Supporting proactive and integrated chronic care in primary care practices in Belgium

Katrien Danhieux, Emy Kool, Charlotte Sercu, Lucky Botteldooren, Josefien Van Olmen

Keywords: organisation of care, chronic care, primary care practices, change

Primary care practices are pressured by the increased numbers of patients with chronic diseases and multimorbidity. Due to this increased workload, answering the needs of patients with complex chronic diseases is particularly challenging. These patients would profit from a more proactive and integrated care organisation. Today, Belgian general practitioners can still make big steps towards integrated care. Many want to improve their care organisation, but they lack the knowledge and skills on how to change.

Research questions:
Is a guided change program effective in supporting general practitioners and their team in optimizing their organization of care for patients with chronic diseases?

The intervention is based upon the ADKAR change model. On multiple study days different care providers will be united. In the first session Awareness on potential improvement is created using the ACIC, an assessment tool based on the chronic care model. In the second session participants’ Desire to change is stimulated by reflecting on the ACIC results and defining goals. Knowledge is central in the third session as participants will develop an improvement plan inspired by a overview of existing tools and guidelines. The Activation of the plan will follow in the practices. In a feedback day a few months later the plan and process is evaluated by a second measurement with the ACIC and arrangements are made on how to Reinforce improvements in practice. This session will also contain an evaluation of the program from the view of the participants. A pilot project will be conducted, to adapt the program as much as possible to the needs of the practitioners.

Results will follow

This practice improvement project will identify the challenges experienced by primary care practices of organizing chronic care in an integrated manner, and support them to come across those challenges.

Points for discussion:
Which frameworks are best suited to guide the evaluation of this program?

Do you know similar programs and have they been successful? What were the pitfalls?

How can we best support general practitioners and their team in optimizing their chronic care organization?