Table 3 Topic list of focus groups and interviews

Institutional factors1.1.1.1.1.1.1.1.1.1.

1. Is there joint policy concerning integrated elderly care? Are objectives defined concerning integrated elderly care?

2. In what way are patients involved in the organization of care?

3. Is the target group of older people delineated? Was screening or case finding used in the elderly population?

4. Who are the stakeholders of the GPs in integrated care for the elderly population?

5. In the multidisciplinary team, what agreements are in writing concerning the organization of integrated care for older people?

6. What are the effects of structural consultation among professionals from care and welfare organizations?

7. What are the effects of health care professionals working under one roof?

8. Does consultation between the multidisciplinary team and care insurers regarding older people take place? What agreements have been made on the funding of integrated elderly care? Is finance of influence on the partnership? In what way?

9. Does consultation between the multidisciplinary team and the municipality regarding older people take place? In what way?

10. Is there systematic evaluation and improvement?

11. Is available knowledge being used? (Guidelines, protocols.)

(Inter)personal factors1.1.1.1.1.1.

12. What are the differences in values, beliefs, and attitudes concerning (a) the integrated elderly care team and (b) the other network partners?

13. Self-efficacy: do professionals feel confident about themselves and each other as collaborator?

14. Social identity: do partners also perceive a shared identity?

15. Nature of interpersonal relationships: do partners get along well with each other as collaborators?

16. Can you describe the role of the GP in the development of integrated elderly care?

17. Can you describe the role of the NHPS in the development of integrated elderly care?

18. Are there any agreements on taking the lead/control in integrated elderly care?

Factors concerning the organization of multidisciplinary teams

19. Flexible timeframe: is time and flexibility available for the development of integrated elderly care? How do you make time?

20. How is (multidisciplinary) consultation organized in the multidisciplinary team? (Frequency, composition, agenda, etc.) Are MTMs minuted? Are agreements transferable to colleagues?

21. Shared mission: did partners agreed on a shared mission, goals, and plan of action?

22. Do team members agree on distribution of roles and responsibilities?

23. Can you describe the influence of the collaboration between the GP and the practice nurse on the development of integrated elderly care?

24. Do team members build on each other’s capacities?

25. Are facilities for formal and informal communication in place?

26. What are the characteristics of the management of the multidisciplinary team (neutral, facilitating, empowering)?

27. Are the results of the personal and the team effort to the team members visible?