Value-based healthcare through the eyes of the patient: PREM integrated care

Healthcare must become more sustainable. We can achieve this by organising care according to the principles of Triple Aim and Value Based Healthcare, or in other words: value driven care. If we want to achieve this, we must have a clear picture of the current fragmentation of care and where the bottlenecks lie. To do this, we must follow those who are directly involved in the care: the patient. Validated questionnaires, the so-called PREMs, are ideally suited for this purpose.

Value-driven care, Triple Aim and the Rainbow Model

Healthcare must change dramatically over the coming decades. The Netherlands is ageing, resulting in more complex demands for care and higher healthcare costs. With value-driven care, we can meet these challenges. Central to this is the Triple Aim: better perceived care, better health and lower healthcare costs. Value-driven care pursues this threefold objective.

To achieve this, we need to gain insight into all levels of care and the collaborations that exist within them, also called integrated care. The Rainbow Model provides an overview of what is needed to realize value-driven care. It incorporates all levels that affect quality, health and cost outcomes.

The micro level represents care for one individual. The meso level reflects the coordination of care between professionals and/or organizations. Finally, the macro level concerns the laws and regulations of the health care system.

Central to the Regen model are the preconditions for good cooperation to prevent fragmentation of care. Because achieving better quality, health and lower healthcare costs stands or falls with good cooperation.

Fragmentation of care

Healthcare anno 2018 is highly fragmented. Healthcare providers are stuck in their own niche or specialty. Cooperation with other professionals, fields of work or organisations is often poor.

Patients who need multiple specialists due to complex chronic disease conditions notice this. Examinations are often unnecessarily extensive and different specialists sometimes perform the same examination. The consequences: double treatments, high unnecessary care costs, and perhaps more importantly, a negative patient experience.

To achieve value-driven care, we need to overcome this fragmentation. For this we need patients and care providers.


Patients can show the bottlenecks within the care. They are the ones who actually experience it. Measuring patient experiences with valid instruments provides us with reliable, scientifically tested knowledge. This knowledge must be the starting point for shaping care.

How can we follow patients on their journey through the care process? To this end, we use validated measuring instruments in the form of questionnaires.

PROMs and PREMs as measuring instruments

Patient experience questionnaires are the Patient Reported Outcome Measures (PROM) and Patient Reported Experience Measures (PREM).

With a PROM, the patient gives an opinion about the perceived health. The questionnaire measures aspects of health as experienced by the patient, the so-called Patient Reported Outcome (PRO). Examples of PROs are pain, or shortness of breath. How are the symptoms now compared to the beginning of the care process? How is the quality of life now?

PROMs are important for measuring the patient experience. However, the PREM is particularly interesting for value-driven care. A PREM measures how the patient experienced the entire care process. It is usually a short questionnaire, with rating questions (from ‘very bad’ to ‘very good’) and open questions with room for suggestions.

The questions are about the experience of the overall process. Do the various care providers work well together? How was the treatment? And how much room was there for the patient’s own input? A PREM can also reveal whether unnecessary research has been carried out. Are things repeated unnecessarily?

Why a PREM integrated care according to the Rainbow Model?

The patient experiences the care. An objective picture of this is the basis of value-driven care. He/she has direct contact with the care providers and the way they do their work and cooperate in a multidisciplinary way.

All levels of care affect patient experiences, as depicted in the Rainbow Model. The use of PREMs brings bottlenecks experienced by patients to the attention of all those involved. Systematic problems experienced by care users may even require adjustments at the macro level, i.e. legislation and regulation.

Measuring instrument for integrated care according to the patient

But how can such questionnaires be applied to value-driven care? Until recently, there was no validated questionnaire that could map all domains of the Rainbow Model. This made it difficult to get a full picture of the extent of integrated care, and all the possible forms of fragmentation. A questionnaire has now been developed and internationally validated. This measures all eight domains based on patient experiences.

PREM integrated care

Essenburgh Training & Advice has developed a PREM for integrated care. It is a short questionnaire of 24 questions. People with chronic conditions report their experiences in the main quality domains of the Rainbow Model.

Examples of questions the instrument provides insight into are: To what extent do patients experience a people-centered rather than disease-centered approach? Is the patient involved in the decision-making process? Do different professionals coordinate care well? Do the organisations involved work well together?

The short questionnaire is linked to the patient’s perception of the situation and shows where he or she experiences fragmentation in the care process.

Reliability of the measuring instrument

The questionnaire complies with international guidelines. The instrument has been scientifically tested in 23 countries. This showed that reliability is good to excellent. Moreover, the instrument is not disease-specific and can therefore be widely used for different target groups.

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Practical applicability of the PREM

For care providers and managers in the health care sector, the instrument is the ideal tool to gain insight into the way in which care is experienced in their organisation. An interactive online dashboard graphically displays the patients’ scores. At a glance, the strengths and weaknesses of the care process become visible. Per domain of the Rainbow Model, the scores can be viewed and compared at the level of the practice, district, and/or (sub) population. This provides insight and concrete tools for improvement.

Practical applicability PREM integrated care

Want to know more?

Do you want to map the patient experience for your own healthcare organization or network? We are happy to help you with the use of our measuring instruments. Please contact us for more information. Or download our brochure on the PREM integrated care. Click on the button below for more information.

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dr. Pim Valentijn

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