during transfers between care providers. The care pathway is relatively predictable in its course and knows certain evaluation points during the process.

In the Service model, the care users need care for chronic and often multiple conditions. Most of the time, the needs of the care users are rather predictable due to recurring conditions, but sometimes new conditions emerge. The care users usually deal with multiple care providers simultaneously, of which one carries primary responsibility. The care pathway is less predictable compared to the Transfer model. In some cases, the care process can easily be scheduled and programmed, in others, it is rather unpredictable and new care providers have to be involved. It is the responsibility of the care provider in charge to timely involve new and appropriate care providers. The collaboration of the care providers is aimed at the execution of plannable and not plannable care activities.

Finally, in the Kluwen model, the care users are increasingly in need of more care by a large number of care providers due to deteriorating health and the disability to take control over their own situation. In these models, the care providers form a team of which one provider is in charge, but they also retain their own responsibility. Within these models, the coordination and collaboration of care providers is extremely important in order to keep the process from becoming unmanageable.

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Characteristics Transfer model Service model Kluwen Model

Demand

Complexity of care needs

Low. Care processes are clear beforehand, but highly unpredictable in

terms of scheduling.

Medium. Care processes are not

always clear beforehand or easy to schedule. High. Care processes are unclear beforehand and hard to schedule. Dynamics of condition(s)

Low. Treatment is often for a returning condition. Small

changes in care needs.

Medium. Treatment is often for

returning conditions, but also

for new ones. Medium changes in

care needs.

High. Chronic conditions often

change in severity and new

conditions emerge. High changes in care

needs. Acuteness of care

needs High Low Medium

Supply

Order of care service Sequential Parallel Parallel

Responsibilities

Decentralized. No one is primarily responsible. Every

link in the chain has own responsibility of care and

treatment. Centralized. One care provider is primarily responsible. This person decides when other care providers have to be contacted (subcontractors). Semi -centralized. Often care is provided by means of a team, of which one carries main responsibility. Focus of collaboration between care providers

Creating a good patient flow with adequate transfers between all

participating parties. Execution of the care processes. Operational agreements between care providers are central. Exploration and solving the problem, aided by standards and guidelines. Mutual dependence of care providers

High in terms of reaching the end goal

High. Only together can they reach their

end goal.

High. Only together can they

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care users during the course of the process.

stimulated throughout the

process.

are often not able to care for

themselves.

Performance measureme

nt

Measured in terms of admittance duration and throughput times, less on functional results for the

care user. Measured on the level or intensity of the condition: optimal configuration of care processes or as little consequences as possible for the

care user. Measured on patient-level and their environment (their experienced appreciation of coordination and support).

According to Donkers et al. (2008), the Service model is best suited for general elderly care. Due to its ability to deal with chronic and complex conditions. However, it can also be said that the Service model mainly concerns chronic conditions that are relatively easy to treat and are predictable in terms of development process. The Kluwen model on the other hand incorporates highly complex and unpredictable care needs and seems more appropriate for elderly people who are not able to take care of themselves and require around the clock care. The Transfer model is the only one that uses sequential care, decreasing in intensity, and appears applicable only for elderly people who are relatively vital and are able to regain complete independence.

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20 Therefore, research question 2 (RQ2) is modified to: To what extend can the basic chain

models by Donkers et al. (2008) be used to organize care supply chain for groups of elderly people who undergo similar transitions in their needs and preferences?

3. METHODOLOGY

The aim of this research is to gain insights into the transition paths of the health trajectory of elderly people in order to develop a service supply chain that matches and supports their changing needs and preferences over time. In order to answer research question [1], data was gathered by means of surveys among elderly people living in the northern part of the Netherlands. By means of basic SPSS and Excel formulas, analyses were performed to investigate the transitory behavior of elderly people over time and the triggers that cause them. After the transitory behavior of elderly people was established, research question [2] on how to design a matching service supply chain, was answered by means of using basic care chains (Donkers et al., 2008) for elderly people. With regard to RQ2, the assumption is made that it is the goal of society to keep elderly people healthy and independent for as long as possible. This concept is also known as healthy ageing and decreases costs of care. More information on the segments and the related costs will be discussed in the results section.

3.1 Research Method

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21 questions and the related answers. One dataset for each TM resulted from the surveys and each was put into the program SPSS 20.0 for statistical analyses.

3.2 Sample Selection

The original sample included 2019 older adults, age 64+, living in the northern part of the Netherlands. In order to ensure that no elderly subgroup was excluded, a stratified sampling based on living condition was performed through 26 diverse healthcare organizations, welfare organizations and elderly associations, from both rural and urban areas. During the data collection process, the living conditions of the elderly, including temporary hospitalization or stays in nursing homes, were monitored. If the received data turned out to be insufficient, the relevant organization or association was contacted and asked to enlarge their sample.

3.3 Analysis Strategy

The analysis strategy contain 3 consecutive steps: namely gathering descriptive information on the sample group, the identification of transitions paths of elderly people and the triggers that cause them, and the organization of a care service supply chain based on the basic chain care models by Donkers et al. (2008). These steps will be elaborated in the following section. 3.3.1 Descriptive information

Before the actual analyses, the SPSS data set was thoroughly checked on irregularities and errors. All errors found (see appendices, table B1) were deleted from the original set of 2019 elderly and a total of 1946 elderly people remained. Seeing as the actual first step of this entire research, the segmentation study, was already performed by Van der Laan et al. (2013), this step was not repeated. Instead of that, basic descriptive information (average age, size, characteristics and living condition) concerning each of the segments was collected in order to gain initial insights in the data. Finally, before starting with the transition analyses, the segments were first linked to the basic chain care models discussed in section 2.3 (Donkers et al., 2008), based on the demand and supply characteristics of each model and each segment. 3.3.2 Identifying transition paths and triggers

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22 percentages indicated the relative size of the flow from one segment to the other over a period of one year. Besides the percentual shifts, the actual individual trajectory followed by an elderly over the total period of three year was also studied. By combining all the individual trajectories, a clear picture could be provided on the actual transitions the elderly people went through.

Adding to the transition analyses, the next step was to look for differences between certain groups of elderly people based on their health trajectory. Mainly, why some elderly improved with regard to their health status and others did not (the triggers mentioned in section 2.2). With the main goal of this study in mind, the elderly people were grouped as followed over the period of three years: improving health, no change (stable) and deteriorating health. Eventually, 5 (segments) x 3 (groups) groups were created. Due to the fact that each segment had specific characteristics, they were kept separate and the health trajectory of elderly people was studied per segment in which they started. The main focus in the analyses was on the improved versus the stable group from segment 2 (PSC) and up. These analyses were chosen due to the fact that the main interest lies in making sure the elderly people remain or return to the vital (1) segment. The relevant items on which to test the differences between the groups, the triggers, originate from the survey ‘Screening of elderly’. Of the total 40 items from the survey, only 16 were used for the segmentation study. These 16 items cannot be used again for determining key differences between groups, because that has already been done in the segmentation study. From the remaining 24 questions, the first four questions provide general information about the participants, such as gender and living situation. Questions 8 – 11 (physical needs), 17 and 18 (psychosocial needs), 26 – 28 (social needs), 30 and 31 (mobility needs) and 39 and 40 (wellbeing) all relate to the demand side of the elderly people. The remaining questions, 32 – 38, relate to the supply side and concern the use of health care services by the elderly people. Especially the items related to the supply and demand side were of interest, because those items could be linked to the characteristics of the basic chain care models by Donkers et al. (2008) in section 2.3. The search for triggers in the health trajectories of the elderly people was facilitated by means of independent samples t-tests in SPSS 20.0 for each group comparison.

3.3.3 Organization of a care service supply chain

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23 behavior of elderly people per starting segment, more insights were provided on the moments elderly people transition towards another model and why. In order to do so, the main focus was on identifying which triggers of the demand side (see table 1 section 2.3) were responsible for triggering these transitions. The reason for focusing on the demand characteristics is the goal of organizing a serve supply chain based on the demand of the target population. Also, the exact moments of transitory behavior towards another model could be addressed. Finally, though it was not within the scope of this research, suggestions were provided for linking the basic chain care models and areas where the models contained room for improvement were pointed out.

4. RESULTS

This section presents the results of the research. First, more information will be provided on the sample group and the five segments identified by Van der Laan et al. (2013). Second, the three basic models from Donkers et al. (2008) will be linked to the needs and preferences per segment. Third, the transitory behavior of the elderly people and the triggers will be identified and, finally, the link will be made between the health trajectories of the elderly people and the basic care chain models by Donkers et al. (2008).

4.1 Descriptive Information

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24 TABLE 2. Average segment scores on the five needs.

Range Vital PSC PM MD Extremely Frail Mobility needs 0 – 4 0,05 0,01 1,62 1,81 3,67 Psychosocial needs 0 – 15 0,32 2,68 0,97 4,88 9,16 Social needs 0 – 6 0,41 1,55 0,92 2,05 2,88 Cognitive needs 0 – 2 0,30 0,57 0,43 1,05 1,90 Physical needs 0 – 14 2,88 4,78 5,97 8,00 9,82

General information concerning segment size, average age, man/female ratio, living condition and group characteristics per segment can be found in table 3.

TABLE 3. Descriptive information about the segments. Size Average

age

Man/female

ratio Group Characteristics Living condition

Vital 29% 76 52%-48%

In this group, 45% experiences chronic conditions, but are able to manage their situation. They often require some extra care for a short period of time and are able to regain independence.

Home 48%

Elderly care home 11% Nursing home 6% Hospital 36%

PSC 18% 78 40%-60%

This group experiences chronic conditions, they sometimes feel fearful, tense and sometimes miss attention from others. These elderly require more frequent care and support.

Home 44%

PM 27% 81 31%-39%

This group experiences chronic conditions and struggles with activities in daily life. They often require help from others on a daily basis and often do not regain independence.

Home 21%

MD 23% 81 32%-68%

This group has chronic conditions and struggles with activities in daily life. They also experience psychosocial problems and cognitive impairment. These elderly require daily care and are dependent on other.

Home 25%

Extremely

Frail 3% 83 27%-73%

This group experiences severe problems in multiple domains. They are not able to take care of themselves and depend heavily upon others.

Home 16%

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25 Although table 3 shows the average segments sizes, there was an overall decrease in segment size during the three year period. Meaning that the number of elderly people per segment decreases every year (see appendix II, table B3). In total, 821 elderly drop out of the project, either due to lack of interest, death, inability to communicate properly or even due to inability of the hospital to find them. These elderly are represented as missing values and are called Lost To Follow-up (LTF). Table B3 in the appendix II, shows that the percentages of LTF increase alongside the complexity of the segments. In other words, the lowest percentage of LTF, after both TMt=1 (2010) and TMt=2 (2011), is found in the Vital segment. The highest percentage of LTF occurs in the extremely frail segment after both TM’s. Of the 1946 elderly people, the total LTF is 42% at the end of the project.

Finally, to conclude the descriptive information, figure 1 shows the average costs per elderly per segment. These costs per person include the AWBZ (Algemene Wet Bijzondere Ziektekosten) and the ZVW (Zorgverzekeringswet). The elderly in the vital and PSC segments are relatively low on costs, but after that, they increase exponentially. Costs per are definitely highest in the extremely frail group, with approximately €47.000,- per elderly. FIGURE 1. Costs per elderly per segment.

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4.2 The Basic Chain Care Models and the Segments

In this section, the three basic care chains by Donkers et al. (2009) will first be linked to the five segments of Van der Laan et al. (2013). By doing this, the transitions between segments and their effect on the type of care model can be discussed. As mentioned in section 2.3, the Service model is claimed to be most suited for general elderly care (Donkers et al., 2008). The Service model deals with both complex and routine conditions, plannable and not plannable, it seems to incorporate the total care package. However, the remaining two models both have characteristics that are definitely suited for two distinct segments. First, the Transfer model is most suited for elderly people who temporary need extra care services and afterwards regain their independence: elderly people who reside and remain in the vital segment. This model aims at decreasing the intensity of care in order for the elderly to regain independence. Although the complexity of care in this model is relatively low and the care processes are predictable, the conditions of the elderly are often of an acute nature and require a quick response. In order for elderly people to remain in this model, they have to be able to recover almost completely and regain their independence. Second, the Kluwen model is best suited for elderly people who are increasingly in need of more complex care and have lost the ability to take care of themselves. They need around the clock care and depend heavily upon others: the extremely frail elderly. The model incorporates highly complex and mostly unpredictable conditions, as is the case with the extremely frail elderly.

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4.3 Identifying Transition Paths

From here, the results of the actual analyses of this research will be provided. From the transition analyses, it became clear that there is no long term effect when it comes to the transition flows of elderly people between the segments. This means that the percentual shifts are relatively the same between each TM and the percentages can be combined in one table. Table 4 provides the average yearly percentual shifts that occurred. The actual shifts between TMt=1 - TMt=2 (2010-2011) and TMt=2 – TMt=3 (2011-2012) can be found in appendix II, table B4 and B5.

TABLE 4. Transition Matrix To Vital PSC PM MD Frail From Vital 54% 21% 21% 5% 1% PSC 25% 33% 25% 18% 1% PM 18% 18% 42% 22% 2% MD 4% 13% 25% 49% 9% Frail 1% 2% 10% 34% 54%

Based on these percentages, the chance that an elderly person at one random moment moves from the Physical Mobility segment (PM) toward the Multi Domain segment MD), a transition towards an unhealthier segment, within one year is roughly 22%. Another example, the chance that an elderly moves from the Extremely frail segment towards the PSC segment, a transition towards a healthier segment, within one year is about 2%. It also becomes clear from the largest percentages (in bold) that most elderly people remain within the same segment over a period of one year and that the second largest shifts occur between neighboring segments (underlined). The transitions between neighboring segments occurs both towards healthier and unhealthier segments.

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28 numbers are elderly who were LTF after TM2. The largest group concerns elderly who start and remain in the vital segment, a total of 209 people (15%) of the 1946 participants.

TABLE 6. Most common transition paths.

Path Frequency Percentage

1 111 209 15% 2 333 89 6% 3 444 79 6% 4 222 60 4% 5 44 53 4% 6 33 47 3% 7 11 28 2% 8 34 33 2% 9 112 35 2% 10 122 34 2% 11 113 27 2% 12 211 26 2%

When these transition paths are compared with the transition matrices, it is not illogical that the largest groups follow a health trajectory that show they stay in the same segment over the period of three years. This trend is also shown in the transition matrices, where the largest percentages per column indicate that those elderly remained within the same segment.

4.4 Identifying Transition Triggers

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29 too small in order to compare on items from the survey by means of an independent samples t-test (N<30), so it was excluded from the analyses. The reason for focusing only on transitions towards healthier segments is due to the fact that by focusing on delaying deteriorating health (comparing the stable with the deteriorating group), the elderly people will, at best, remain in the segment where they already are.

As mentioned earlier, the significant differences or triggers will be determined with the remaining items from the survey ‘Screening of elders’ that were not used in the segmentation study by Van der Laan et al. (2013). An overview of all items (possible triggers) and their scores per group can be found in appendix III. The following information per segment resulted:

Segment 2: Psychosocial problems

By comparing the two groups of elderly that started in this segment, it became clear that the two groups scored significantly different on items concerning social areas. Elderly people who started in this segment, but improved over the three years scored significantly better on the item concerning contact with other people (item 27). Relating to this item, the improved group also indicated that they received more support from their surroundings (item 28). These two items relate to the characteristics of this segment, being psychosocial problems. Also, the stable group scores higher on two areas of wellbeing: namely being active and pleasant living (item 39). The stable group indicated that they find these two areas especially more important than the improved group. Finally, another important factor for improvement concerns medication. Elderly in the improved group receive more than four different types of medication; the stable group received significantly less.

Segment 3: Physical mobility problems

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30 supply of the care services, the improved group has significantly received more care from specialists, hospitals (item 33) and nursing homes (item 35). Adding to the previous, the stable groups were also significantly more negative about the properness of care they received (item 36) and about the collaboration of their providers (item 37). Next, the groups score significantly different on a number of wellbeing areas that they find important: pleasant relationships and contacts, being active, being able to take care of yourself and feeling healthy of body and mind (item 39) (demand side). On all these wellbeing areas, the improved group indicated they found them significantly more important than the stable group. The results did not indicate they were also more satisfied about these areas of wellbeing. Finally, the result showed a difference in group characteristics, a significant difference in age between the groups. The elderly people that remain in the PM segment over the period of three years are generally older (83 years on average) than the elderly who showed improvement in their health status (77 years on average).

Segment 4: Multiple domain problems

Concerning all the elderly that started in this segment in the first year, the stable group indicated that they less often felt calm and peaceful (item 18) when compared with the improved group. Also, their contact with other people was significantly harder to establish or maintain (item 27). The improved group indicated they had contact with their GP less than four times a year, while the stable group indicated to have contact more than four times a year (item 33). Related to this item, the stable group had a significantly more negative experience with their care providers (item 34).

4.5 From Need-based Segmentation to Organizing Chain Care

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5. DISCUSSION

The main goal of this research is to research how service chain care should be organized in order to keep elderly people as healthy as possible for as long as possible and to provide them with the care they need in order to fulfill their changing needs and preferences for care services. With regard to RQ1, it can be said that no specific health trajectory was identified among the sample. From the data it became clear that close to half of the participating elderly people, a total of 40%, remained within the same segment for the duration of three years. Although that does not mean that their heath needs were completely identical every year, they did stay stable enough for the elderly to be placed within the same segment. This results in arguing if, on the one hand, the period of three years is too short in order to be able to properly identify health trajectories. On the other hand, due to the dynamic nature of elderly people’s health, a period of three years should suffice, based on the fact that no long term effect was found in their needs and preferences. The results of the transition analyses support the latter by showing that there is no long term effect in the transitions, the shifts remain relatively the same each year. Whether elderly people are followed over a period of ten years or three, the percentual shifts will most probably remain the same. It does become interesting to find out why elderly people tend to get ‘stuck’ in their segment. Why do most of them remain in their starting segment for a period of three year? Whether that is a result from the current state of care provision or due to other factors, is unknown. However, from the results it can be said that not much attention by care providers so far is directed on stimulating the movement of elderly people towards healthier segments, seeing as they largely remain in the same segment. Besides elderly people remaining within the same segments, it was also found that the shifts towards neighboring segments, both towards healthier and unhealthier segments, was second largest. This trend, especially the transitions towards unhealthier segments, is not unexpected since the natural course of elderly people often entails becoming more frail as the years go by.

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32 used as care arrangements in the future, but they also each have characteristics that provide a good basis for care arrangements in elderly care. Although Donkers et al. (2008) state that their Service model is most suited for elderly care, it focuses more on general elderly care and does not provide a complete fit with the variety of needs and preferences of all segments. Combining all three models, the Service-, Kluwen- and Transfer model, would best represent the identified needs and preferences of the sample population. The Kluwen model fits best with elderly people who need increasingly more and complex care and cannot take care of themselves, and the Transfer model best suits vital elderly people who momentarily need extra care and are able to regain independence. However, it is not always so black and white, there are also elderly who are close to the boundary that divides two segments. For example, an elderly who is placed in its entirety in the Vital (first) segment can have a number of the same needs as the elderly in the PSC (second) segment. It then becomes difficult in determining which chain care model is best suited for their needs. This research provides no insights on this topic, but it can be said that the health situations of these border cases will differ per person and that the GP will probably be best suited in determining what is best for the elderly involved.

Concerning the health trajectories, whenever an elderly shifts from or to segment 1 (Vital) and 5 (Extremely frail), the link with another model has to be made. Though it is outside the scope of this research to research which supply chain mechanism can best facilitate these transitions, a number of suggestions can be made. First, the general practitioner will play an important coordinating and supporting role in the care processes of elderly people in the future. As in the current Service model, the GP will have main responsibility of a specific elderly and will decide when and if an elderly needs different care. It is important that the GP remains the focal point in all care processes and that he or she makes sure that all parties involved have the necessary information about the elderly involved.

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33 demand of elderly people, feeling calm and peaceful and maintaining good contacts with other people (psychosocial and social needs) seem to trigger improving health states. So, when it is detected that elderly people starting in this segment score low on these needs, their care providers need to find out the underlying reason for their situation and aim at fulfilling those needs. Adding to that, when elderly people indicate that they have contact with their GP’s more than four times a year, there is good reason to believe they will not improve in the following years. Related to their social needs, their experiences with their GP are most likely to be negative. A GP could see these triggers as a combined warning for elderly people who need more attention in order for their health to improve. If elderly people do transition from this segment (MD) towards healthier segments, they are most likely to first arrive at the third segment (PM).

In order to stimulate elderly people from the PM segment towards healthier segments (2 or 1), the triggers discussed next are of importance. First, general characteristics of people who are for more likely to move towards healthier segment include age, the ability to fill out the survey themselves and their home situation. The improved elderly are often younger (77 years), are able to fill out the survey themselves and depend less on others in daily life. Concerning the age factor, it is interesting to see that the PM segment is the only one in which the improvement trajectory is related to age. It seems that improvement after physical problems coincide with age more than with psychological problems. Also, as in the previous segment, the stable elderly in this group also have difficulty with maintaining good relationships with other people. The main issue that seems to trigger improving health in this segment concerns independence of the elderly. The improved group scores better on items concerning being able to take care of yourself and being healthy of body and mind. It seems that this group needs more care services from specialists, hospitals and nursing homes in order to regain independence. Although this seems like a paradox, receiving more care services can facilitate a faster recovery for this particular segment that copes mainly with physical mobility problems. Also, it is important that the care providers are collaborating in order to make this recovery possible.

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34 are triggered to transition towards segment 1. Another important trigger concerns medication. The improved group uses significantly more types of medication. Whether this enables them to be more active or, for example, repress unhappy feelings, is unknown but nevertheless an important trigger.

When all previous mentioned triggers are taken into account, the transitory behavior of elderly people from their starting segment towards healthier segments can be stimulated. The ultimate goal is to stimulate transitions towards the Vital segment for as long as possible. Note, if the elderly people transition into the vital segment, they switch from the Service model to the Transfer model. Also, when elderly transition from the Extremely Frail segment towards, for example, the MD segment, they switch from the Kluwen model to the Service model. Unfortunately, as explained in the previous section, the extremely frail segment was not included in these analyses and, consequently, the triggers within that segment and its link to the Kluwen model will not be elaborated on in this study.

Now that the two research questions are answered, the final conclusion can be drawn and recommendations for future research will be made.

6. CONCLUSION

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35 The result from this research has several theoretical implications. For one, it adds to the development of chain care programs based on need-based segmentation of the target population by suggesting the basic chain care models as a starting point for developing a service supply chain. However, linking these models in order to provide the right care has not been researched in this study. Furthermore, it provides some interesting insights on transitions paths in elderly care and the factors that trigger transitory behavior. Finally, this research supports earlier findings made by Donkers et al. (2008), who stated that the Service model can be used in general elderly care. This research adds to theirs by suggesting that the Transfer- and Kluwen model are also suited for elderly chain care, mainly for the Vital and the Extremely frail segments. The main managerial implication of this research concerns the fact that initial steps are made for organizing a service supply chain for elderly care. BY suggesting the basic chain care models as a starting point, the steps necessary in order to link them can be studied next. Also, the transitory behavior of elderly people identified could assist management in directing their focus for improvement of supplying care services.

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APPENDIX I. Survey ‘Screening of elderly’

Netwerk Ouderenzorg Regio Noord

Vragenlijst “Behoefte als kompas, de oudere aan het roer”

Deze vragenlijst bestaat uit 39 vragen. Er wordt gevraagd naar uw algemene situatie, lichamelijke en geestelijke gezondheid, omgang met gezondheid en ziekte, relaties, zelfredzaamheid, gebruik gezondszorg en welbevinden.

Instructies voor het invullen:

Lees voordat u de vragen beanwoordt eerst de antwoorden goed door. Kies het antwoord dat het best bij uw situatie past. Soms mag u meerdere antwoorden invullen, dit staat dan bij de vraag. Neem rustig de tijd voor het invullen. Het kan voorkomen dat bepaalde vragen op elkaar lijken. Toch is het belangrijk dat u alle vragen invult.

Markeer het vakje van uw keuze. Indien u zich vergist, markeert u het juiste vakje én omcirkelt u deze binnen het vakje

Uw naam Straat + huisnummer Postcode Woonplaats Telefoonnr. E-mail adres Burgerservice nummer

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APPENDIX II. Excel tables

Table B1 provides an overview of all errors that were deleted from the dataset. The UID represents the unique identification number that was given to each participating elderly. Besides errors 1 through 8, 63 elderly people were identified in the data set who participated only in TMt=1 and TMt=3, but skipped TMt=2. These 63 people are indicated under error 9 through 71. Seeing as no proper trajectory could be identified due to one year of missing information, these people were also deleted. The first two errors both count twice, seeing as they occurred double in the dataset. Bringing the total of errors to 73.

TABLE B1. Errors from data set

UID Reason for exclusion

1 34705527057 Appears twice in TMt=1 2 999516886486 Appears twice in both TMt=1 and TMt=2 3 992015606310 Not placed in a segment in TMt=1 4 909119376889 Not placed in a segment in TMt=1 5 889900355054 Not placed in a segment in TMt=1 6 783291924745 Not placed in a segment in TMt=1 7 456869211959 Not placed in a segment in TMt=1 8 455869981614 Not placed in a segment in TMt=1

9 - 71 X Skipped TMt=2

Table B2 gives an overview of the scores per segment and per year on each of the five health needs. These scores were combined into one table (table 2 in section 4.1) that provides the averages per segment and per health need.

TABLE B2. Segment scores on the five needs per segment

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(Psychosocial Coping problems) PsN 3,04 2,55 2,44

SN 0,65 1,99 2,00

CN 0,56 0,53 0,61

PhN 4,63 4,86 4,84

Segment 3

(Physical Mobility problems)

MN 1,72 1,63 1,51 PsN 1,07 0,92 0,91 SN 0,38 1,36 1,01 CN 0,42 0,47 0,39 PhN 6,05 5,80 6,05 Segment 4

(Multiple Domain problems)

MN 1,83 1,77 1,82 PsN 5,13 4,83 4,68 SN 0,87 2,70 2,57 CN 1,07 1,05 1,05 PhN 7,99 7,95 8,05 Segment 5 (Extremely Frail) MN 3,53 3,78 3,68 PsN 9,50 9,15 8,83 SN 1,03 3,73 3,88 CN 1,92 1,85 1,93 PhN 10,02 9,95 9,49

Table B3 shows the segment sizes in each TM. Also, the LTF after each TM is provided. The table shows that 510 people dropped out after TM1. The largest number of elderly that dropped out occurred in the PM segment, but the largest percentage is from the Extremely Frail segment. Note, the percentages become larger as the segments increase in complexity of care needs. This holds for LTF after TM1 and for LTF after TM2.

TABLE B3. Segment growth

TM1 LTF after TM1 Percentage TM2 LTF afterTM2 Percentage TM3

DEMAND-DRIVEN SERVICES IN HEALTH CARE: A PATIENT-CENTERED TRANSITION ANALYSIS IN ELDERLY CARE