When do physicians perceive the success of a new care model differently? A qualitative study on personal values of physicians and their expected advantages through the implementation of a new care model in a primary care setting

When do physicians perceive the success of a new care model differently? 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A qualitative study on personal values of physicians and their expected advantages through the implementation of a new care model in a primary care setting Simone Richter, Ibrahim Demirer, Maya Nocon, Holger Pfaff, Ute Karbach This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-125775/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background The health care innovation "MamBo – people with multimorbidity in outpatient care: patient-focused and needs-oriented healthcare management” aims to improve the efficiency and quality of care for multimorbid patients by delegating tasks (e.g. taking over house calls or coordinating specialist appointments) to a monitoring and coordination assistant (MoniKa). Participating physicians are very important for the success of the health care innovation due to their direct involvement as practitioners and their task of enrolling patients. The aim of this part of the evaluation study is therefore to identify the physician’s personal values, which influence the individual perception of the project’s advantages and thus possibly the acceptance and sustainable implementation of new care structures. Methods Two Focus groups (n = 4; n = 6) and three individual interviews with general practitioners and specialists who decided to implement the health care innovation within the first year were conducted. The semi-structured guidelines were developed by the research team. The interviews were analysed according to the content analysis by Mayring. We used the learning model of operant conditioning to place our study results in a theoretical context. Result Two central personal values of the participants, which determine the desired advantages of the health care innovation were identified: More patient-oriented and more economic-oriented values. Participants with more patient-oriented values quickly perceived advantages, which seems to be beneficial for the acceptance of the new care structures. Economic-oriented participants tended to be more critical. The benefits of the health care innovation, which was expressed, for example, in an improvement of the practice routine, has not yet been perceived by this group, or only to a limited extent. Conclusion The results suggest that the respective values of the participants define the individual perceived advantages and thus, the assessment of the success of the health care innovation in general. These findings could be used in the implementation process by increasing the motivation of the project participants through typified supervision. Trial registration: The study has been registered in the German Clinical Trials Register (DRKS00014047). Health Economics & Outcomes Research Health Policy health services research qualitative approach relative advantage outpatient care diffusion of Innovations theory of planned behaviour operant conditioning care management case management Figures Figure 1 Figure 2 1 Background Demographic change will lead to ageing of society and, in this context, to an increasing proportion of people suffering from several chronic diseases. There is a growth in the number and proportion of older people in practically every country in the world. In highly industrialized countries, the population is significantly older than in other parts of the world. However, the fastest growth in the older population between 2019 and 2050 is likely to occur in the least developed countries [ 1 ]. Also, in Germany, the age structure is shifting. Around every fifth person is aged 65 or over. The number of people aged 80 and over is forecasted to rise from 4.4 million in 2013 to around 6 million people in 2020 [ 2 ]. This development is accompanied by an increasing of non-communicable diseases, chronic conditions and multimorbidity. As a result, the demand for healthcare services is rising. Besides that, the health care of chronically ill and multimorbid patient’s is complex and requires interprofessional cooperation between general practitioners (GPs), specialists, the inpatient sector and nursing care [ 3 , 4 ]. Patients with serious illnesses or chronic conditions and thus with complex care needs often report a lack of integrated and well-coordinated care. This is seen in many countries including Canada, Germany, France, the Netherlands, Great Britain or the United States. When different professions and disciplines are involved, it is often unclear who is responsible for patient coordination. This is where the GPs play an important role [ 3 , 5 , 6 ]. As one way of assigning this responsibility more clearly, many countries have a gatekeeper system. In Germany, there is no overall legal regulation for it [ 7 ]. However, McKinglay et al. pointed out that, although general practitioners are believed to be best placed to coordinate the care, the situation is further complicated when several professionals and, in addition, authorities are involved [ 6 ]. Besides the clinical difficulties faced by general practitioners in the care of multimorbid patients, the load from non-medical tasks is increasing, and delegation of tasks is therefore playing a greater role [ 8 ]. To meet these challenges, scientists and health professionals are working on the development, implementation and evaluation of innovations in the healthcare sector. In line with this, the care model “MamBo- People with Multimorbidity in Outpatient Care: Patient-Focused and Needs-Oriented Healthcare Management” has been introduced in an urban region in Germany, in 2017. The core element of an implemented care management is the case-related, cross-sectoral coordination of multimorbid patients by the case management – including monitoring and coordination assistants (MoniKas) who conduct house calls, delegated by physicians. At the patients’ home, the Monikas first assess the needs of the patients, including medical, nursing and social-legal needs. Then the MoniKas take over the coordination with numerous actors in the health and social care sector while being in regular contact with the treating physicians. The implementation of the health care innovation “MamBo” is accompanied by an evaluation study with a project duration of 3.5 years. Forty-one out of about 100 potential physicians (only physicians who are part of a regional physicians network) participate in the project and in October 2020, 2615 patients were enrolled. During the project, two to three MoniKas were employed in the physician network. Further information on the evaluation study of Mambo can be found in our study protocol [ 9 ]. Participating GPs are in charge of delegating house calls, caring for and enrolling patients. Thus, their acceptance of the new structures is essential for the successful and sustainable implementation of healthcare innovation. Experiences show that the implementation of innovations, like the establishment of case management, often takes a long time and remains a challenge, especially concerning achieving adoption in the primary care setting. In this respect, it is crucial to understand which factors influence the sustainablilty of an implementation of complex health care innovation [ 10 – 12 ]. According to Roger's Diffusion of Innovations Theory [ 13 ], the relative advantage desired by potential users is a characteristic of an innovation that strongly influences the individual's decision to implement it. It is the degree to which an innovation is perceived as being better than the idea it replaces. In the theory of planned behaviour, the behaviour is determined by behavioural beliefs, and the perception of positive or negative outcomes through the behaviour form the behavioural beliefs [ 14 ]. Accordingly, well-known theories referred to implementation research show that the relative advantage is an essential factor for the implementation of an innovation. Innovations that have a decisive advantage over the conventional standard are more easily adopted and implemented [ 13 , 15 , 16 ]. Not only theoretical but also current research evidence indicates that the relative advantage is an essential factor for the adoption of an innovation [ 12 , 16 – 18 ]. In a quantitative analysis of the association of certain attributes on physicians’ intention and actual use of an intervention, Scott and colleagues[ 17 ] found two of its qualities to be more influential than the others, namely relative advantage and observability. But the benefit of e.g. the implementation of a new care model conceptualize differently between the potential adopters for instance in terms of economy, social reputation or user-friendliness [ 16 , 17 , 19 ]. Denis and colleagues pointed out that potential adopters do not act in an entirely rational manner, but according to their interests or values and power dependencies [ 19 ]. Also Greenhalgh et al. identified in their systematic review cognitive and social psychology factors such as the individual’s motivation, values and learning styles, which influence the implementation of innovations [ 16 ]. Furthermore, after implementing a new innovation, participants must decide whether to continue or discontinue the adoption [ 13 ]. In our case, physicians may also choose to take a more passive role and not, for example, continue with all aspects of MamBo such as patient’s enrolment. Based on the fact that relative advantages play a driven role in the implementation of innovations, this study aims to identify the personal values of physicians, which determine their benefits desired by their participation. We further address the question of how this may affect a sustainable implementation of the new care model in our study population. 2 Methods 2.1 Study design Since little is known, we used an explorative research design to identify personal values and expected advantages. In the context of the formative evaluation of the evaluation study MamBo, interviews with MamBo-physicians were conducted. The interviews were performed in the form of focus groups, which were supplemented by face-to-face interviews. This study shows the results of the focus groups and qualitative interviews based on qualitative content analysis with both a deductive and inductive approach [20, 21]. The Diffusion of Innovation Theory by Rogers was stated to underpin the development and analysis of the interviews [13]. We have further used the learning model of operant conditioning to place our study results in a theoretical context [22] [23]. 2.2 Research Team and Reflexivity 2.3 Sampling The recruitment of physicians for the focus groups was based on the Theory Rogers “Diffusion of Innovation”, i.e. physicians that were active from the beginning (“early adopters”, within the first year) where interviewed separately from physicians that became active later (“late adopters”) [13]. Physicians who had participated once couldn’t participate in the formative evaluation again. The board of the care management provided access to physicians. In addition, the research team sent out invitations and information letters explaining the objectives, ethical aspects and procedure of the study, as well as a letter of consent via fax and e-mail. Also, an expense allowance (120 €) was offered for participation. This analysis is based on data from the group of early adopters, collected by two focus groups and additional face-to-face interviews. For this, all participating physicians, who intended to implement the health care innovation within the first year of its begin, formed the study population and were approached in June 2018 and in January 2019 [24]. 2.4 Data collection The interviews followed a semi-structured guideline [20, 24], which was developed by two well-trained researches (SR, UK). The interview guide revolved around five main topics: ➢ Intention to participate in the healthcare innovation ➢ Implementation of the healthcare innovation and its evaluation ➢ Perceived changes in daily work routine: advantage or disadvantage of the innovation ➢ Communication channels (way of spreading the word about the innovation) ➢ Change requests for the further course of the project/ transmission in regular care For each main topic, open questions were designed to generate narratives from the participants. Depending on the course of the respective interview, more concrete follow-up questions were asked. Thus, the interview guide was flexibly adapted to the course of the conversation. Adaptations of the guide, according to the background and type of physician, were made prior to the interviews [20, 24]. The guidelines that were used for the focus groups are attached as additional file [see Additional file 1}. To take field notes, two research assistants took part in the first focus group in addition to the moderating researcher and one assistant in the second focus group. The focus groups were conducted in the premises of a regional physicians' network. The face-to-face interviews were held in the physician’s practices. All interviews and focus groups were audio- recorded and ruled led transcribed and pseudonymised [25]. Right after a focus group or interview, a memo was written by the interviewee to obtain supplementary and contextual information for the analysis [24]. 2.5 Data analysis To analyse the interviews, qualitative content analysis was used [21]. The analysis contained three phases: the preparation phase, the familiarisation phase and coding phase. Before working with the collected data, single words, a sentence or a paragraph relating to the research questions were defined as units of analysis. We have defined to consider mainly manifest content in the analysis, but also general agreement and disagreement among participants on individual statements [26]. We also tried to examine underlying meanings to identify personal values and interrelations between statements. At the end we classified our interview partners according to identified value orientations and compared their statements regarding their perceived advantages and the success of the project. To get completely familiar with the data two researches (SR, UK and a research assistant in various combinations) read the transcripts intensely before conducting the initial data analysis. The coding of the material was conducted in two steps. First, main categories and subcategories were defined deductive, based on the guideline topics and Rogers’s theory “Diffusion of Innovations”. The resulting codebook, including definitions, coding-rules and examples out of the material, were developed by the first author and revised by UK, In the second step, this codebook was used to initially code the material by an inductive approach. Inductively developed codes either fit into a deductively defined category or were included as a new category in the codebook. The codebook was repetitively discussed and revised among the researches until consensus was obtained. Table 1 provides an extract and example of the considered categories. The final codebook includes a short description for each code which is relevant for the research question. Further interpretation was performed by the first author and reviewed by as well as discussed with UK. The coding was assisted by the use of the computer software MAXQDA (VERBI GmbH, Berlin, Germany). Table 1: Extract of the codebook- Code examples of one Category Category Subcategories Definition Example out of the material Intention to participate MamBo as a solution for patient-related challenges Challenges in the care of multimorbid patients from different perspectives: 1. Challenges related to the characteristics of a multimorbid patient are of interest (impaired cognitive performance, mobility, communication, social support). 2. Aspects of the health care system that make it difficult to care for multimorbid patients and their characteristics. "In addition, mobility is becoming increasingly restricted, which makes communication with patients who otherwise come to the practice regularly more difficult. " (FG1; paragraph 23) 3 Results One focus group was conducted in June 2018 with six GPs. A second focus group took part in January 2019 with three GPs and one specialist. Since three doctors expressed their interest in being interviewed, but no common date for a focus group for all suitable could be found, the second wave was supplemented by individual face-to-face interviews with two GPs and one specialist. Both focus groups lasted about 90 minutes, and the face-to-face interviews lasted between 30 and 60 minutes. In all, the results are based on data of 13 physicians who have been physicians in residential practice for in average 20 years and who had implemented the new care model. All participating doctors have used the service of the case management at the time of being interviewed. Some physicians were less active in delegating tasks and enrolling patients. The main categories “Compatibility”, “Intention to participate”, “(not) perceived advantages of the innovation” and “System-related challenges for implementation and transfer” include in total 22 subcategories relevant for the research question. A detailed description of the categories and their definitions is added additionally [see Additional file 2]. The personal values and their relation to the perception of advantages as well as the assessed success of the healthcare innovation were analysed by comparing statements that were assigned to the four categories mentioned above and their sub-categories. 3.1 Values determining the perception of advantage All informants acknowledged the work done by the MoniKas, in particular the assumption of non-medical, but social management tasks. All interviewed doctors received positive feedback from patients and their relatives and emphasized their satisfaction with the visits of a MoniKa - for example, in terms of patients feeling better informed and better cared for socially. But also, the challenges of the transfer to standard care, such as the question of how to cover necessary resources, were addressed in all interviews. Even if these potentials and challenges are recognized by almost all interviewees, the evaluation of these according to the personally perceived advantages is different. Thus, we found that the desired relative advantage, as most relevant for implementing the healthcare innovation, were mainly determined by (a) patient-oriented values or (b) economic-oriented values - taking into account that people with stronger economic-oriented values can also be driven by patient-oriented values or vice versa. However, certain values have a greater priority than others, which then determines the mainly desired advantage. We also identified further values and factors influencing the intention to participate (e.g. social norms, former project experience), which, however, do not seem to determine the desired advantage, or not in a substantial way. We now present the characteristics of participants with patient-oriented and economic-oriented values. (A) patient-oriented values Doctors interviewed, who had strong patient-oriented values, emphasized the importance of holistic patient care (medical, emotional, social) and were very concerned about the care of elderly people living alone at home and experiencing poor social support. “And indeed, there are many ways. It doesn't have to be Mambo. The main thing is that the patients are well cared for.” (Exp. 03) They also felt that the new care model could be a solution to the challenges associated with the medical care of multimorbidity, such as reduced mobility, communication problems and low compliance of multimorbid patients. “[...] cognitive impairment of the patients, which lead to the fact that they are not in compliance with instructions, as we wish as physicians. In addition, mobility is becoming increasingly limited, which makes communication with patients who otherwise regularly come to the practice more difficult. The decreasing support from the family, which does not exist in small families. The wife is there because children often move far away, if there are children at all.“ (FG 1. BB) (B) economic-oriented values We identified that the desired advantage of participants with stronger economic-oriented values was mainly based on monetary interests and interests to improve processes within their practice. The focus was on the cost-effectiveness of the new model, which was assessed by comparing the resources used to implement it with, for example, the reduction of workload or hospital stays of patients. Thus economic-oriented values could manifest not only in the form of personal cost-benefits but also in the interest of reducing social costs “I might have to say again that all the non-medical task we do here, they don't get paid. Yes, we do it all for free. And who will do that in the future? I don't see that. And then what will the care landscape look like, so it is really urgently necessary to have something like this.” (FG1, GG) “The second is, I believe, that it is very important that money flows into this area. If there is no economy, they can forget everything. That is daydreaming. We have that in masses behind us.” (FG1, DD) Table 2 includes identified factors which determine patient-oriented and economic-oriented values. Table 2: Conceptualisation of patient- and economic- oriented values patient-oriented values economic-oriented values · social management · drug management · patient information · patient satisfaction · patient’s security · continuous care · cost reduction · practice procedure · social costs 3.2 Perceived advantages and evaluation of the project’s success Participants with more patient-oriented values experienced the benefit for the patient also as an immediate personal advantage. “Well, that's what I meant in the first place. Seldom something like that is so well accepted. The patients call and are so happy that they are in the project. Such statements are made spontaneously. And I didn't hear anybody say, well, listen, that's nothing or something like that. Never. Not once. Well, in that respect, I can only say positive things, yes.” (Exp 01) “And with such a positive tailwind, which they bring with them because, as I said, they feel that they are in good hands, things run easier. And safer.” (FG 2, AA) These participants felt a work relief through the delegation of home visits, although most of the tasks undertaken by MoniKa were social-management rather than medical. They communicated a perceived advantage in terms of patient safety. On the one hand, they expressed that they have an advantage from the fact that their patients are safer at home when someone trained has taken a look at the home environment. “I think this is useful for me, too, when I know that patients are at least safer at home. There is no longer the tripping hazard of the carpet, there is perhaps also a nursing classification that is now happening here. There's someone who looks to see if a severely disabled person's ID card is necessary or something else.” (FG1, BB) On the other hand, they feel better when they know that their patients are being cared for safely, for example, during their practice holidays. By delegating tasks to MoniKa’s continuous care can also be ensured in that case. “That there is a continuity of care when you are on holiday, that the patient does not have to go to the substitute doctor. The patient is overstrained with such a big thing.” (FG1, EE) Furthermore, participants with strong patient-oriented values quickly perceived advantages, shortly after implementation. They were more optimistic about the success of the project and spoke very positively about the new care model as a whole. Also, they reported that the enrolment of patients also became more straightforward when a direct benefit was noticed. “Basically, I specifically addressed those where I saw that they would directly benefit from it. And after I noticed that it actually works well, that it is actually a good offer, it was much easier.” (FG2, DD) In contrast, participants with more economic-oriented values did not see a direct advantage for themselves from the patient benefits, and they experienced (only) little connection to the success of the project in general. “Nope, so, a care level has now been classified in a case or one or the other care aid has been purchased. Well, these are then improvements for the patients in the care level. They could also pay someone or...that's something concrete, yeah. And beyond that I wouldn't know right now if something has changed.” (Exp. 2) “So, for me the use of MamBo is very difficult to evaluate, because of course the problems remain in my memory, where something doesn't work. And when I have hired MamBo like MoniKa, I get a feedback and I think it’s very positive, but I don't notice a direct advantage for me“. (FG1, AA) For example, one participant with strong economic interests did not see any relief in his work, although he recognized and positively mentioned the work of the MoniKas who conducted home visits. He explained this by the fact that so far too few patients of his practice are involved in MamBo and have received a Monika. “Well, […] nothing worth mentioning has changed. Because we have two and a half thousand patients a quarter and from this 40 are, or, I don't know, maybe a little more, are in the Mambo project. Well, that is an amount that is not really worth mentioning. And the patients, for some of them the one or other advantage resulted from the visit of Monika, that was quite helpful.” (Exp. 2) So far, no changes in daily practice or at the societal level have been noticed in the outcomes relevant to them. They were less convinced of the new care model and expressed scepticism, especially with regard to proof its cost-effectiveness within the limited study period. Figure 1 models the link between the desired advantage, depending on the personal value orientation, and the perceived project success. Furthermore, negative consequences, such as the current expenditure of resources were more present in the interview when participants represented more substantial economic interests. “Well, for that, Mambo would have to prove that it's somehow cost effective. I think it's going to be very difficult. It's going to be hard, just because of the amount of staff involved. I can hardly imagine that it will be successful in the end. Or it is still way too early for that or there are still too few people included. Well, you really should be able to prevent a stay in hospital or perhaps improve the medication etc. somehow, so that people really get a better care and have to go to hospital less often. And I'm sceptical about whether that will succeed. We're all sceptical about that, I suppose.“ (Exp. 2) “Nah, I don't see any relief. So what perhaps relieves me is that MoniKa now makes house calls and makes useful proposals, which I think is good. But I have more documentation and communication work to do.” (Exp. 2) 3.3 Relevance of a rapid perception of advantages on the implementation process Based on our findings of the interviews with participating physicians and with reference to a theoretical learning approach, we assume that quickly noticeable advantages are promotive for a continuous as well as a sustainable implementation. Accordingly, relative advantages that only become noticeable after a more extended period, such as economic benefits, inhibit the perception of the project’s success and its continuous implementation. The approach of operant conditioning can be used to support our assumption. As long as a positive consequence is expected or occurs, it is more likely that the behaviour will be repeated. However, the shorter the time between the behaviour and its consequence, the stronger the effect on the repetition of the behaviour [22] [23]. Figure 2 shows the transfer of the approach to our study results. The behaviour “Implementation of MamBo” should be repeated, or in our case, continued. The perceived advantages, conceptualized by the respective outcome relevant for either patient-oriented or business-oriented participants, are the consequence of the behaviour. Following this approach, MamBo participants with stronger patient-oriented values would be more likely to continue the adoption of the MamBo structures as the relevant advantages for them are quickly noticeable after implementation. Moreover, optimistic and convinced participation promotes communication and thus, the diffusion of innovation [13]. In contrast, it is less likely that economic-oriented participants will continue the implementation in its complete form. Since so far, no or only little advantages have been perceived, no desired consequences reinforces the behaviour. 4 Discussion This study aimed to identify physicians’ values, which influence the individual perception of the success of the health care innovation and thus possibly the acceptance and dissemination of new care structures. Following what we found in the analysis, differences in a perceived success of the health care innovation could be explained by different personal values which determine the desired advantage by implementing the new care model. Even if positive changes for patients are recognized, this does not necessarily led to an sustainable implementation of the new care structures by participating physicians. We found that participants with more patient-oriented values quickly perceived a personal advantage and experienced great success, which is also in line with the learning theory of operant conditioning. Participants with more economically oriented values tended to be more critical about the innovation, although patient-related benefits are seen. Advantages have not been perceived by this group yet, as they only become apparent later. Our study is mainly limited by a small study population, but also by inconsistencies in interview formats and the long period between the two focus groups. Nevertheless, our findings support the observations of Denis and colleagues in their multiple case study, namely that the perceived advantage is based on individual interests or values, such as economic interests, social prestige or to follow best clinical practice [19]. The findings of our study also support the suggestion of Scott and colleagues that the advantage relative to a participant is conceptualized differently by those potential adopters [17]. As Greenhalgh et al. found out, it is more likely that potential adopters will use an innovation, if it meets their needs [16]. As personal values predict the relative advantage of an innovation, it gives an indication of how the individual participants would evaluate the success of the health care innovation. By considering the personal values of potential study participants already during the planning and implementation of new care structures, a significant contribution can be made to the successful implementation of them. Typified support could increase the motivation of the participants to adapt to new structures. By using a qualitative approach, personal values and intentions for participation as well as the complexity of the innovation were revealed, which would have been difficult to identify with quantitative methods. While studies use the theory of operant learning to improve the adherence of treatments, the application of a learning theory in implementation science seems quite rare - although the adoption of new structures is a complex learning mechanism. The use of a learning theory like operant conditioning helps to understand and explain phenomena and dynamics in the adoption process [22][23]. By applying a learning theory, our findings have been further developed theoretically. It is, therefore, helpful to look at related areas and transfer theories from psychology to implementation research in healthcare. Initially, purposeful sampling was planned to achieve a variation of the participants in terms of gender and work experience on the one hand, but also only the early adopters on the other hand [20, 24]. However, since we were unable to convince as many physicians to participate in the project as planned, the pool of potential participants for a focus group was smaller than assumed. Thus, we had to consider any interested physician for participation in our study independent from gender and work experience. Due to a communicated lack of time of the doctors and difficulties to obtaining an answer from the doctors, even with the support of the board of the Care Management, we could not win more participants for different focus groups in either of the two waves. To be able to collect more data, we had to conduct supplemented face-to-face interviews. We interviewed only two specialists and three female physicians, however, all but one of them had been in the profession for a similar length of time. The associated increased risk of selection bias and an incomplete, as well as a small sample in our study, limits the credibility and transferability of the results. It is also possible that the participants in the first wave experienced the implementation process differently from those in the second survey wave. In any case, the participants of both groups were defined as "early adopters". Based on previous research, we have focused on relative advantage, as this factor is known to be one of the most critical determinants for the implementation and diffusion of an innovation [12, 16–18]. Other determinants of implementation were not considered. Besides the importance of personal values and the time lag between implementation and consequence, numerous other factors influence the successful implementation of an innovation (e.g. complexity, trialability and observability of an innovation, information, support) [27]. The interpreted data are trustworthy in that three researchers read the transcriptions, participated in the discussions about the coding and reviewed the interpretations [26]. 5 Conclusion This study contributes to the investigation of the determinants for the successful implementation of new forms of care. Our results suggest that the respective personal values of the participants can predict the individually perceived success of the health care innovation and that a quickly perceived advantage may affect the sustainable implementation of e.g. a new healthcare model. Since this is a theoretical assumption based on the subjective perception of individual participants, further investigations with a more extensive study population must be carried out, including quantitative process data such as the number of enrolled patients or satisfaction in people with different value orientations. Future research is encouraged to use learning models as theoretical constructs for implementation research since implementation is a complex learning process. Abbreviations Care management CM Demand management DM General Practitioners GP Monitoring and coordinating assistant MoniKa People with Multimorbidity in Outpatient Care: Patient-Focused and Needs-Oriented Healthcare Management” MamBo Declarations Ethics approval and consent to participate The study has been approved by the Ethics Committee of both the Medical Faculty University Hospital of Cologne (ref. nr. 17/-327) and the North Rhine Medical Association (ref. nr. 2018191), thus all methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtainied from all the participants in the study. They received a letter of consent for participation, including information about our publication intention, prior to the focus group or interviews. All participants obtained a copy of the consent form. The transcripts do not contain data of any individual person.The study is registered at the German clinical trials register (DRKS00014047). Consent for publication Not applicable Availability of data and material It is planned to submit the results of the formative and summative evaluation for publication in peer-reviewed journals and to present them at national and international conferences. The dissemination will also be supported by professional public relation activities. The anonymous datasets generated during the current study may be made available from the corresponding author on reasonable request. Protocol modifications will be communicated to relevant parties. such as the publisher of this study protocol or the trial registry. The study manager will oversee the intra-study sharing process. All project members listed in this study protocol will have access to the cleaned anonymous data sets of their respective work packages. Competing interests Prof. Dr. Holger Pfaff is an Associate Editor in BMC Health Services Research. Furthermore, the remaining authors declare no conflicts of interest. Funding This study was funded by the Innovation Fund of the Federal Joint Committee, Germany (grant number 01NVF17001). The funding institution is not actively involved in the study. Author’s contributions SR, UK, MN and ID planned and developed the interview and focus group guide. ID conducted the first focus group as moderator and SR the second focus group plus interviews. SR, MN and UK planned and carried out data analysis. HP and UK designed the study and supervised the project administration. MN, ID, and UK assisted with interpreting the results. SR drafted the manuscript with support of ID and UK. The final manuscript has been read and approved by all authors. Acknowledgments We would like to thank Maya Nocon and Florian Wurster, our student assistants at the Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR) for their assistance in conduction the focus groups. We also would like to thank all physicians who were willing either to participate in the focus group or to be interviewed. We gratefully acknowledge the support and cooperation within the MamBo-project as well as the support by fonoskript, who transcript the audio-records. Authors’ information SR is a well trained research assistant and PhD student in the Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR) and in response of the formative evaluation of the project MamBo. Besides focus group with doctors she also conducted interviews and focus group with various auteurs involved in the project. Dr. UK is an expert in qualitative research and has several years of experience in conducting qualitative studies. Dr. UK is currently working as a guest professor at the TU Dortmund University, Faculty of Rehabilitation Sciences and is working on her habilitation. Before that she worked as a postdoc at the IMVR, where she initiated and supervised numerous projects using qualitative evaluation methods. References United Nations. World population ageing 2019: highlights. New York: United Nations; 2019. Robert Koch-Institut. Welche Auswirkungen hat der demografische Wandel auf Gesundheit und Gesundheitsversorgung? Berlin: RKI-Bib1 (Robert Koch-Institut); 2015. Haslam D. "You're an expert in me": the role of the generalist doctor in the management of patients with multimorbidity. J Comorb. 2015;5:132–4. Tetzlaff J, Muschik D, Epping J, Eberhard S, Geyer S. Expansion or compression of multimorbidity? 10-year development of life years spent in multimorbidity based on health insurance claims data of Lower Saxony, Germany. Int J Public Health. 2017;62:679–86. Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Aff (Millwood). 2011;30:2437–48. McKinlay EM, Morgan SJ, Gray BV, Macdonald LM, Pullon SRH. Exploring interprofessional, interagency multimorbidity care: case study based observational research. J Comorb. 2017;7:64–78. World Health Organization. Ambulatory care sensitive conditions in Germany. Denmark; 2015. Sinnott C, Mc Hugh S, Browne J, Bradley C. GPs' perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open. 2013;3:e003610. Richter S, Demirer I, Choi K-E, Hartrampf J, Pfaff H, Karbach U. People with multimorbidity in outpatient care: patient-focused and needs-oriented healthcare management (MamBo) - protocol for a multiperspective evaluation study. BMC Health Serv Res. 2020;20:296. Hroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF. Challenges of change: a qualitative study of chronic care model implementation. Ann Fam Med. 2006;4:317–26. Vedel I, Ghadi V, Stampa M de, Routelous C, Bergman H, Ankri J, Lapointe L. Diffusion of a collaborative care model in primary care: a longitudinal qualitative study. BMC Fam Pract. 2013;14:3. Gustavsson C, Nordqvist M, Bröms K, Jerdén L, Kallings LV, Wallin L. What is required to facilitate implementation of Swedish physical activity on prescription? – interview study with primary healthcare staff and management. BMC Health Serv Res. 2018;18:196. Rogers EM. Diffusion of innovations. New York, London, Toronto, Sydney: Free Press; 2003. Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991;50:179–211. Holden RJ, Karsh B-T. The technology acceptance model: its past and its future in health care. J Biomed Inform. 2010;43:159–72. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581–629. Scott SD, Plotnikoff RC, Karunamuni N, Bize R, Rodgers W. Factors influencing the adoption of an innovation: an examination of the uptake of the Canadian Heart Health Kit (HHK). Implement Sci. 2008;3:41. Ernstmann N, Ommen O, Neumann M, Hammer A, Voltz R, Pfaff H. Primary care physician's attitude towards the German e-health card project--determinants and implications. J Med Syst. 2009;33:181–8. Denis J-L, Hébert Y, Langley A, Lozeau D, Trottier L-H. Explaining diffusion patterns for complex health care innovations. Health Care Manage Rev. 2002;27:60–73. Sánchez-Gómez MC, Martín-Cilleros MV. Implementation of Focus Group in Health Research. In: Costa AP, Reis LP, Neri de Sousa F, Moreira A, Lamas DR, editors. Computer supported qualitative research. Cham: Springer; 2017. p. 49–61. Mayring P. Qualitative content analysis: theoretical foundation, basic procedures and software solution. Klagenfurt, Austria; 2014. Staddon JER, Cerutti DT. Operant conditioning. Annu Rev Psychol. 2003;54:115–44. Angermeier WF. Kontrolle des Verhaltens: Das Lernen am Erfolg. Berlin, Heidelberg: Springer; 1976. Pope C, Mays N. Qualitative research in health care. 3rd ed. Malden, Mass: Blackwell Pub; 2006. Fuß S, Karbach U. Grundlagen der Transkription: Eine praktische Einführung. Opladen, Stuttgart: Budrich; UTB; 2014. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62:107–15. Fleuren M, Wiefferink K, Paulussen T. Determinants of innovation within health care organizations: literature review and Delphi study. Int J Qual Health Care. 2004;16:107–23. Supplementary Files Additionalfile1.docx The additional file 1 includes the Interview-guidelines used in the first focus group and the adapted interview guideline used in the second focus group. Additionalfile2.docx The additional file 2 indcludes a detailed description of the main categories, subcategories and their definitions. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 08 Jun, 2021 Reviewers agreed at journal 14 May, 2021 Reviews received at journal 25 Apr, 2021 Reviewers agreed at journal 21 Apr, 2021 Reviewers invited by journal 22 Dec, 2020 Editor assigned by journal 22 Dec, 2020 Editor invited by journal 22 Dec, 2020 Submission checks completed at journal 22 Dec, 2020 First submitted to journal 10 Dec, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-125775","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":6906469,"identity":"a5cfd743-ecb3-4d25-a905-1ce73e4f3944","order_by":0,"name":"Simone Richter","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIie2PMUvDQBTHn8tl8KVzStB8hQtdi5/FR6CTSMcOBU8K51J0TRHqZxDByeHgoFlSXYUKBgp1bbcORbwk3WwOR4f7wfGHx/147w/gcPxDolGdVwywzC4EwEz2zVOHFa7rJAl4JAB6e4VblH2SqBX9B8U7pmV/AHTrzbNi8/JGE8GoWPMPaGWioYv/1Elz0wUv6TpdLegemI5TvoJ23rBG+8+hL2HIAoxHqBY0jb5kiKYjfz+3KN/Qq5SdeqUpeDLclcpnYVEEJJUCSpWHzUKotjTU16YLzgKSeBFPxirpmPpJPOYa2/nhw6K7+eMSh116uMn5eqvOTlLF4mI70KetrKF+TfB7hLb/DofD4bDzAxz8XyiQgNBZAAAAAElFTkSuQmCC","orcid":"","institution":"Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Simone","middleName":"","lastName":"Richter","suffix":""},{"id":6906470,"identity":"0baf6a9e-df86-4337-b43c-e1ac683b3d1c","order_by":1,"name":"Ibrahim 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Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Holger","middleName":"","lastName":"Pfaff","suffix":""},{"id":6906473,"identity":"f0e0a35b-4aad-4e40-9f31-62d1be13ce76","order_by":4,"name":"Ute Karbach","email":"","orcid":"","institution":"TU Dortmund University, Faculty of Rehabilitation Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ute","middleName":"","lastName":"Karbach","suffix":""}],"badges":[],"createdAt":"2020-12-10 10:59:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-125775/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-125775/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":4546659,"identity":"b4e035d3-50ac-49e1-bd1e-27ec49dc6b2d","added_by":"auto","created_at":"2020-12-28 17:14:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57713,"visible":true,"origin":"","legend":"Theoretical model of the link between personal value orientations, desired advantages, and perceived project success","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-125775/v1/61a2bcc76cb531d0172faa92.png"},{"id":4546824,"identity":"8e183941-e8e1-4eb7-bee6-faa634545f40","added_by":"auto","created_at":"2020-12-28 17:17:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":139520,"visible":true,"origin":"","legend":"Application of the learning model operant conditioning to the study results","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-125775/v1/6824fdbdd5b33ba14528c8c7.png"},{"id":13639204,"identity":"a8b5bb7b-979a-4443-b335-5d7cd674b5db","added_by":"auto","created_at":"2021-09-17 08:54:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":661045,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-125775/v1/81056c6a-6f40-4792-a669-e7075df22a96.pdf"},{"id":4546825,"identity":"e08b4ae0-ec03-457c-bc15-e4e7acc8b9e9","added_by":"auto","created_at":"2020-12-28 17:17:48","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31630,"visible":true,"origin":"","legend":"The additional file 1 includes the Interview-guidelines used in the first focus group and the adapted interview guideline used in the second focus group.","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-125775/v1/fbe48e414330a87a42e29513.docx"},{"id":4546826,"identity":"ae6103bb-e458-49a3-91d1-8df6ab31ed8a","added_by":"auto","created_at":"2020-12-28 17:17:48","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":24376,"visible":true,"origin":"","legend":"The additional file 2 indcludes a detailed description of the main categories, subcategories and their definitions.","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-125775/v1/026593e9019b198aa6e209e5.docx"}],"financialInterests":"","formattedTitle":"When do physicians perceive the success of a new care model differently? A qualitative study on personal values of physicians and their expected advantages through the implementation of a new care model in a primary care setting","fulltext":[{"header":"1 Background","content":" \u003cp\u003eDemographic change will lead to ageing of society and, in this context, to an increasing proportion of people suffering from several chronic diseases. There is a growth in the number and proportion of older people in practically every country in the world. In highly industrialized countries, the population is significantly older than in other parts of the world. However, the fastest growth in the older population between 2019 and 2050 is likely to occur in the least developed countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Also, in Germany, the age structure is shifting. Around every fifth person is aged 65 or over. The number of people aged 80 and over is forecasted to rise from 4.4\u0026nbsp;million in 2013 to around 6\u0026nbsp;million people in 2020 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This development is accompanied by an increasing of non-communicable diseases, chronic conditions and multimorbidity. As a result, the demand for healthcare services is rising. Besides that, the health care of chronically ill and multimorbid patient\u0026rsquo;s is complex and requires interprofessional cooperation between general practitioners (GPs), specialists, the inpatient sector and nursing care [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Patients with serious illnesses or chronic conditions and thus with complex care needs often report a lack of integrated and well-coordinated care. This is seen in many countries including Canada, Germany, France, the Netherlands, Great Britain or the United States. When different professions and disciplines are involved, it is often unclear who is responsible for patient coordination. This is where the GPs play an important role [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As one way of assigning this responsibility more clearly, many countries have a gatekeeper system. In Germany, there is no overall legal regulation for it [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, McKinglay et al. pointed out that, although general practitioners are believed to be best placed to coordinate the care, the situation is further complicated when several professionals and, in addition, authorities are involved [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Besides the clinical difficulties faced by general practitioners in the care of multimorbid patients, the load from non-medical tasks is increasing, and delegation of tasks is therefore playing a greater role [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo meet these challenges, scientists and health professionals are working on the development, implementation and evaluation of innovations in the healthcare sector. In line with this, the care model \u0026ldquo;MamBo- People with Multimorbidity in Outpatient Care: Patient-Focused and Needs-Oriented Healthcare Management\u0026rdquo; has been introduced in an urban region in Germany, in 2017. The core element of an implemented care management is the case-related, cross-sectoral coordination of multimorbid patients by the case management \u0026ndash; including monitoring and coordination assistants (MoniKas) who conduct house calls, delegated by physicians. At the patients\u0026rsquo; home, the Monikas first assess the needs of the patients, including medical, nursing and social-legal needs. Then the MoniKas take over the coordination with numerous actors in the health and social care sector while being in regular contact with the treating physicians. The implementation of the health care innovation \u0026ldquo;MamBo\u0026rdquo; is accompanied by an evaluation study with a project duration of 3.5\u0026nbsp;years. Forty-one out of about 100 potential physicians (only physicians who are part of a regional physicians network) participate in the project and in October 2020, 2615 patients were enrolled. During the project, two to three MoniKas were employed in the physician network. Further information on the evaluation study of Mambo can be found in our study protocol [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipating GPs are in charge of delegating house calls, caring for and enrolling patients. Thus, their acceptance of the new structures is essential for the successful and sustainable implementation of healthcare innovation. Experiences show that the implementation of innovations, like the establishment of case management, often takes a long time and remains a challenge, especially concerning achieving adoption in the primary care setting. In this respect, it is crucial to understand which factors influence the sustainablilty of an implementation of complex health care innovation [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to Roger's Diffusion of Innovations Theory [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], the relative advantage desired by potential users is a characteristic of an innovation that strongly influences the individual's decision to implement it. It is the degree to which an innovation is perceived as being better than the idea it replaces. In the theory of planned behaviour, the behaviour is determined by behavioural beliefs, and the perception of positive or negative outcomes through the behaviour form the behavioural beliefs [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Accordingly, well-known theories referred to implementation research show that the relative advantage is an essential factor for the implementation of an innovation. Innovations that have a decisive advantage over the conventional standard are more easily adopted and implemented [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNot only theoretical but also current research evidence indicates that the relative advantage is an essential factor for the adoption of an innovation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In a quantitative analysis of the association of certain attributes on physicians\u0026rsquo; intention and actual use of an intervention, Scott and colleagues[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] found two of its qualities to be more influential than the others, namely relative advantage and observability. But the benefit of e.g. the implementation of a new care model conceptualize differently between the potential adopters for instance in terms of economy, social reputation or user-friendliness [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Denis and colleagues pointed out that potential adopters do not act in an entirely rational manner, but according to their interests or values and power dependencies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Also Greenhalgh et al. identified in their systematic review cognitive and social psychology factors such as the individual\u0026rsquo;s motivation, values and learning styles, which influence the implementation of innovations [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, after implementing a new innovation, participants must decide whether to continue or discontinue the adoption [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In our case, physicians may also choose to take a more passive role and not, for example, continue with all aspects of MamBo such as patient\u0026rsquo;s enrolment.\u003c/p\u003e \u003cp\u003eBased on the fact that relative advantages play a driven role in the implementation of innovations, this study aims to identify the personal values of physicians, which determine their benefits desired by their participation. We further address the question of how this may affect a sustainable implementation of the new care model in our study population.\u003c/p\u003e "},{"header":"2 Methods","content":"\u003ch2\u003e2.1 Study design\u003c/h2\u003e\n\u003cp\u003eSince little is known, we used an explorative research design to identify personal values and expected advantages. In the context of the formative evaluation of the evaluation study MamBo, interviews with MamBo-physicians were conducted. The interviews were performed in the form of focus groups, which were supplemented by face-to-face interviews. This study shows the results of the focus groups and qualitative interviews based on qualitative content analysis with both a deductive and inductive approach [20, 21]. The Diffusion of Innovation Theory by Rogers was stated to underpin the development and analysis of the interviews [13]. We have further used the learning model of operant conditioning to place our study results in a theoretical context [22] [23].\u003c/p\u003e\n\u003ch2\u003e2.2 Research Team and Reflexivity\u003c/h2\u003e\n\u003ch2\u003e2.3 Sampling\u003c/h2\u003e\n\u003cp\u003eThe recruitment of physicians for the focus groups was based on the Theory Rogers \u0026ldquo;Diffusion of Innovation\u0026rdquo;, i.e. physicians that were active from the beginning (\u0026ldquo;early adopters\u0026rdquo;, within the first year) where interviewed separately from physicians that became active later (\u0026ldquo;late adopters\u0026rdquo;) [13]. Physicians who had participated once couldn\u0026rsquo;t participate in the formative evaluation again. The board of the care management provided access to physicians. In addition, the research team sent out invitations and information letters explaining the objectives, ethical aspects and procedure of the study, as well as a letter of consent via fax and e-mail. Also, an expense allowance (120 \u0026euro;) was offered for participation. This analysis is based on data from the group of early adopters, collected by two focus groups and additional face-to-face interviews. For this, all participating physicians, who intended to implement the health care innovation within the first year of its begin, formed the study population and were approached in June 2018 and in January 2019 [24].\u003c/p\u003e\n\u003ch2\u003e2.4 Data collection\u003c/h2\u003e\n\u003cp\u003eThe interviews followed a semi-structured guideline [20, 24], which was developed by two well-trained researches (SR, UK). The interview guide revolved around five main topics:\u003c/p\u003e\n\u003cp\u003e➢\u0026nbsp;Intention to participate in the healthcare innovation\u003c/p\u003e\n\u003cp\u003e➢\u0026nbsp;Implementation of the healthcare innovation and its evaluation\u003c/p\u003e\n\u003cp\u003e➢\u0026nbsp;Perceived changes in daily work routine: advantage or disadvantage of the innovation\u003c/p\u003e\n\u003cp\u003e➢\u0026nbsp;Communication channels (way of spreading the word about the innovation)\u003c/p\u003e\n\u003cp\u003e➢\u0026nbsp;Change requests for the further course of the project/ transmission in regular care\u003c/p\u003e\n\u003cp\u003eFor each main topic, open questions were designed to generate narratives from the participants. Depending on the course of the respective interview, more concrete follow-up questions were asked. Thus, the interview guide was flexibly adapted to the course of the conversation. Adaptations of the guide, according to the background and type of physician, were made prior to the interviews [20, 24]. The guidelines that were used for the focus groups are attached as additional file [see Additional file 1}.\u003c/p\u003e\n\u003cp\u003eTo take field notes, two research assistants took part in the first focus group in addition to the moderating researcher and one assistant in the second focus group. The focus groups were conducted in the premises of a regional physicians' network. The face-to-face interviews were held in the physician\u0026rsquo;s practices. All interviews and focus groups were audio- recorded and ruled led transcribed and pseudonymised [25]. Right after a focus group or interview, a memo was written by the interviewee to obtain supplementary and contextual information for the analysis [24].\u003c/p\u003e\n\u003ch2\u003e2.5 Data analysis\u003c/h2\u003e\n\u003cp\u003eTo analyse the interviews, qualitative content analysis was used [21]. The analysis contained three phases: the preparation phase, the familiarisation phase and coding phase. Before working with the collected data, single words, a sentence or a paragraph relating to the research questions were defined as units of analysis. We have defined to consider mainly manifest content in the analysis, but also general agreement and disagreement among participants on individual statements [26]. We also tried to examine underlying meanings to identify personal values and interrelations between statements. At the end we classified our interview partners according to identified value orientations and compared their statements regarding their perceived advantages and the success of the project. To get completely familiar with the data two researches (SR, UK and a research assistant in various combinations) read the transcripts intensely before conducting the initial data analysis. The coding of the material was conducted in two steps. First, main categories and subcategories were defined deductive, based on the guideline topics and Rogers\u0026rsquo;s theory \u0026ldquo;Diffusion of Innovations\u0026rdquo;. The resulting codebook, including definitions, coding-rules and examples out of the material, were developed by the first author and revised by UK, In the second step, this codebook was used to initially code the material by an inductive approach. Inductively developed codes either fit into a deductively defined category or were included as a new category in the codebook. The codebook was repetitively discussed and revised among the researches until consensus was obtained. Table 1 provides an extract and example of the considered categories. The final codebook includes a short description for each code which is relevant for the research question. Further interpretation was performed by the first author and reviewed by as well as discussed with UK. The coding was assisted by the use of the computer software MAXQDA (VERBI GmbH, Berlin, Germany).\u003c/p\u003e\n\u003cp\u003eTable 1: Extract of the codebook- Code examples of one Category\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003eCategory \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003eSubcategories\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003eDefinition \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExample out of the material\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003eIntention to participate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eMamBo as a solution for patient-related challenges\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003eChallenges in the care of multimorbid patients from different perspectives: 1. Challenges related to the characteristics of a multimorbid patient are of interest (impaired cognitive performance, mobility, communication, social support). 2. Aspects of the health care system that make it difficult to care for multimorbid patients and their characteristics.\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cem\u003e\"In addition, mobility is becoming increasingly restricted, which makes communication with patients who otherwise come to the practice regularly more difficult. \" (FG1; paragraph 23)\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e "},{"header":"3 Results","content":"\u003cp\u003eOne focus group was conducted in June 2018 with six GPs. A second focus group took part in January 2019 with three GPs and one specialist. Since three doctors expressed their interest in being interviewed, but no common date for a focus group for all suitable could be found, the second wave was supplemented by individual face-to-face interviews with two GPs and one specialist. Both focus groups lasted about 90 minutes, and the face-to-face interviews lasted between 30 and 60 minutes. In all, the results are based on data of 13 physicians who have been physicians in residential practice for in average 20 years and who had implemented the new care model.\u003c/p\u003e\n\u003cp\u003eAll participating doctors have used the service of the case management at the time of being interviewed. Some physicians were less active in delegating tasks and enrolling patients. The main categories \u0026ldquo;Compatibility\u0026rdquo;, \u0026ldquo;Intention to participate\u0026rdquo;, \u0026ldquo;(not) perceived advantages of the innovation\u0026rdquo; and \u0026ldquo;System-related challenges for implementation and transfer\u0026rdquo; include in total 22 subcategories relevant for the research question. A detailed description of the categories and their definitions is added additionally [see Additional file 2]. The personal values and their relation to the perception of advantages as well as the assessed success of the healthcare innovation were analysed by comparing statements that were assigned to the four categories mentioned above and their sub-categories.\u003c/p\u003e\n\u003ch2\u003e3.1 Values determining the perception of advantage\u003c/h2\u003e\n\u003cp\u003eAll informants acknowledged the work done by the MoniKas, in particular the assumption of non-medical, but social management tasks. All interviewed doctors received positive feedback from patients and their relatives and emphasized their satisfaction with the visits of a MoniKa - for example, in terms of patients feeling better informed and better cared for socially. But also, the challenges of the transfer to standard care, such as the question of how to cover necessary resources, were addressed in all interviews. Even if these potentials and challenges are recognized by almost all interviewees, the evaluation of these according to the personally perceived advantages is different. Thus, we found that the desired relative advantage, as most relevant for implementing the healthcare innovation, were mainly determined by (a) patient-oriented values or (b) economic-oriented values - taking into account that people with stronger economic-oriented values can also be driven by patient-oriented values or vice versa. However, certain values have a greater priority than others, which then determines the mainly desired advantage. We also identified further values and factors influencing the intention to participate (e.g. social norms, former project experience), which, however, do not seem to determine the desired advantage, or not in a substantial way. We now present the characteristics of participants with patient-oriented and economic-oriented values.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A) patient-oriented values \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDoctors interviewed, who had strong patient-oriented values, emphasized the importance of holistic patient care (medical, emotional, social) and were very concerned about the care of elderly people living alone at home and experiencing poor social support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;And indeed, there are many ways. It doesn't have to be Mambo. The main thing is that the patients are well cared for.\u0026rdquo; (Exp. 03)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThey also felt that the new care model could be a solution to the challenges associated with the medical care of multimorbidity, such as reduced mobility, communication problems and low compliance of multimorbid patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[...] cognitive \u003c/em\u003e\u003cem\u003eimpairment\u003c/em\u003e\u003cem\u003e of the patients, which lead to the fact that they are not in compliance with instructions, as we wish as physicians. In addition, mobility is becoming increasingly limited, which makes communication with patients who otherwise regularly come to the practice more difficult. The decreasing support from the family, which does not exist in small families. The wife is there because children often move far away, if there are children at all.\u0026ldquo; (FG 1. BB)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;(B) economic-oriented values\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe identified that the desired advantage of participants with stronger economic-oriented values was mainly based on monetary interests and interests to improve processes within their practice. The focus was on the cost-effectiveness of the new model, which was assessed by comparing the resources used to implement it with, for example, the reduction of workload or hospital stays of patients. Thus economic-oriented values could manifest not only in the form of personal cost-benefits but also in the interest of reducing social costs\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I might have to say again that all the non-medical task we do here, they don't get paid. Yes, we do it all for free. And who will do that in the future? I don't see that. And then what will the care landscape look like, so it is really urgently necessary to have something like this.\u0026rdquo; (FG1, GG)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The second is, I believe, that it is very important that money flows into this area. If there is no economy, they can forget everything. That is daydreaming. We have that in masses behind us.\u0026rdquo; (FG1, DD)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 includes identified factors which determine patient-oriented and economic-oriented values.\u003c/p\u003e\n\u003cp\u003eTable 2: Conceptualisation of patient- and economic- oriented values\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003epatient-oriented values\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u003cstrong\u003eeconomic-oriented values\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd\u003e\n\u003cp\u003e\u0026middot; social management\u003c/p\u003e\n\u003cp\u003e\u0026middot; drug management\u003c/p\u003e\n\u003cp\u003e\u0026middot; patient information\u003c/p\u003e\n\u003cp\u003e\u0026middot; patient satisfaction\u003c/p\u003e\n\u003cp\u003e\u0026middot; patient\u0026rsquo;s security\u003c/p\u003e\n\u003cp\u003e\u0026middot; continuous care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd\u003e\n\u003cp\u003e\u0026middot; cost reduction\u003c/p\u003e\n\u003cp\u003e\u0026middot; practice procedure\u003c/p\u003e\n\u003cp\u003e\u0026middot; social costs\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e3.2 Perceived advantages and evaluation of the project\u0026rsquo;s success\u003c/h2\u003e\n\u003cp\u003eParticipants with more \u003cstrong\u003e\u003cem\u003e\u003cu\u003epatient-oriented values\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003eexperienced the benefit for the patient also as an immediate personal advantage.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Well, that's what I meant in the first place. Seldom something like that is so well accepted. The patients call and are so happy that they are in the project. Such statements are made spontaneously. And I didn't hear anybody say, well, listen, that's nothing or something like that. Never. Not once. Well, in that respect, I can only say positive things, yes.\u0026rdquo; (Exp 01)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;And with such a positive tailwind, which they bring with them because, as I said, they feel that they are in good hands, things run easier. And safer.\u0026rdquo; (FG 2, AA)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese participants felt a work relief through the delegation of home visits, although most of the tasks undertaken by MoniKa were social-management rather than medical. They communicated a perceived advantage in terms of patient safety. On the one hand, they expressed that they have an advantage from the fact that their patients are safer at home when someone trained has taken a look at the home environment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think this is useful for me, too, when I know that patients are at least safer at home. There is no longer the tripping hazard of the carpet, there is perhaps also a nursing classification that is now happening here. There's someone who looks to see if a severely disabled person's ID card is necessary or something else.\u0026rdquo; (FG1, BB)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the other hand, they feel better when they know that their patients are being cared for safely, for example, during their practice holidays. By delegating tasks to MoniKa\u0026rsquo;s continuous care can also be ensured in that case.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;That there is a continuity of care when you are on holiday, that the patient does not have to go to the substitute doctor. The patient is overstrained with such a big thing.\u0026rdquo; (FG1, EE)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, participants with strong patient-oriented values quickly perceived advantages, shortly after implementation. They were more optimistic about the success of the project and spoke very positively about the new care model as a whole. Also, they reported that the enrolment of patients also became more straightforward when a direct benefit was noticed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Basically, I specifically addressed those where I saw that they would directly benefit from it. And after I noticed that it actually works well, that it is actually a good offer, it was much easier.\u0026rdquo; (FG2, DD)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast, participants with more \u003cstrong\u003e\u003cem\u003e\u003cu\u003eeconomic-oriented values\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e did not see a direct advantage for themselves from the patient benefits, and they experienced (only) little connection to the success of the project in general.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Nope, so, a care level has now been classified in a case or one or the other care aid has been purchased. Well, these are then improvements for the patients in the care level. They could also pay someone or...that's something concrete, yeah. And beyond that I wouldn't know right now if something has changed.\u0026rdquo; (Exp. 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;So, for me the use of MamBo is very difficult to evaluate, because of course the problems remain in my memory, where something doesn't work. And when I have hired MamBo like MoniKa, I get a feedback and I think it\u0026rsquo;s very positive, but I don't notice a direct advantage for me\u0026ldquo;. (FG1, AA)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor example, one participant with strong economic interests did not see any relief in his work, although he recognized and positively mentioned the work of the MoniKas who conducted home visits. He explained this by the fact that so far too few patients of his practice are involved in MamBo and have received a Monika.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Well, [\u0026hellip;] nothing worth mentioning has changed. Because we have two and a half thousand patients a quarter and from this 40 are, or, I don't know, maybe a little more, are in the Mambo project. Well, that is an amount that is not really worth mentioning. And the patients, for some of them the one or other advantage resulted from the visit of Monika, that was quite helpful.\u0026rdquo; (Exp. 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSo far, no changes in daily practice or at the societal level have been noticed in the outcomes relevant to them. They were less convinced of the new care model and expressed scepticism, especially with regard to proof its cost-effectiveness within the limited study period. Figure 1 models the link between the desired advantage, depending on the personal value orientation, and the perceived project success. Furthermore, negative consequences, such as the current expenditure of resources were more present in the interview when participants represented more substantial economic interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;Well, for that, Mambo would have to prove that it's somehow cost effective. I think it's going to be very difficult. It's going to be hard, just because of the amount of staff involved. I can hardly imagine that it will be successful in the end. Or it is still way too early for that or there are still too few people included. Well, you really should be able to prevent a stay in hospital or perhaps improve the medication etc. somehow, so that people really get a better care and have to go to hospital less often. And I'm sceptical about whether that will succeed. We're all sceptical about that, I suppose.\u0026ldquo; (Exp. 2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Nah, I don't see any relief. So what perhaps relieves me is that MoniKa now makes house calls and makes useful proposals, which I think is good. But I have more documentation and communication work to do.\u0026rdquo; (Exp. 2)\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e3.3 Relevance of a rapid perception of advantages on the implementation process\u003c/h2\u003e\n\u003cp\u003eBased on our findings of the interviews with participating physicians and with reference to a theoretical learning approach, we assume that quickly noticeable advantages are promotive for a continuous as well as a sustainable implementation. Accordingly, relative advantages that only become noticeable after a more extended period, such as economic benefits, inhibit the perception of the project\u0026rsquo;s success and its continuous implementation. The approach of operant conditioning can be used to support our assumption. As long as a positive consequence is expected or occurs, it is more likely that the behaviour will be repeated. However, the shorter the time between the behaviour and its consequence, the stronger the effect on the repetition of the behaviour [22] [23].\u003c/p\u003e\n\u003cp\u003eFigure 2 shows the transfer of the approach to our study results. The behaviour \u0026ldquo;Implementation of MamBo\u0026rdquo; should be repeated, or in our case, continued. The perceived advantages, conceptualized by the respective outcome relevant for either patient-oriented or business-oriented participants, are the consequence of the behaviour.\u003c/p\u003e\n\u003cp\u003eFollowing this approach, MamBo participants with stronger patient-oriented values would be more likely to continue the adoption of the MamBo structures as the relevant advantages for them are quickly noticeable after implementation. Moreover, optimistic and convinced participation promotes communication and thus, the diffusion of innovation [13]. In contrast, it is less likely that economic-oriented participants will continue the implementation in its complete form. Since so far, no or only little advantages have been perceived, no desired consequences reinforces the behaviour.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study aimed to identify physicians\u0026rsquo; values, which influence the individual perception of the success of the health care innovation and thus possibly the acceptance and dissemination of new care structures. Following what we found in the analysis, differences in a perceived success of the health care innovation could be explained by different personal values which determine the desired advantage by implementing the new care model. Even if positive changes for patients are recognized, this does not necessarily led to an sustainable implementation of the new care structures by participating physicians. We found that participants with more patient-oriented values quickly perceived a personal advantage and experienced great success, which is also in line with the learning theory of operant conditioning. Participants with more economically oriented values tended to be more critical about the innovation, although patient-related benefits are seen. Advantages have not been perceived by this group yet, as they only become apparent later.\u003c/p\u003e\n\u003cp\u003eOur study is mainly limited by a small study population, but also by inconsistencies in interview formats and the long period between the two focus groups. Nevertheless, our findings support the observations of Denis and colleagues in their multiple case study, namely that the perceived advantage is based on individual interests or values, such as economic interests, social prestige or to follow best clinical practice [19]. The findings of our study also support the suggestion of Scott and colleagues that the advantage relative to a participant is conceptualized differently by those potential adopters [17]. As Greenhalgh et al. found out, it is more likely that potential adopters will use an innovation, if it meets their needs [16].\u003c/p\u003e\n\u003cp\u003eAs personal values predict the relative advantage of an innovation, it gives an indication of how the individual participants would evaluate the success of the health care innovation. By considering the personal values of potential study participants already during the planning and implementation of new care structures, a significant contribution can be made to the successful implementation of them. Typified support could increase the motivation of the participants to adapt to new structures.\u003c/p\u003e\n\u003cp\u003eBy using a qualitative approach, personal values and intentions for participation as well as the complexity of the innovation were revealed, which would have been difficult to identify with quantitative methods. While studies use the theory of operant learning to improve the adherence of treatments, the application of a learning theory in implementation science seems quite rare - although the adoption of new structures is a complex learning mechanism. The use of a learning theory like operant conditioning helps to understand and explain phenomena and dynamics in the adoption process [22][23]. By applying a learning theory, our findings have been further developed theoretically. It is, therefore, helpful to look at related areas and transfer theories from psychology to implementation research in healthcare.\u003c/p\u003e\n\u003cp\u003eInitially, purposeful sampling was planned to achieve a variation of the participants in terms of gender and work experience on the one hand, but also only the early adopters on the other hand [20, 24]. However, since we were unable to convince as many physicians to participate in the project as planned, the pool of potential participants for a focus group was smaller than assumed. Thus, we had to consider any interested physician for participation in our study independent from gender and work experience. Due to a communicated lack of time of the doctors and difficulties to obtaining an answer from the doctors, even with the support of the board of the Care Management, we could not win more participants for different focus groups in either of the two waves. To be able to collect more data, we had to conduct supplemented face-to-face interviews. We interviewed only two specialists and three female physicians, however, all but one of them had been in the profession for a similar length of time. The associated increased risk of selection bias and an incomplete, as well as a small sample in our study, limits the credibility and transferability of the results. It is also possible that the participants in the first wave experienced the implementation process differently from those in the second survey wave. In any case, the participants of both groups were defined as \"early adopters\".\u003c/p\u003e\n\u003cp\u003eBased on previous research, we have focused on relative advantage, as this factor is known to be one of the most critical determinants for the implementation and diffusion of an innovation [12, 16\u0026ndash;18]. Other determinants of implementation were not considered. Besides the importance of personal values and the time lag between implementation and consequence, numerous other factors influence the successful implementation of an innovation (e.g. complexity, trialability and observability of an innovation, information, support) [27]. The interpreted data are trustworthy in that three researchers read the transcriptions, participated in the discussions about the coding and reviewed the interpretations [26].\u003c/p\u003e"},{"header":"5 Conclusion","content":" \u003cp\u003eThis study contributes to the investigation of the determinants for the successful implementation of new forms of care. Our results suggest that the respective personal values of the participants can predict the individually perceived success of the health care innovation and that a quickly perceived advantage may affect the sustainable implementation of e.g. a new healthcare model. Since this is a theoretical assumption based on the subjective perception of individual participants, further investigations with a more extensive study population must be carried out, including quantitative process data such as the number of enrolled patients or satisfaction in people with different value orientations. Future research is encouraged to use learning models as theoretical constructs for implementation research since implementation is a complex learning process.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eCare management CM\u003c/p\u003e \u003cp\u003eDemand management DM\u003c/p\u003e \u003cp\u003eGeneral Practitioners GP\u003c/p\u003e \u003cp\u003eMonitoring and coordinating assistant MoniKa\u003c/p\u003e \u003cp\u003ePeople with Multimorbidity in\u003c/p\u003e \u003cp\u003eOutpatient Care: Patient-Focused and\u003c/p\u003e \u003cp\u003eNeeds-Oriented Healthcare Management\u0026rdquo; MamBo\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThe study has been approved by the Ethics Committee of both the Medical Faculty University Hospital of Cologne (ref. nr. 17/-327) and the North Rhine Medical Association (ref. nr. 2018191), thus all methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtainied from all the participants in the study. They received a letter of consent for participation, including information about our publication intention, prior to the focus group or interviews. All participants obtained a copy of the consent form. The transcripts do not contain data of any individual person.The study is registered at the German clinical trials register (DRKS00014047).\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is planned to submit the results of the formative and summative evaluation for publication in peer-reviewed journals and to present them at national and international conferences. The dissemination will also be supported by professional public relation activities. The anonymous datasets generated during the current study may be made available from the corresponding author on reasonable request. Protocol modifications will be communicated to relevant parties. such as the publisher of this study protocol or the trial registry. The study manager will oversee the intra-study sharing process. All project members listed in this study protocol will have access to the cleaned anonymous data sets of their respective work packages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProf. Dr. Holger Pfaff is an Associate Editor in BMC Health Services Research. Furthermore, the remaining authors declare no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was funded by the Innovation Fund of the Federal Joint Committee, Germany (grant number 01NVF17001). The funding institution is not actively involved in the study.\u003c/p\u003e\n\u003ch2\u003eAuthor\u0026rsquo;s contributions\u003c/h2\u003e\n\u003cp\u003eSR, UK, MN and ID planned and developed the interview and focus group guide. ID conducted the first focus group as moderator and SR the second focus group plus interviews. SR, MN and UK planned and carried out data analysis. HP and UK designed the study and supervised the project administration. MN, ID, and UK assisted with interpreting the results. SR drafted the manuscript with support of ID and UK. The final manuscript has been read and approved by all authors.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eWe would like to thank Maya Nocon and Florian Wurster, our student assistants at the Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR) for their assistance in conduction the focus groups. We also would like to thank all physicians who were willing either to participate in the focus group or to be interviewed. We gratefully acknowledge the support and cooperation within the MamBo-project as well as the support by fonoskript, who transcript the audio-records.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e\n\u003cp\u003eSR is a well trained research assistant and PhD student in the Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR) and in response of the formative evaluation of the project MamBo. Besides focus group with doctors she also conducted interviews and focus group with various auteurs involved in the project. Dr. UK is an expert in qualitative research and has several years of experience in conducting qualitative studies. Dr. UK is currently working as a guest professor at the TU Dortmund University, Faculty of Rehabilitation Sciences and is working on her habilitation. Before that she worked as a postdoc at the IMVR, where she initiated and supervised numerous projects using qualitative evaluation methods.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnited Nations. World population ageing 2019: highlights. New York: United Nations; 2019.\u003c/li\u003e\n\u003cli\u003eRobert Koch-Institut. Welche Auswirkungen hat der demografische Wandel auf Gesundheit und Gesundheitsversorgung? Berlin: RKI-Bib1 (Robert Koch-Institut); 2015.\u003c/li\u003e\n\u003cli\u003eHaslam D. \"You're an expert in me\": the role of the generalist doctor in the management of patients with multimorbidity. J Comorb. 2015;5:132\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eTetzlaff J, Muschik D, Epping J, Eberhard S, Geyer S. Expansion or compression of multimorbidity? 10-year development of life years spent in multimorbidity based on health insurance claims data of Lower Saxony, Germany. Int J Public Health. 2017;62:679\u0026ndash;86.\u003c/li\u003e\n\u003cli\u003eSchoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated. Health Aff (Millwood). 2011;30:2437\u0026ndash;48.\u003c/li\u003e\n\u003cli\u003eMcKinlay EM, Morgan SJ, Gray BV, Macdonald LM, Pullon SRH. Exploring interprofessional, interagency multimorbidity care: case study based observational research. J Comorb. 2017;7:64\u0026ndash;78.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Ambulatory care sensitive conditions in Germany. Denmark; 2015.\u003c/li\u003e\n\u003cli\u003eSinnott C, Mc Hugh S, Browne J, Bradley C. GPs' perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research. BMJ Open. 2013;3:e003610.\u003c/li\u003e\n\u003cli\u003eRichter S, Demirer I, Choi K-E, Hartrampf J, Pfaff H, Karbach U. People with multimorbidity in outpatient care: patient-focused and needs-oriented healthcare management (MamBo) - protocol for a multiperspective evaluation study. BMC Health Serv Res. 2020;20:296.\u003c/li\u003e\n\u003cli\u003eHroscikoski MC, Solberg LI, Sperl-Hillen JM, Harper PG, McGrail MP, Crabtree BF. Challenges of change: a qualitative study of chronic care model implementation. Ann Fam Med. 2006;4:317\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eVedel I, Ghadi V, Stampa M de, Routelous C, Bergman H, Ankri J, Lapointe L. Diffusion of a collaborative care model in primary care: a longitudinal qualitative study. BMC Fam Pract. 2013;14:3.\u003c/li\u003e\n\u003cli\u003eGustavsson C, Nordqvist M, Br\u0026ouml;ms K, Jerd\u0026eacute;n L, Kallings LV, Wallin L. What is required to facilitate implementation of Swedish physical activity on prescription? \u0026ndash; interview study with primary healthcare staff and management. BMC Health Serv Res. 2018;18:196.\u003c/li\u003e\n\u003cli\u003eRogers EM. Diffusion of innovations. New York, London, Toronto, Sydney: Free Press; 2003.\u003c/li\u003e\n\u003cli\u003eAjzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991;50:179\u0026ndash;211.\u003c/li\u003e\n\u003cli\u003eHolden RJ, Karsh B-T. The technology acceptance model: its past and its future in health care. J Biomed Inform. 2010;43:159\u0026ndash;72.\u003c/li\u003e\n\u003cli\u003eGreenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581\u0026ndash;629.\u003c/li\u003e\n\u003cli\u003eScott SD, Plotnikoff RC, Karunamuni N, Bize R, Rodgers W. Factors influencing the adoption of an innovation: an examination of the uptake of the Canadian Heart Health Kit (HHK). Implement Sci. 2008;3:41.\u003c/li\u003e\n\u003cli\u003eErnstmann N, Ommen O, Neumann M, Hammer A, Voltz R, Pfaff H. Primary care physician's attitude towards the German e-health card project--determinants and implications. J Med Syst. 2009;33:181\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eDenis J-L, H\u0026eacute;bert Y, Langley A, Lozeau D, Trottier L-H. Explaining diffusion patterns for complex health care innovations. Health Care Manage Rev. 2002;27:60\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003eS\u0026aacute;nchez-G\u0026oacute;mez MC, Mart\u0026iacute;n-Cilleros MV. Implementation of Focus Group in Health Research. In: Costa AP, Reis LP, Neri de Sousa F, Moreira A, Lamas DR, editors. Computer supported qualitative research. Cham: Springer; 2017. p. 49\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eMayring P. Qualitative content analysis: theoretical foundation, basic procedures and software solution. Klagenfurt, Austria; 2014.\u003c/li\u003e\n\u003cli\u003eStaddon JER, Cerutti DT. Operant conditioning. Annu Rev Psychol. 2003;54:115\u0026ndash;44.\u003c/li\u003e\n\u003cli\u003eAngermeier WF. Kontrolle des Verhaltens: Das Lernen am Erfolg. Berlin, Heidelberg: Springer; 1976.\u003c/li\u003e\n\u003cli\u003ePope C, Mays N. Qualitative research in health care. 3rd ed. Malden, Mass: Blackwell Pub; 2006.\u003c/li\u003e\n\u003cli\u003eFu\u0026szlig; S, Karbach U. Grundlagen der Transkription: Eine praktische Einf\u0026uuml;hrung. Opladen, Stuttgart: Budrich; UTB; 2014.\u003c/li\u003e\n\u003cli\u003eElo S, Kyng\u0026auml;s H. The qualitative content analysis process. J Adv Nurs. 2008;62:107\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eFleuren M, Wiefferink K, Paulussen T. Determinants of innovation within health care organizations: literature review and Delphi study. Int J Qual Health Care. 2004;16:107\u0026ndash;23.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"health services research, qualitative approach, relative advantage, outpatient care, diffusion of Innovations, theory of planned behaviour, operant conditioning, care management, case management","lastPublishedDoi":"10.21203/rs.3.rs-125775/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-125775/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe health care innovation \"MamBo \u0026ndash; people with multimorbidity in outpatient care: patient-focused and needs-oriented healthcare management\u0026rdquo; aims to improve the efficiency and quality of care for multimorbid patients by delegating tasks (e.g. taking over house calls or coordinating specialist appointments) to a monitoring and coordination assistant (MoniKa). Participating physicians are very important for the success of the health care innovation due to their direct involvement as practitioners and their task of enrolling patients. The aim of this part of the evaluation study is therefore to identify the physician\u0026rsquo;s personal values, which influence the individual perception of the project\u0026rsquo;s advantages and thus possibly the acceptance and sustainable implementation of new care structures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTwo Focus groups (n\u0026thinsp;=\u0026thinsp;4; n\u0026thinsp;=\u0026thinsp;6) and three individual interviews with general practitioners and specialists who decided to implement the health care innovation within the first year were conducted. The semi-structured guidelines were developed by the research team. The interviews were analysed according to the content analysis by Mayring. We used the learning model of operant conditioning to place our study results in a theoretical context.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eTwo central personal values of the participants, which determine the desired advantages of the health care innovation were identified: More patient-oriented and more economic-oriented values. Participants with more patient-oriented values quickly perceived advantages, which seems to be beneficial for the acceptance of the new care structures. Economic-oriented participants tended to be more critical. The benefits of the health care innovation, which was expressed, for example, in an improvement of the practice routine, has not yet been perceived by this group, or only to a limited extent.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe results suggest that the respective values of the participants define the individual perceived advantages and thus, the assessment of the success of the health care innovation in general. These findings could be used in the implementation process by increasing the motivation of the project participants through typified supervision.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eThe study has been registered in the German Clinical Trials Register (DRKS00014047).\u003c/p\u003e","manuscriptTitle":"When do physicians perceive the success of a new care model differently? A qualitative study on personal values of physicians and their expected advantages through the implementation of a new care model in a primary care setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-28 17:14:46","doi":"10.21203/rs.3.rs-125775/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-06-08T09:46:24+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"3f16bd8c-f117-4550-8859-c5179edeb7b0","date":"2021-05-14T13:25:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-04-25T18:44:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9891f115-91ed-4769-b6b0-55ee3b2c6667","date":"2021-04-22T01:50:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-12-22T14:33:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-12-22T08:35:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-12-22T05:55:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-12-22T05:46:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2020-12-10T10:54:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1f3d2a36-ec8f-427c-9204-e25156b1ff17","owner":[],"postedDate":"December 28th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":1617978,"name":"Health Economics \u0026 Outcomes Research"},{"id":1617979,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-09-15T16:29:10+00:00","versionOfRecord":[],"versionCreatedAt":"2020-12-28 17:14:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-125775","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-125775","identity":"rs-125775","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}