What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium

Danhieux, Katrien; Martens, Monika; Colman, Elien; Wouters, Edwin; Remmen, Roy; Olmen, Josefien Van; Anthierens, Sibyl

doi:10.5334/ijic.5671

Cited by 15 publications

(17 citation statements)

References 35 publications

(41 reference statements)

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“…Whereas in the capitation practices, there was complete freedom to organise and divide tasks as suited the practice best. Previous studies have signalled the dominant feefor-service system as a barrier to IC in Belgium [54,57] and the superiority of the capitation system concerning the quality of care in the eld of diabetes care [58]. Even though the capitation system scored signi cantly better in our study, it is debated whether it is the ideal system to stimulate qualitative chronic care, as it could provide caregivers with the option to enrol more patients than can be taken care of [59].…”

Section: Discussionmentioning

confidence: 62%

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

Danhieux

Buffel

Remmen

et al. 2022

Preprint

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Background Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system—the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types. Methods Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices. Results The ACIC scores of the fee-for-service practices—containing 97% of Belgian patients—only corresponded to basic support for chronic illness care. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the EMD, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks. Conclusions Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.

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Section: Discussionmentioning

confidence: 62%

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

Danhieux

Buffel

Remmen

et al. 2022

Preprint

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“…The latter was one of the main barriers reported by every project in the network underlining the need for an 'interprofessional integrated goaloriented electronic health record. ' 2,6,8 To conclude, Martens et al accurately described how Belgian IC policies do not support integration of care. The establishment of a LHCN is one way to unite multidisciplinary stakeholders and become more visible for policy makers in a fragmented political system.…”

Section: A Learning Healthcare Network As a Meso-level Mechanismmentioning

confidence: 99%

Integration of Chronic Care in a Fragmented Healthcare System Comment on "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study"

Smeets

Baldewijns

Vaes

et al. 2022

Int J Health Policy Manag

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The authors of "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study" present a fresh perspective on the inertia of integrated care (IC) implementation. They conclude that the decisive power in Belgium is fragmented and undermines efforts towards IC. As researchers in integrated heart failure care and active primary health care professionals, we comment on the three policy initiatives evaluated by Martens et al from a bottom-up perspective. A Learning Health Care Network (LHCN) was established Sept 2019 to overcome fragmentation, the lack of evaluation and capacity loss each time a pilot project ends. This commentary wishes to illustrate that a LHCN can be a powerful meso-level mechanism to engage in alignment work and to overcome macro-level barriers that are often difficult to change and not supportive of IC.

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“…. (18,19): Interactions are limited between hospital specialists, general practitioners, and other primary care providers, such as pharmacists, physiotherapists, and home care nurses. This lack of interprofessional collaboration has detrimental consequences for multimorbid patients, whose care pathway and experience suffer disruptions.…”

Section: "Integrated Care For Better Health": a Policy Program In Bel...mentioning

confidence: 99%

“…Multimorbid patient care requires inputs from different providers. However, the Belgian healthcare system is mainly focused on acute diseases, with a high degree of specialization resulting in organizational fragmentation of services and a lack of coordination between care providers ( 18 , 19 ): Interactions are limited between hospital specialists, general practitioners, and other primary care providers, such as pharmacists, physiotherapists, and home care nurses. This lack of interprofessional collaboration has detrimental consequences for multimorbid patients, whose care pathway and experience suffer disruptions.…”

Section: “Integrated Care For Better Health”: a Policy Program In Bel...mentioning

confidence: 99%

Developing evaluation capacities in integrated care projects: Lessons from a scientific support mission implemented in Belgium

Charlier

Colman

Irusta

et al. 2022

Front. Public Health

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The capacity of self-assessment, to learn from experience, to make information-based decisions, and to adapt over time are essential drivers of success for any project aiming at healthcare system change. Yet, many of those projects are managed by healthcare providers' teams with little evaluation capacity. In this article, we describe the support mission delivered by an interdisciplinary scientific team to 12 integrated care pilot projects in Belgium, mobilizing a set of tools and methods: a dashboard gathering population health indicators, a significant event reporting method, an annual report, and the development of a sustainable “learning community.” The article provides a reflexive return on the design and implementation of such interventions aimed at building organizational evaluation capacity. Some lessons were drawn from our experience, in comparison with the broader evaluation literature: The provided support should be adapted to the various needs and contexts of the beneficiary organizations, and it has to foster experience-based learning and requires all stakeholders to adopt a learning posture. A long-time, secure perspective should be provided for organizations, and the availability of data and other resources is an essential precondition for successful work.

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What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium

Cited by 15 publications

References 35 publications

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

Integration of Chronic Care in a Fragmented Healthcare System Comment on "Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study"

Developing evaluation capacities in integrated care projects: Lessons from a scientific support mission implemented in Belgium

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