Transcript Dia 1 - NFZP

Integrale zorg een blijvende
ontwikkeling
FRITS HUYSE
Psychiater, Consulent Integrale Zorg
Afdeling Algemene Interne Geneeskunde
UMCG GRONINGEN
Lid council Academy of Psychosomatic Medicine
USA
NFZP 9-6-2006
Universitair Medisch Centrum Utrecht
UMCG
Groningen
Hoofdstuk 6 Complexe patienten Huyse Slaets de Jonge
THE FUTURE OF
CONSULTATION-LIAISON
PSYCHIATRY
Graeme C Smith
Consultation-Liaison Psychiatry Research Unit
Monash University Department of Psychological Medicine
Keynote speaker Anual meeting Dutch Psychiatric Association
Maastricht The Netherlands 2005
CONCLUSIONS
 Patients with physical/psychiatric comorbidity and
somatisation continue to be discriminated against in the
public sector, despite the acknowledgement of this in the
Second National Mental Health Plan
 The implication for patients is both primary and secondary;
the context in which psychiatrists are training is helping
perpetuate the problem
 Development of a seamless web of preadmission/admission/post discharge functions is required if
patients are to receive effective care and services are to be
able to demonstrate efficacy
Zorg coördinatie in relatie tot zorgbehoefte
Type patiënt
• Bezorgdheid
• Voorbijgaande ziekte
• Minder ernstige acute ziekte
%
Verzekerden
100
Kosten/
Verzekerde
90
Low
Vraag
gestuurd
Medium
Ziekte
gestuurd
80
• Chronische ziekte
• Matig tot ernstige acute ziekte
Beleid
70
60
Complexe medische patiënten
Multi-morbiditeit, waaronder
psychiatrische
50
40
Zorg
coördinatie
30
Meerder hulpverleners
20
High
Psychologische, sociale en
financiële ontregeling
Cartesian Solutions Kathol 2002
Ambulant`/
Klinisch
10
Wie?
Hoe?
Results of ECLW Collaborative Study
14470 patients 56 hospitals 11 countries
CONSULTATION
PSYCHIATRY
EMERGENCY
equals
PSYCHIATRY
• Consultation psychiatry
• Rate 1% of all admissions
• Reactive (wait and see)
• Doctors and nurses needs driven
• Liaison
• Theory not practice
Huyse, Herzog, Lobo, Malt e.a. Gen Hosp Psychiatry 23(3):124-132, 2001
General hospital
population
Consults; psychiatric, psychological, social work
THE FUTURE OF
CONSULTATION-LIAISON
PSYCHIATRY
Graeme C Smith
Consultation-Liaison Psychiatry Research Unit
Monash University Department of Psychological Medicine
Keynote speaker Anual meeting Dutch Psychiatric Association
Maastricht The Netherlands 2005
CONCLUSIONS
 Patients with physical/psychiatric comorbidity and
somatisation continue to be discriminated against in the
public sector, despite the acknowledgement of this in the
Second National Mental Health Plan
 The implication for patients is both primary and secondary;
the context in which psychiatrists are training is helping
perpetuate the problem
 Development of a seamless web of preadmission/admission/post discharge functions is required if
patients are to receive effective care and services are to be
able to demonstrate efficacy
THE FUTURE OF
CONSULTATION-LIAISON
PSYCHIATRY
Graeme C Smith
Consultation-Liaison Psychiatry Research Unit
Monash University Department of Psychological
Medicine
Keynote speaker VJC NVvP Maastricht 2005
CONCLUSIONS 1
Patients with physical/psychiatric comorbidity
and somatisation continue to be discriminated
against in the public sector, despite the
acknowledgement of this in the Second
National Mental Health Plan.
Huyse NRC mei 2005: Geef psychiaters in ziekenhuizen de ruimte
“De ziekenhuispsychiatrie kan
mijns inziens een belangrijke
rol vervullen. In dit opzicht
sluit ik mij aan bij het
standpunt van de heer Huyse.
De stelselwijziging in de zorg
die nu plaatsvindt, is mede
bedoeld om de “ontschotting”
van de lichamelijke en
psychische zorg te
verwezenlijken. …”
CONCLUSIONS 2
The implication for patients is both primary
and secondary; the context in which
psychiatrists are training is helping
perpetuate the problem.
Huyse FJ, van der Mast RC, Boenink AD: De psychiater als medisch
specialist: de psychiatrie een zorg? Tijdschrift voor Psychiatrie
44:795-802, 2002
CONCLUSIONS 3
Development of a seamless web of preadmission/admission/post discharge functions
is required if patients are to receive effective
care and services are to be able to
demonstrate efficacy.
Integrated care for the complex medically ill.
Editors Huyse FJ, Stiefel FC
Medical clinics of North America Elsevier Juli 2006
Crossing the Quality Chasm
“Quality problems occur typically
not because of failure of goodwill,
knowledge, effort or resources
devoted to health care, but
because
of fundamental shortcomings in the
ways care is organized”
Trying harder will not work:
changing systems of care
will!
a new HEALTH system for the 21st century (IOM, 2001)
The Crossing the Quality Chasm Series
To Err is Human (1999)
Crossing the Quality Chasm - A New Health System for the 21st Century
(2001)
Leadership by Example (2002)
Fostering Rapid Advances in Health Care (2002)
Priority Areas for National Action (2003)
Health Professions Education (2003)
Keeping Patients Safe – Transforming the Work Environment of Nurses
(2004)
Patient Safety – Achieving a New Standard for Care (2004)
Quality through Collaboration – the Future of Rural Health (2005)
Improving the Quality of Health Care for Mental and Substance-use
Conditions (2005)
Improving the Quality of Health Care for
Mental and Substance-Use Conditions
A Report in the Quality Chasm Series
• Ensure that multiple providers’ care
of the same patient is coordinated
• Plea for integration and removal of
dysfunctional barriers
Commission of Quality of Care, Institute of Medicine, USA 2005
www.nap.edu
19
Six Aims of Quality Health Care
1.
Safe – avoids injuries from care
bijvoorbeeld psychopharmaca en electieve
chirurgie
2.
Effective – provides care based on scientific
knowledge and avoids services not likely to help
bijvoorbeeld Pathway- (diabetes and depression)
en IMPACT-studies (ouderen met somatische
ziekten en depressies)
3. Patient-centered – respects and responds to
patient preferences, needs, and values
bijvoorbeeld algemeen ziekenhuis setting en geen
RIAGG
Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM, 2001)
De berg naar Mohammed of …………
……… of de psychiatrie naar de AGZ !
Six Aims (cont.)
4.
Timely – reduces waits and sometimes harmful delays for
those receiving and giving care
bijvoorbeeld geïntegreerde consulten bij onbegrepen klachten
poli interne UMCG; gelijktijdig consult internist en psychiater
5.
Efficient – avoids waste, including waste of equipment,
supplies, ideas and energy
bijvoorbeeld rechtstreekse verwijzing naar collega; “snuffelconsult”
6.
Equitable – care does not vary in quality due to personal
characteristics (gender, ethnicity, geographic location, or
socio-economic status)
bijvoorbeeld psychiatrische patient heeft gelijke toegang tot
somatische zorg vv
Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM, 2001)
Ten Rules for Achieving the Aims
Old Rules
1. Care is based on visits
2. Professional autonomy
drives variability
3. Professionals control care
4. Information is a record
5. Decisions are based upon
training and experience
New Rules
1. Care is based upon
continuous healing
relationships
2. Care is customized to patient
needs and values
3. The patient is the source of
control
4. Knowledge is shared and
information flows freely
5. Decision making is evidencebased
Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM, 2001)
Ten Rules for Achieving the Aims
Old Rules
6.
7.
8.
9.
New Rule
“Do no harm” is an
individual clinician
responsibility
Secrecy is necessary
6.
Safety is a system
responsibility
7.
Transparency is necessary
The system reacts to
needs
Cost reduction is sought
8.
Needs are anticipated
10. Preference for professional
roles over the system
9.
Waste continuously
decreased
10. Cooperation among
clinicians is a priority
Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM, 2001)
Achieving Aims and Rules Requires
• News ways of delivering care
• Effective use of information technology (IT)
• Managing the clinical knowledge, skills, and
deployment of the workforce
• Effective teams and coordination of care
across patient conditions, services and
settings
• Improvements in how quality is measured
• Payment methods conducive to good quality
Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM, 2001)
Interdisciplinaire Opleidingen
Een kans voor Interne
Geneeskunde en
Psychiatrie?
ROB Gans Hoogleraar Interne UMCG
VJC NVvP Amsterdam,
April 4, 2003
Thisbee en ….
Mental health services in the general hospital
1. Emergency services
a. Attempted suicide
b. Acute behavioral disturbances
a. Deliria
b. Withdrawal
2. Integrated services
a. Screening and integrated assessment
b. Patient tailored multidisciplinary care
(horizontal integration) and care
trajectories (vertical integration)
Arie Querido
(1901-1983)
A Dutch psychiatrist:
his views on integrated health care.
Boenink AD, Huyse FJ.
J Psychosom Res. 1997 Dec;43(6):551-7.
Visie Querido
1935: Psychiatrie d’urgence
– Naast gestichtspsychiatrie moet ambulante psychiatrie
ontwikkeld worden tbv voor en nazorg
– Dit is de motor achter de RIAGG vorming (70er jaren) en
zorgcircuitgedachte (negentiger jaren) geweest
1955: Integrale geneeskunde
– Populatie gebaseerde studie in Weesperplein ziekenhuis
waarin hij als een van de eersten aantoonde dat PScomorbiditeit leidt tot slechte uitkomsten van somatische
zorg
Ontwikkeling integrale geneeskunde
Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde
Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie
op de kaart
De huidige academische psychiatrie heeft geen visie op dit vakgebied
Ontwikkeling integrale geneeskunde
Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde
Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie
op de kaart
De huidige academische psychiatrie heeft geen visie op dit vakgebied
USA
1980: alle kernhoogleraren psychiatrie zijn psychoanalytici
1990: geen kernhoogleraar is psychoanalyticus
Ontwikkeling integrale geneeskunde
Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde
Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie
op de kaart
De huidige academische psychiatrie heeft geen visie op dit vakgebied
USA
1980: alle kernhoogleraren psychiatrie zijn psychoanalytici
1990: geen kernhoogleraar is psychoanalyticus
2004: Ziekenhuispsychiatrie subspecialisatie in USA
Ontwikkeling integrale geneeskunde
Querido verliet de psychiatrie en werkte uiteindelijk in de sociale geneeskunde
Rooijmans, voormalig voorzitter van de NVvP, zette de ziekenhuispsychiatrie
op de kaart
De huidige academische psychiatrie heeft geen visie op dit vakgebied
USA
1980: alle kernhoogleraren psychiatrie zijn psychoanalytici
1990: geen kernhoogleraar is psychoanalyticus
2004: Ziekenhuispsychiatrie subspecialisatie in USA
Nederland
2006: Geen hoogleraren ziekenhuispsychiatrie
2010: Kernhoogleraren psychiatrie zijn ziekenhuispsychiaters
General hospital
population
Multidisciplinary care
Physical: High acuity/intensity
no artificial respiration
Psychiatric: High acuity
no severe behavioral dist
MPU
MPU =
MedicalPsychiatricUnit
Screening for complexity
Indicator-INTERMED
Nurse specialist
Multidisciplinary care
Integrated assessment
Psychiatrist/geriatrician
Nurse specialist psychiatry
Psychologist
Social work
Chronische ziekte en depressie
• Verhoogde prevalentie
• Versterkt de symptomen van de somatische ziekte
• Vergroot de functionele beperkingen
• Vermindert de compliance met somatische
behandeling
• Gaat gepaard met negatief gezondheidsgedrag
(dieet, lichamelijke oefening, roken)
• Gaat gepaard met een verhoogde mortaliteit
Physical illness
• Smoking
• Sedentary
lifestyle
Major
• Obesity
Depression
• Lack of
adherence to
medical
regimens
• Medical illness
at earlier age
• Poor symptom
control
•  functional
impairment
•  complications
of medical
illness
Adverse Bidirectional Interaction
After Katon
DOES TREATMENT of
the DEPRESSED MEDICALLY ILL HELP ?
SYSTEMATIC REVIEW OF ANTIDEPRESSANTS IN
THE PHYSICALLY ILL
 N of RCTs = 18
 Adverse reactions:

No differences of placebo

No difference between drugs
 Number needed to treat 4
Gill and Hatcher Cochrane Review 2001
Behavioral change can be considered according to a hierarchy of behavioral
challenge, ranging from those that are least difficult (i.e., the initiation of new
practices in which there is no preexisting habit that needs to be broken) to the
most difficult (i.e., breaking addictive habits which satisfy physiological drives).
Rozanski: Psychosom Med 2005; 67 [Suppl 1]: s67-s73
MODELLEN VOOR
INTEGRALE ZORG
MODELLEN VOOR INTEGRALE
ZORG
• Depressie en somatische ziekte
Multifactorial Interventions for
Depression in Primary Care
•
•
•
•
Literature synthesis
12 RCTs involving 6,274 patients
Most trials had 3-4 components
All 12 had care management; 7 had
augmented mental health
• 10 studies → improved outcomes
Gerrity et al, J Gen Intern Med
2004 (abstract)
Effectiveness Studies of Depression in Primary Care
Tx
Case ID/
Patient
Physician Tracking
Tx
MH
Effective
Guidelines
Screening
Educ
Educ
Systems
Schulberg
+
+
+
+
+
+
++++ Yes
Mynors-Wallis
+
+
+
+
+
+
+++
Yes
Katon
+
+
+
+
+
+
++
Yes
Katzelnick
+
+
+
+
+
+
++
Yes
Rost
+
+
+
+
+
+
+/-
Yes
Hunkeler
+
+
+
+
+
+
+/-
Yes
Simon
+
+
+
+
+
+
-
Yes
Simon
+
+
+
+
+
-
-
No
Callahan
+
+
+
+
-
-
-
No
Goldberg
+
+
+
-
-
-
-
No
Dowrick
+
+
-
-
-
-
-
No
Coord. Spec.
Stepped Care
1. Patient self-management
2. Primary care provider
3. Care manager
4. Collaborative care
–
Indirect (TCM) – MHS supervises CM
–
Direct – MHS sees pt in consultation
5. Referral to Mental Health Specialist
PC
MH
PHQ - 9
Over the last 2 weeks, how often have you
been bothered by the following problems?
Not
at all
0
Several
days
1
More than
half the
days
2
Nearly
every
day
3
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f.
Feeling bad about yourself, or that you are a failure . . .
g. Trouble concentrating on things, such as reading . . .
h. Moving or speaking so slowly . . .
i.
Thoughts that you would be better off dead . . .
Subtotals:
0
3
4
TOTAL = 16
9
PHQ-9 as Severity Measure
• Cutpoints proposed on PHQ-9 for
depression severity are:
 5 = mild
 10 = moderate
 15 = moderately severe
 20 = severe
• Response to therapy = 5 point ↓
• Remission = score < 5
Translating PHQ-9 Scores into Action
0–4
No action (community norms)
5–9
Watchful waiting in most
10 – 14
Education, counseling, active rx based upon diagnosis,
duration, impairment, patient preferences
15 – 19
Active treatment in most
20 +
May need combination of Rx and/or referral
The Pathway Study
• RCT: depressie en diabetes mellitus
– Verbetert diabetes door verbeterde depressie
zorg?
• Intervention: stepped care Tx depression
– N=329 (int: 164; CAU 165)
– 9 primary care klinieken
• Outcomes:
–
–
–
–
Verbetering depressie 6 en 12 mnd
Verbetering algemeen gevoel na 6 en 12 mnd
Meer satisfactie met type zorg na 6 en 12 mnd
HBA-1C gelijk in interventie en controle groep
Katon, Von Korff (2004) Arch Gen Psych 61:1042-1049
IMPACT
Improving Mood – Promoting Access
to Collaborative Treatment
for Late-Life Depression
1801
18
8
depressive elderly (>/60 years)
clinical practices
healthplans
Funded by
John A. Hartford Foundation
California HealthCare Foundation
California Geriatric Education Center (via the Bureau of
Health Professions, HRSA)
Unutzer J, Katon W, Callahan CM ea. IMPACT. JAMA 2002;288(22):2835-45
IMPACT
Improving Mood – Promoting Access
to Collaborative Treatment
for Late-Life Depression
1801
18
8
depressive elderly (>/60 years)
clinical practices
healthplans
Funded by
John A. Hartford Foundation
California HealthCare Foundation
California Geriatric Education Center (via the Bureau of
Health Professions, HRSA)
3.8 chronic conditions
Unutzer J, Katon W, Callahan CM ea. IMPACT. JAMA 2002;288(22):2835-45
In the IMPACT study the patients had 3.8 chronic conditions in
addition to depression
• e.g. cardiac
• diabetes
• parkinson
• ....
number of diagnoses
In the IMPACT study the patients had 3.8 chronic conditions in
addition to depression
450
• e.g. cardiac
400
DSM-IV
• diabetes
350
300
DSM-IIIR
• parkinson
DSM-III
250
• ....
200
DSM-II
150
100
DSM-I
50
0
1945
1955
1965
1975
1985
1995
year of publication
What about patients with psychiatric co-morbidities?
As comorbidity is rather the rule then the exception!
Kroenke and Rosmalen Symptoms, syndromes and
psychiatric diagnosis
in Huyse and Stiefel “Integrated care for the complex medically ill”
2005
2015
number of diagnoses
In the IMPACT study the patients had 3.8 chronic conditions in
addition to depression
450
• e.g. cardiac
400
DSM-IV
• diabetes
350
300
DSM-IIIR
• parkinson
DSM-III
250
- add
200
DSM-II
150
• anxiety
DSM-I
100
• substance abuse
50
0
• somatization
1945
1955
1965
1975
1985
1995
2005
year of publication
• xx
- managers!
What about patients with psychiatric co-morbidities?
As comorbidity is rather the rule then the exception!
Kroenke and Rosmalen Symptoms, syndromes and
psychiatric diagnosis
in Huyse and Stiefel “Integrated care for the complex medically ill”
2015
Chronic Disease Focused Depression Care:
New Grant
• Nurse will provide depression, heart disease and
diabetes case management
• Behavior intervention-especially exercise,
positive life activities
• Optimize medication for depression, heart
disease and diabetes
• Supervision of nurses by psychiatrists and PCPs
Katon and Unutzer
Chronic Disease Focused Depression Care:
New Grant
• Nurse will provide depression, heart disease and
diabetes case management
• Behavior intervention-especially exercise,
positive life activities
• Optimize medication for depression, heart
disease and diabetes
• Supervision of nurses by psychiatrists and PCPs
Katon and Unutzer
= Complexity management
MODELLEN VOOR INTEGRALE
ZORG
• Depressie en somatische ziekte
• Ziekte specifiek
MODELLEN VOOR INTEGRALE
ZORG
• Depressie en somatische ziekte
• Ziekte specifiek
• Complexiteit
MODELLEN VOOR INTEGRALE
ZORG
• Depressie en somatische ziekte
• Ziekte specifiek
• Complexiteit
• Generiek
INTERMEDc
PROGRAM GROUP
RESEARCH COORDINATOR
Groningen
Peter De Jonge
PARTICIPATING CENTERS
Lausanne
Groningen
Groningen
Nürnberg
CONSULTANTS
John Lyons
Corine Latour
Roger Kathol
Fritz Stiefel
Frits Huyse
Joris Slaets
Wolfgang Söllner
Chicago
Amsterdam
Burnsville
C
Huyse, Lyons, Stiefel, Slaets, De Jonge ea
Gen Hosp Psychiatry 21:39-48, 1999
www.vumc.nl/INTERMED
Step wise method for detection and assessment of
COMPLEXITY
Admission/referral
Indicator
negative
positive
Assessment
negative
positive
Step wise method for detection and assessment of
COMPLEXITY
Possible indicators:
Admission/referral
• Excess utilization
• Non-Compliance
• Questionnaires
• COMPRI)1
• Groningen Frailty
Index
= filter =
Indicator
negative
positive
• Type of illness
• Transplant
• Cancer
Assessment
• Research
• Etcetera
negative
positive
Step wise method for detection and assessment of
COMPLEXITY
Admission/referral
Indicator
negative
=
positive
Assessment
negative
Integrated health risks and needs
positive
Intervention studies
Pre/post internal medicine IP
(NL)
– Reduction of LOS in elderly (16 -> 11 days)
– Improvement in psychological functioning
RCT prevention readmission post discharge
(NL)
– No effects; restricted funding and lack of cooperation/integration
Intervention Study
Internal Medicine Vumc
• Effect on QoL: specifically Mental Health (SF36)
– P 0.03
(Z -2.17)
• Effect on LOS: specifically in elderly
– P 0.05
(Z -1.95) from 16 to 11.5 days
• Costs of the intervention
– 1 nurse specialist
– 1/4 C-L psychiatrist
de Jonge P, Latour CH, Huyse FJ.
Implementing psychiatric interventions on a medical ward
Psychosom Med. 2003 Nov-Dec;65(6):997-1002
Intervention studies
Pre/post internal medicine IP
(NL)
– Reduction of LOS in elderly (16 -> 11 days)
– Improvement in psychological functioning
RCT prevention readmission post discharge
(NL)
– No effects; restricted funding and lack of cooperation/integration
RCT depression and DM or Rheuma
– In analysis; positive effects on most outcomes
(SU)
A randomised psychiatric intervention in
complex medical patients: Effects on
depression
• Outpatients of department of
endocrinology and rheumatology
• University center
• Complexity screen with INTERMED; inclusion > 20
• Assessment of depression with MINI and CES-D
• Randomisation
• Intervention based on risks and needs
as assessed with the INTERMED
Stiefel F, Bel Hadj B, Zdrojewski C, Boffa D,
(announcement poster)
de Jonge P Dorogi Y, Miéville JC, Ruiz J, So A. J Psychosomatic Res 2004,56:578-9
Sample
No
INT
CAU
Age
50.9 (14.1)
53.1 (15.3)
INTERMED
24.6
(3.7)
26.1
EuroQuol
44.7
(22.2)
45.1 (21.2)
CES-D
27.1
(11.4)
27.5 (10.8)
SF-36 physical
31.8
(10.9)
29.6 (10.0)
SF-36 mental
34.8
(11.6)
35.4 (10.4)
Female sex
58.3%%
57.5%
Major depression
60.5%
55.8%
Stiefel, ... , So Lausanne Suisse
(4.6)
No significant differences
Sample
No
INT
CAU
Age
50.9 (14.1)
53.1 (15.3)
INTERMED
24.6
(3.7)
26.1
EuroQuol
44.7
(22.2)
45.1 (21.2)
CES-D
27.1
(11.4)
27.5 (10.8)
SF-36 physical
31.8
(10.9)
29.6 (10.0)
SF-36 mental
34.8
(11.6)
35.4 (10.4)
Female sex
58.3%%
57.5%
Major depression
60.5%
55.8%
Stiefel, ... , So Lausanne Suisse
(4.6)
No significant differences
Intervention (N=120)
Psycho education
43.3%
Emotional expression
72.6%
Psychodynamic
47.2%
Pragmatic
70.8%
# of Follow-ups (median)
Stiefel, ... , So Lausanne Suisse
7
Effects on general health perception (Euroqol)
60
55
50
Care as usual
45
Intervention
40
35
30
0
3
6
9
12
Effects on physical health (SF-36)
40
38
36
34
Care as usual
Intervention
32
30
28
26
0 3 6 9 12
Effects on prevalence (%) of major depression (MINI)
65
60
55
50
Care as usual
45
Intervention
40
T=3: P=0.06
T=6: P=0.12
T=9: P=0.15
T=12: P=0.01
35
30
25
0
3
6
9
12
9 praktijken in Minnesota hebben interesse
oa huisartsen geneeskunde Univ of Mineapolis
RCT in voorbereiding
2 zorgverzekeraars hebben interesse
7 talen: Engels, Nederlands, Frans, Duits, Spaans, Italiaans, Turks
Jaarlijkse Cursussen
• NL Wenckebach Groningen
• EU EACLPP satelite
• USA Chicago CANS satelite
Developments
Several studies on their way and in preparation
– TransplantMC outcome prediction study
Europe
– MC RCT in oncology
Germany
– Preassessment in elective surgery
Groningen
– RCT depression and rheuma/diabetes
Minneapolis USA
– RCT Functional neurologic complaints
– Touchscreen module for patient self assessment
INTERMEDFoundation
INTERMED BV
• webbased training
• webbased clinical support
AMC NL
Groningen
January 2006
Beginning 2007
Staatsecretaris voor Integrale zorg
Na regen komt zonneschijn!