Co-producing high quality personalized care for persons with a chronical condition

Elaboration on the presentation at The International Forum on Quality and Safety in Healthcare (BMJ/IHI), Copenhagen 2023

This poster show-cases two practices. One, in care for persons with rheumatoid arthritis, its A second, in care for persons with Metabolic Disease. Both including co-produced redesign and results as exemplary cases in personalized care. Further on it highlights the most crucial founding and facilitating factors in establishing personalized care and factors to give it a sustainable future. This poster is presented by the Dutch Society Personalized Healthcare, which unites healthcare professionals, patients, and others with the ambition to spread and develop personalized healthcare. (Find the original e-poster here.)


Referral and treatment of people with RA

• GP refers to exclude RA given persistent joint complaints
• Rheumatologist’s practice is flooded
• Treatment is mainly navigated by disease activity

• Referral tool for GP
• Clinical and patient reported outcomes available in the consulting room
• Hybrid outpatient services

• 50% reduction of referrals
• Continuous shared decision-making in
specialty care
• Better life with chronic condition

Co-creation and co-production
• Consultation is guided by what matters to the patient
• Outcome measures selected with patients and international consensus
• A three-months cycle to evaluate outcomes and attune the process


Care for persons with Metabolic Disease

• GP refers to medical specialist best matching current complaints
… and again to another Treatment is fragmented

• Development of a Network of GPs and most involved specialties
• Creation of a Platform for interprofessional consultation

• Est. 80% reduction of referrals
• One-point consultationIntegrated treatment

Co-creation and co-production
• Information and education is defragmented, personalized and better understood
• Improved shared decision making
Patients included in learning cycle

Common factors for success

Founding factors (microlevel): Address personal needs, preferences and values

  • Co-creation: redesign of the care-process
  • Co-production: shared decision making, self-management
  • Integration of dispersed contributions to the care and well-being of persons with a chronic condition
  • Well-organized collaborative learning

Therefor build new habits of systematically engaging patients and their relatives in the design, delivery, evaluation and improvement of care to personalize health care.

Facilitating factors (mesolevel): Entertain a team of health professionals collaborating in the care for a (combination of) chronic condition(s)

  • The team has two jobs: deliver care and improve it
  • It holds responsibility for the whole cycle of care and an appropriate mandate for change
  • Patient reported and clinical outcome data are suitably available in the consultation room
  • Improvement techniques are available and supported
  • Costing barriers are actively addressed, if necessary in collaboration with payers

Future factors (macrolevel): Broaden societal engagement

  • Include the use of resources in the learning
  • • Find a common language among clinician, patient, management, policy-maker, payer
    • Develop appreciative enquiry and genuine dialogue with stakeholders


    van Delft E, Lopes Barreto D, Han KH, Tchetverikov I, Evertse A, Kuijper TM, Hazes J, Weel-Koenders A. Impact of triage by a rheumatologist on appropriateness of referrals from primary to secondary care: a cluster randomized trial. Scand J Rheumatol. 2022 Sep 29:1-9. doi: 10.1080/03009742.2022.2112833. Epub ahead of print. PMID: 36173970.

    van den Dikkenberg M, Kuijper T, Conijn N, Kok M, Lopes Barreto D, Weel A. Patient and clinical relevant outcomes in rheumatoid arthritis; experience from daily practice. ICHOM2021.

    Kaasjager K, Prinssen M, Zwart D. Cardiometabolic Health-Care Network: The Right Care in the Right Place Through Customized Treatment. In: Van Weert N, Hazelzet J, eds. Personalized Specialty Care – Value-Based Healthcare Frontrunner from the Netherlands. Springer; 2021.

    Jamal M, Korver AM, Kuijper M, Lopes Barreto D, Appels CWY, Spoorenberg APL, Koes BW, Hazes JMW, Hoeven LV, Weel AEAM. The IMPACT study: A clustered randomized controlled trial to assess the effect of a referral algorithm for axial spondyloarthritis. PLoS One. 2020 Jan 28;15(1):e0227025. doi: 10.1371/journal.pone.0227025. PMID: 31990912; PMCID: PMC6986702.

    Koster F, Lopes Barreto D, Nair SC, Kok MR, Weel-Koenders AEAM. Defining the care delivery value chain and mapping the patient journey in rheumatoid arthritis. Rheumatol Int. 2023 Apr;43(4):743-750. doi: 10.1007/s00296-022-05215-z. Epub 2022 Sep 23. PMID: 36149462; PMCID: PMC9510493.

    Weel-Koenders A, Kok M, Lopes Barreto D. Better Experiences for Inflammatory Arthritis Patients Through Value-Based Patient Journey. In: van Weert N, Hazelzet J, eds. Personalized Specialty Care – Value-Based Healthcare Frontrunner from the Netherlands. Springer; 2021.

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