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Background : There are a variety of learning communities in the healthcare sector that are promoted as a means of generating and sharing knowledge, improving clinical practice, or increasing organizational performance. However, these models vary considerably in terms of mode of operation, structure, activities, and performance depending on the context in which these practices take place. [...]

BACKGROUND : In several countries, including Canada, Switzerland, France, and others, there have been efforts to establish university general practitioner (GP) practices. These practices serve as training grounds for medical students, conduct research activities, and offer comprehensive services to patients. However, despite these initiatives, there is currently no consensus on the criteria that define a “good” GP practice or what differentiates a “university” GP practice. [...]

Introduction: Improving the quality of health services can hardly be done without questioning the quality of the healthcare system. The DEQuaP program ("Let's develop the quality of our practices"), co-constructed through an action-research with healthcare professionals, is a participatory self-evaluation program for primary care in Belgium. The program invited all care providers of community health centres (CHC) to question, as an interdisciplinary team, their practices and collective functioning in order to embark themselves, or to become more firmly anchored, in a process of continuous quality improvement (QI). CHC users were also invited to contribute to its evaluation. Through this collaboration, the aim of the DEQuaP program is to improve the practices and functioning of the structure, in order to provide care adapted to the community. Aim: Although the context-sensitive nature of the QI programs is well known, it is still poorly understood how such programs target primary health care (2). Our study aim was to know why CHC teams sometimes engage in DEQuaP program whereas others do not. To do so, we investigated how contextual factors (at the individual, team and organisational levels) could explain the CHC team engagement. We further explored how these factors can be managed to support healthcare quality improvement.Methods:We conducted semi-structured interviews with CHC team members in French-speaking Belgium. An in-depth thematic analysis of the data using an inductive coding approach was completed to examine aspects of the individual, team and organizational factors that influence engagement in QI evaluation. Results: Preliminary results highlight themes representing contextual factors that motivate CHC teams to engage or not, in DEQuaP program. These included: 1) diversity in the definition of quality among care providers, mostly depending on their background and on characteristics of CHC users, 2) diversity in the perceived meaning and purpose of the evaluation process proposed by DEQuaP program among care prodivers and 3) diversity in motivations to work in the CHC. Above these three factors, a crucial element seems to be related to the organisational dynamics within the CHC. Although CHC are based on a non-hierarchical functioning, findings showed how power dynamics within CHC teams has been influential to QI program participation. Conclusion: The contextual factors that were highlighted in this study relate to factors outlined in the literature on professional and organizational cultures. Such factors, and their interaction, appear to be essential to understand the engagement in a QI initiative like the DEQuaP program. Implications: Exploring professional and organizational cultures should help us to better understand how and why QI interventions work in interdisciplinary teams, such as in community health centres. 1.Ploeg J, Wong ST, Hassani K, Yous ML, Fortin M, Kendall C, et al. Contextual factors influencing the implementation of innovations in community-based primary health care: the experience of 12 Canadian research teams. Primary health care research & development. 2019; 20: e107.

ispartof: issue:359 status: Published online

Problématique La première ligne de soins endosse des rôles importants dans le système de soins afin d’assurer la globalité, la continuité et la coordination auprès de personnes dans leur lieu de vie. Un grand nombre de personnes atteintes de plaie(s) chronique(s) sont soignées principalement à domicile et bénéficient de l’intervention de professionnels de la santé et de l’aide. Chez ces personnes les mécanismes de cicatrisation de la peau sont altérés par la confluence de différents facteurs : l’âge avancée, des maladies et ses traitements médicaux, la réduction de la mobilité, la malnutrition, etc. Chez une proportion importante de ces personnes ces différents facteurs s’entrecroisent pour créer des situations complexes. Les professionnels de première ligne sont de plus en plus fréquemment amenés à offrir de soins à des personnes en situation complexe. La provision de soins adaptés et cohérents aux préférences de la personne dans son environnement de vie met au défi la première de soins. La collaboration interprofessionnelle va jouer un rôle central afin de le relever. Cette étude est financée par la Chaire interdisciplinaire et interuniversitaire de la première ligne (BE.HIVE.be). La recherche sera deployée en Belgique francophone entre novembre de 2020 et mars 2023 par des investigateurs de l’IRSS de l’UCLouvain. But Le but est d’étudier les différentes approches collaboratives entre les professionnels de la santé et de l’aide auprès de personnes atteintes de plaie chronique soignées à domicile et vivant en situation complexe. Nous visons à relever les mécanismes qui favorisent ou entravent l’intégration du contexte et des préférences de la personne dans les décisions de soins et l’implémentation du plan de soins. Méthodologie Cette étude s’inspire de l’approche systémique et du réalisme critique. En cohérence avec ce cadre général, la méthode choisie est celle de l’étude de cas multiple qui permettra de tester et raffiner dans différents contextes de soins une théorie initiale sur la nature de la collaboration et des mécanismes sous-jacents. Un cas est constitué par trois personnes en situation complexe, l’équipe infirmière qui leur prodigue des soins à domicile pour des plaie(s) chronique(s) et tous les professionnels intervenant directement dans leur prise en charge. Cette méthode est particulièrement adéquate pour l’étude approfondie de phénomènes (dans notre cas, la collaboration interprofessionnelle) dans des contextes précis. Méthodes de collecte de données Différentes méthodes de collecte de données seront mobilisées : des entretiens individuels et collectifs, de l’observation, l’étude de documents tel que des protocoles, conventions. Participants Personnes et leurs aidants proches ainsi que les professionnels de soins et de l’aide impliqués dans leurs soins.

This presentation aims to share an approach of analysis of care contexts. In these contexts, nurses and other primary care providers are involved in the care of patients with chronic wounds, cared for at home and living in complex situations. In Europe, people with chronic wounds are mostly cared for at home by nurses and other primary care providers. Chronic wounds are generally associated with age, the presence of chronic diseases and vulnerability, creating multiple needs. This means that many care providers may be involved in their care, which can jeopardise the continuity of care. The combination of patient-specific factors and the interaction with multiple providers creates very different care contexts, with specific resources and barriers. Because of these interactions of multiple factors, the situation can be described as complex. We collected stories from care providers (mostly nurses) through interviews and work groups in a workshop. These stories are based on the participants' experiences in various contexts of home care of people with chronic wounds. In view of the complexity of the situations but also of the materials, we opted for a realist approach (identifying different hypotheses in the form of context-mechanisms-outcomes). The analysis identified hypothetical relationships between interprofessional collaboration and patient-specific factors and the role of nurses that impact on relational, clinical and organisational continuity. Contextual factors seem to shape the role of primary care nurses, restricting or expanding their potential for action.

43 p. ill., Notre système actuel de soins de santé est essentiellement basé sur une approche par maladie et financé par prestation, ce qui n’est pas optimal pour faire face aux défis du vieillissement et de la multiplication des maladies chroniques. C’est pourquoi il est souhaitable d’évoluer vers un système de « soins intégrés », c’est-à-dire des soins plus adaptés aux besoins multidimensionnels des patients atteints de maladies chroniques, tout au long de leur vie et à travers les différentes lignes de soins. Différentes initiatives en ce sens sont déjà en cours en Belgique, tant au niveau fédéral que des entités fédérées, mais les acteurs de terrain ont l’impression que celles-ci ne sont pas encore assez coordonnées. Le nouveau Plan interfédéral sur les Soins intégrés, prévu pour début 2024, devrait pouvoir y remédier. PRÉFACE 1 -- SYNTHÈSE 2 -- 1. INTRODUCTION 4 -- 1.1. QU’EST-CE QUE LES “SOINS INTÉGRÉS” ? 4 -- 1.2. LES SOINS INTÉGRÉS EN BELGIQUE 4 -- 1.3. OBJECTIFS DE CETTE ÉTUDE 7 -- 2. OBJECTIFS DE SOINS INTÉGRÉS MENTIONNÉS DANS LES DOCUMENTS POLITIQUES BELGES 9 -- 3. MATURITÉ DES SOINS INTÉGRÉS EN BELGIQUE 10 -- 3.1. ÉVALUATION DE LA MATURITÉ DES SOINS INTÉGRÉS PAR LES PROFESSIONNELS 11 -- 3.2. ÉVALUATION DU VÉCU DES PATIENTS 12 -- 4. PISTES D’ACTION PROPOSÉES PAR LES PROFESSIONNELS BELGES 13 -- 4.1. OBSTACLES ET FACILITATEURS 14 -- 4.2. TROIS AXES FONDAMENTAUX 17 -- 5. EN AVANT VERS DES SOINS PLUS INTÉGRÉS ! 18 -- 5.1. STRUCTURER LE CADRE POLITIQUE 19 -- 5.2. DÉFINIR UNE APPROCHE TERRITORIALE 20 -- 5.2.1. Choisir la taille du ou des territoire(s) 20 -- 5.2.2. Intégrer les prestataires de soins et renforcer la 1e ligne 21 -- 5.2.3. Organiser la gestion des données vers une approche populationnelle 22 -- 5.3. REVOIR LE MODÈLE DE FINANCEMENT 23 -- 5.3.1. Vers des modèles mixtes 23 -- 5.3.2. Un déploiement progressif 24 -- 5.3.3. Renforcement des soins de 1e ligne 25 -- 5.3.4. Un investissement initial pour démarrer 25 -- 6. CONCLUSION 25 -- RECOMMANDATIONS 28

Many protracted crises are largely in resource poor settings affecting billions of people around the world. Efforts are being made globally to mitigate the impact of protracted crises on affected populations. However, these places typically lack the required health information systems for the collection of birth and death records needed to conduct a comprehensive assessment of the public health status and needs of the population. In particular, Yemen has been experiencing drawn out conflict, exposing children and adults to untold hardship and diseases as well as the risk of losing their lives increases as the crisis continues. A comprehensive nationwide analysis of the impact of the protracted crisis in Yemen on mortality is lacking. However, over the course of the crisis in Yemen, series of small-scale surveys have been conducted on regional/zonal levels for planning purposes by humanitarian organizations operating on ground. Because of the costs and the impracticability of conducting an indepth, nation-wide assessment, we have attempted to conduct an effective and robust investigation for a better understanding of the impact of the conflict on mortality by combining the sparse, publicly available data. We started by assessing the methods used for the collection and presentation of mortality data obtained from the small-scale survey. We found no strict adherence to standardized methodology guidelines, and reporting of mortality and sample size data. Adherence to methodological guidelines and complete reporting of surveys in humanitarian settings will vastly improve the estimation of mortality rate and also uptake of key data on health indicators of the affected population. We also assessed the change in number of deaths as a result of the conflict using a Bayesian mixture model approach. Despite an increase in the estimated number of deaths attributed to the conflict, we observed uncertainty surrounding the point estimates, which calls for caution while interpreting the result from our data. The difference observed could range from fewer deaths, or more deaths during the conflict when compared to period before the conflict. In addition, we developed a simple and parsimonious classification of insecurity level using publicly available data. We examined the relationship between patterns in under-five mortality and level of insecurity using a Bayesian finite mixture model, and we found that high number of under-five deaths are clustered around regions/zones experiencing high levels of insecurity. (SP - Sciences de la santé publique) -- UCL, 2022

43 p. ill., Ons huidig gezondheidszorgsysteem is hoofdzakelijk gericht op de aanpak van acute ziekte-episodes met een betaling per prestatie als voornaamste financieringsmechanisme. Dit is niet optimaal om de uitdagingen ten gevolge van de vergrijzing en de toename van chronische ziekten het hoofd te bieden. Het is nodig om te evolueren naar geïntegreerde zorg. We verstaan hieronder een zorgsysteem dat beter afgestemd is op de multi-dimensionele noden van mensen met chronische aandoeningen, dat rekening houdt met de behoeften van mensen gedurende hun hele leven, en dat over de verschillende zorglijnen heen. In België lopen er hierover al verschillende initiatieven, zowel op federaal niveau als op het niveau van de deelstaten. Maar de actoren op het terrein hebben de indruk dat deze nog niet voldoende gecoördineerd worden. Het nieuw Interfederaal Plan voor Geïntegreerde zorg, gepland voor begin 2024, zou hierin een belangrijke stap kunnen zijn. VOORWOORD 1 -- SYNTHESE 2 -- 1. INLEIDING 4 -- 1.1. WAT IS ‘GEÏNTEGREERDE ZORG’? 4 -- 1.2. GEÏNTEGREERDE ZORG IN BELGIË 4 -- 1.3. DOELSTELLINGEN VAN DEZE STUDIE 7 -- 2. DOELSTELLINGEN GEÏNTEGREERDE ZORG VERMELD IN BELGISCHE BELEIDSDOCUMENTEN 10 -- 3. MATURITEIT VAN GEÏNTEGREERDE ZORG IN BELGIË 11 -- 3.1. BEOORDELING VAN DE MATURITEIT VAN GEÏNTEGREERDE ZORG DOOR PROFESSIONALS 11 -- 3.2. BEOORDELING VAN DE ERVARINGEN VAN PATIËNTEN 12 -- 4. ACTIEPUNTEN VOORGESTELD DOOR BELGISCHE PROFESSIONALS 14 -- 4.1. BARRIÈRES EN FACILITATOREN 14 -- 4.2. DRIE FUNDAMENTELE ASSEN 17 -- 5. OP WEG NAAR MEER GEÏNTEGREERDE ZORG! 19 -- 5.1. STRUCTURERING VAN HET BELEIDSKADER 19 -- 5.2. DEFINIËREN TERRITORIALE AANPAK 20 -- 5.2.1. De omvang van het gebied/territorium (of de gebieden/territoria) bepalen 20 -- 5.2.2. Integratie van professionals en versterking van de eerstelijnszorg 21 -- 5.2.3. Organisatie van het gegevensbeheer naar een populatiegerichte benadering 22 -- 5.3. HERZIENING VAN HET FINANCIERINGSMODEL 23 -- 5.3.1. Naar gemengde financieringsmodellen 23 -- 5.3.2. Een geleidelijke uitrol 24 -- 5.3.3. Versterking van de eerstelijnszorg 25 -- 5.3.4. Een initiële investering om te beginnen 25 -- 6. CONCLUSIE 26 -- AANBEVELINGEN 28

135 p. ill., 1. APPENDIX: TERRITORIAL UNIT FOR ANALYSIS PURPOSES 6 -- 2. APPENDIX: MATURITY OF INTEGRATED CARE IN BELGIUM 7 -- 2.1. PROFESSIONAL’S ASSESSMENT OF INTEGRATED CARE 7 -- 2.1.1. Dutch survey 7 -- 2.1.2. French version of professional questionnaire available upon request 20 -- 2.1.3. Professional’s profiles 34 -- 2.1.4. Results of descriptive analysis by respondent’s professional category and level 38 -- 2.1.5. Scirocco spider diagrams per region 62 -- 2.2. ASSESSMENT OF MATURITY OF INTEGRATED CARE BY THE PATIENTS 63 -- 2.2.1. EuroQol Licence agreement for the EQ-5D-5L 63 -- 2.2.2. French patient questionnaire 67 -- 2.2.3. Dutch version of the patient questionnaire 71 -- 2.2.4. German version of the patient questionnaire 76 -- 2.2.5. Recruitment targets and response per geographical region 81 -- 2.2.6. Detailed list of participating recruiting organisations 82 -- 2.2.7. EQ – 5D -5L profiles 84 -- 2.2.8. EQ-5D-5L dimensions 86 -- 2.2.9. PACIC models 87 -- 3. APPENDIX: PROVIDER PAYMENT REFORMS – NARRATIVE LITERATURE REVIEW 89 -- 3.1. TYPES OF PAYMENT MECHANISMS 89 -- 3.2. PAY-FOR-PERFORMANCE (P4P) 91 -- 3.3. POPULATION-BASED PAYMENTS (INCLUDING ACCOUNTABLE CARE ORGANISATIONS (ACO)) 92 -- 3.4. BUNDLED PAYMENTS 99 -- 3.5. REFERENCE LIST OF THE LITERATURE REVIEW 102 -- 4. APPENDIX – TRAJECTORY OF CHANGE 107 -- 4.1. DUTCH VERSION OF THE TRAJECTORY OF CHANGE 107 -- 4.2. FRENCH VERSION OF THE TRAJECTORY OF CHANGE 116 -- 4.3. RÉFÉRENCES 125 -- 4.4. REFERENCES FOR THE TRAJECTORY OF CHANGE 126 -- 5. APPENDIX: SCRIPT OF DISCUSSION GROUPS AND TEMPLATE OF DATA REPORTING 127

224 p. ill., SCIENTIFIC REPORT 13 -- 1 INTRODUCTION .13 -- 1.1 WHAT IS INTEGRATED CARE? 13 -- 1.2 INTEGRATED CARE IN BELGIUM 17 -- 1.3 SCOPE OF THE PROJECT 21 -- 1.4 METHODS 21 -- 2 INTEGRATED CARE AS EXPRESSED IN THE BELGIAN POLICIES .24 -- 2.1 INTRODUCTION .25 -- 2.2 METHODS 25 -- 2.3 RESULTS 26 -- 2.3.1 Overview of the selected policy documents by level of authority 27 -- 2.3.2 Aims according to the dimensions of the SCIROCCO self-assessment tool .42 -- 2.4 DISCUSSION AND CONCLUSIONS 61 -- 2.4.1 Consistency in policy documents of both federal and federated entities despite different emphasis 61 -- 2.4.2 The complexity of Belgium's governance structure and its impact on integrated care policy 63 -- 2.4.3 Limitations of the policy documents review 64 -- 3 MATURITY OF INTEGRATED CARE IN BELGIUM 65 -- 3.1 PROFESSIONALS' ASSESSMENT OF INTEGRATED CARE 67 -- 3.1.1 Introduction .67 -- 3.1.2 Methods 67 -- 3.1.3 Results 69 -- 3.2 PATIENTS' EXPERIENCE OF INTEGRATED CARE .87 -- 3.2.1 Introduction .87 -- 3.2.2 Method 87 -- 3.2.3 Results 90 -- 3.3 DISCUSSION .102 -- 4 STAKEHOLDERS’ PROPOSITIONS OF ACTIONS TO DEVELOP AND IMPLEMENT INTEGRATED CARE .106 -- 4.1 INTRODUCTION 107 -- 4.2 METHODS 107 -- 4.3 RESULTS .111 -- 4.3.1 Discussion group participants .111 -- 4.3.2 Facilitators & barriers 112 -- 4.3.3 Action points .116 -- 4.4 DISCUSSION .135 -- 5 PROVIDER PAYMENT REFORMS FOR IMPLEMENTING INTEGRATED CARE AND VALUEBASED HEALTH CARE: A NARRATIVE LITERATURE REVIEW 137 -- 5.1 INTRODUCTION 138 -- 5.2 METHODS 139 -- 5.2.1 Provider payment mechanisms and integrated care 139 -- 5.2.2 Transition from a fee-for-service financing system to a mixed payment system 141 -- 5.3 RESULTS .142 -- 5.3.1 Provider payment mechanisms 142 -- 5.3.2 Mixed Provider Payment Systems (including alternative payment methods) .145 -- 5.3.3 Payment reforms: conditions and conducive factors 153 -- 5.4 DISCUSSION .161 -- 5.4.1 An incremental reform process 162 -- 5.4.2 New mode of governance at meso level is indispensable to optimise Value-Based Payment reform 164 -- 6 TRANSITION PATHWAY FOR FURTHER IMPLEMENTATION OF INTEGRATED CARE IN BELGIUM .166 -- 6.1 INTRODUCTION 167 -- 6.2 METHODS 167 -- 6.2.1 Preparatory phase: transition pathway 168 -- 6.2.2 Data collection tool: World Café .169 -- 6.2.3 Recruiting the expert panel 170 -- 6.2.4 Developing the expert panels .170 -- 6.2.5 Analysing and interpreting actions 170 -- 6.3 ACTIONS FOR FURTHER IMPLEMENTATION OF INTEGRATED CARE IN BELGIUM .171 -- 6.3.1 Input on the transition pathway 171 -- 6.3.2 Expert meeting participant profiles 171 -- 6.3.3 The fundamental pillars of an integrated health system in Belgium 172 -- 6.3.4 The reworked version of the transition pathway 173 -- 6.4 DISCUSSION .186 -- 7 INTEGRATED CARE: TIME TO MOVE FORWARD 190 -- 7.1 FROM SCATTERED INITIATIVES TO A PHASED IMPLEMENTATION OF INTEGRATED CARE 191 -- 7.2 TRANSITION TO INTEGRATED CARE: MAIN HIGHLIGHTS THAT EMERGED FROM THE STAKEHOLDER CONSULTATION 192 -- 7.2.1 Structuring the integrated care provision 192 -- 7.2.2 From disease management to population approach in a territory 193 -- 7.2.3 Integration of care providers 194 -- 7.2.4 Revised funding model for integrated care 194 -- 7.2.5 Supporting data for integration of care 196 -- 7.3 IMPACT OF INTEGRATED CARE ON QUINTUPLE AIM: WHAT WE LEARN FROM THE LITERATURE .197 -- REFERENCES 199