Search

Background: Despite its overall good performance, the Belgium healthcare system scores less well in providing equal access to healthcare compared to other European countries. This increases the risk of people worse off to receive late diagnosis and to get complications of chronic diseases. Methods: This study aims to achieve a deeper understanding of how people with complications of a chronic disease – diabetes type 2 – experience care in the Belgium health system through semi-structured interviews with extreme case study sampling of people with advanced diabetes, and inductive analysis. Results: The results show that most respondents were diagnosed late in the course of their disease. There are variations in treatment and type of provider. People appreciate the personal and long-lasting contact with a medical doctor, while the contact with and role of paramedical providers was less recognized. Disease management has a significant impact on their financial budget and some respondents experienced barriers to obtain additional financial support. Discussion: Non-medical costs are not reimbursed, presenting a high burden to people. Self-management is tedious and hampered by other worries that people may have, such as financial constraints and coping with important life events. To conclude this study highlighted the need to improve diabetes screening. We suggest to enhance the role of paramedical professionals, integrate a social care worker, reduce financial constraints, and increase health literacy through more patient-centered, goal-oriented care. [ABSTRACT FROM AUTHOR]

Introduction: Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view. Methods: 27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Semi-structured interviews were guided by a timeline of policies and an inductive thematic analysis was performed. Results: Barriers and facilitators were identified on both health care and policy level. The major factors restraining the scale-up of integrated care are the fee-for-service reimbursement system, limited data sharing and the fragmentation of responsibilities between different levels of government. Remarkably, these factors strongly interact. Discussion: This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. Political commitment and citizen participation will be crucial. [ABSTRACT FROM AUTHOR]

Introduction: Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. This is also the case in Belgium, which has a complex governing system where both the federal and federated governments have responsibilities concerning health care. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years (the federal care trajectory for diabetes, the joint plan for the chronically ill and the reform of primary care in Flanders), we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view. Methods: 27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Policymakers, public administrators, finance stakeholders, provider organisations, user and patient groups and scientific stakeholders were included. Semi-structured interviews were guided by a timeline of policies and performed by two researchers. The main topics of the interview guide were: stakeholder role, their understanding of integrated chronic care, and the barriers to and facilitators of the development and implementation of integrated care policies. The interviews were transcribed verbatim and an inductive thematic analysis was performed and repeatedly discussed within the team. Results: Stakeholders had diverse interpretations of integrated care, but agreed that implementation of integrated care in Belgium is still suboptimal. Barriers and facilitators were identified on both health care and policy level. A major barriers is the fee-for-service system, which does not stimulate cooperation nor quality of care. Within the topic of data sharing, many strategies have been formulated, but the implementation lacks, which hinders again cooperation. A last major barrier is the fragmentation of responsibilities between different levels of government. It leads to confusion, but mainly it hinders integrated care as different policy-makers head in different directions and so it is difficult to align plans, especially on the long term. Remarkably, these factors strongly interact. Conclusion: The scale-up of integrated care is influenced by multiple factors, which interact with each other. The preparedness to change at both the policy level and health care level will be key to triggering a transformation leading to integrated care. However, important barriers, are hindering a much needed change to the entire Belgian health care system and a shift towards integrated care. Implications: This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. A focus on the financing system seems important in this regard. Political commitment and citizen participation will be crucial. [ABSTRACT FROM AUTHOR]

Introduction: Raised blood pressure (BP) is a major risk factor for cardiovascular disease worldwide. Although effective treatment exists and is widely available, few patients manage to achieve BP control, even in high-income countries such as Belgium. As hypertension (HTN) is a chronic condition, it requires lifelong continuous and coordinated action from healthcare systems along the continuum of care. This raises the need to evaluate the delivery of HTN care accordingly, using a cascade of care (CoC) approach, rather than solely focussing on the outcomes (i.e. BP control). Objectives and methods: The objective of the current study is twofold. First, we use a CoC approach to identify where most patients are lost along the continuum of HTN care. Second, we identify patient characteristics that are associated with the leakages in the CoC. Based on crosssectional data from the 2018 Belgian Health Interview Survey and the Belgian Health Examination Study, we estimate the prevalence of HTN among the Belgian population aged 40-80 and the proportions that reach each stage of the HTN CoC: being screened, diagnosed, linked to care, treated, followed-up and well-controlled. Next, cox regression models are estimated to assess the factors associated with an elevated risk of not being linked to care, treated and followed-up. Results: Our preliminary findings indicate that 44.7% of the Belgian population aged 40-80 has HTN. Of these, 96.7% had their BP measured in the past 3 years, but only 56.1% self-reported having been diagnosed. Furthermore, 52.9% is linked to care, 49.5% is in treatment and 43.1% is followed-up by means of a yearly blood cholesterol measure. Finally, only about a quarter (25.8%) is well controlled. Men diagnosed with HTN are more likely to be unlinked to care, while once they are in treatment, they are more likely to be followed-up appropriately. Age and BMI were positively associated with being linked to care and in treatment, but not with being followed-up. Finally, the results revealed a socio-economic gradient: both perceived financial strain and being lower educated was associated with an increased risk of being diagnosed but unlinked to care. Conclusion: Patients are lost at each stage of the HTN CoC and only about a quarter of the HTN population is well controlled. The largest loss occurs early on in the cascade: less than half of the HTN population reported to be diagnosed. Once diagnosed, the healthcare system retains patients fairly well, but there are differences between population sub-groups. Implications for applicability and limitations: A limitation of the current study is that we were unable to study HTN patients' characteristics that are associated with 'being undiagnosed', due to data limitations. Further research is therefore warranted, as this constitutes the largest drop in the Belgian HTN CoC. Nevertheless, this study is the first to inform Belgian policymakers about where patient retention needs to be improved along the HTN CoC and which high-risk groups require special attention in this regard. [ABSTRACT FROM AUTHOR]

Introduction: To address the increasing burden of non-communicable diseases (NCDs), global commitments have been made towards an integrated care (IC) approach. The 'SCale-Up diaBetes and hYpertension' (SCUBY) project aims to provide implementation science-based solutions through co-creation, implementation and evaluation of roadmaps for scale-up of IC for diabetes and hypertension. We analysed macro-level barriers and facilitators to IC in: a developing health system in a lower middle-income country (Cambodia); a centrally-steered health system in a highincome country (Slovenia); and a publicly-funded highly privatised healthcare health system in a high-income country (Belgium). The results of this study will provide input in roadmap-strategies for scaling up IC in these contexts. Methods: To identify macro-level bottlenecks, documents review (scientific publications, policy documents and grey literature); practice observations; focus groups with patients, health workers and community-based actors; and in-depth stakeholder interviews with health facility managers, policy makers, civil servants (Ministry of Health and health insurance), representatives of professional associations, non-governmental organisations, implementers, academics, and patient platforms were conducted. Thematic analysis utilising the WHO global strategy on integrated people-centred health services, was conducted as a cyclical process including a deductive and inductive analysis approach. Country-specific codes were discussed and complementary literature review performed to get a comprehensive picture of the missing links. Results: We identified differences and similarities in macro-level barriers across the three contexts. The lack of political commitment regarding NCD investment in Cambodia and the limited policy coherence due to the fragmented political structure in Belgium weaken governance for IC. In Slovenia, a change in political leadership has interfered with IC implementation. In Cambodia, the limited financial resources and allocation mechanisms for NCDs at the primary care level and a weak health information system hinder IC implementation, while in Belgium and Slovenia, the financial models are outdated, care integration is not incentivized and data sharing between different health workers is limited. Shortages in human resources for health are common challenges in Slovenia and Cambodia; however, task shifting is being addressed in all country-sites: introducing nurses in primary care in Belgium, involving peers in support groups in Slovenia to strengthen patient empowerment and self-management, and engaging community health workers for support at the primary care level in Cambodia. Conclusions: Common IC challenges in the three contexts are political leadership, the health financing system, health information systems and health workforce. This macro-level barriers analysis stimulates reciprocal learning. Specifically with regards to task shifting, Slovenia can learn from Cambodia on community health and peer support workers and Belgium from Slovenia on integrating nurses into primary care. Understanding the link between macro-level, contextual factors and specific health system challenges and opportunities are key to improve the implementation of IC. Implications for transferability and limitations: Strategies to integrate care include actions to reorient care models and coordinate services towards empowering and engaging people, and to create enabling environments in systems with proper accountability and governance at the micromeso- and macro-levels. Mechanisms to address macro-level barriers can be replicated, considering country/health system contextual factors. [ABSTRACT FROM AUTHOR]

Although current guidelines recommend collaborative care for severely depressed patients, few patients get adequate treatment. In this study we aimed to identify the thresholds for interdisciplinary collaboration amongst practitioners when treating severely depressed patients. In addition, we aimed to identify specific and feasible steps that may add to improved collaboration amongst first and second level Belgian health care providers when treating depressed patients. In two standard focus groups (n = 8; n = 12), general practitioners and psychiatrists first outlined current practice and its shortcomings. In a next phase, the same participants were gathered in nominal groups to identify and prioritise steps that could give rise to improved collaboration. Thematic analyses were performed. Though some barriers for interdisciplinary collaboration may seem easy to overcome, participants stressed the importance of certain boundary conditions on a macro- (e.g., financing of care, secure communication technology) and meso-level (e.g., support for first level practitioner). Findings are discussed against the background of frameworks on collaboration in healthcare and recent developments in mental health care. [ABSTRACT FROM AUTHOR]

This study describes the characteristics of extramural and transmural telemonitoring projects on chronic heart failure in Belgium. It describes to what extent these telemonitoring projects coincide with the Chronic Care Model of Wagner. Background: The Chronic Care Model describes essential components for high-quality health care. Telemonitoring can be used to optimise home care for chronic heart failure. It provides a potential prospective to change the current care organisation. Methods: This qualitative study describes seven non-invasive home-care telemonitoring projects in patients with heart failure in Belgium. A qualitative design, including interviews and literature review, was used to describe the correspondence of these home-care telemonitoring projects with the dimensions of the Chronic Care Model. Results: The projects were situated in primary and secondary health care. Their primary goal was to reduce the number of readmissions for chronic heart failure. None of these projects succeeded in a final implementation of telemonitoring in home care after the pilot phase. Not all the projects were initiated to accomplish all of the dimensions of the Chronic Care Model. A central role for the patient was sparse. Conclusion: Limited financial resources hampered continuation after the pilot phase. Cooperation and coordination in telemonitoring appears to be major barriers but are, within primary care as well as between the lines of care, important links in follow-up. This discrepancy can be prohibitive for deployment of good chronic care. Chronic Care Model is recommended as basis for future. [ABSTRACT FROM AUTHOR]

Introduction: Informal caregivers are important resources for community-dwelling frail elderly. But caring can be challenging. To be able to provide long-term care to the elderly, informal caregivers need to be supported as well. The aim of this study is to review the current best evidence on the effectiveness of different types of support services targeting informal caregivers of community-dwelling frail elderly. Methods: A systematic literature search was performed in Medline, PsychINFO, Ovid Nursing Database, Cinahl, Embase, Cochrane Central Register of Controlled Trials and British Nursing Index in september 2010. Results: Overall, the effect of caregiver support interventions is small and also inconsistent between studies. Respite care can be helpful in reducing depression, burden and anger. Interventions at the individual caregivers' level can be beneficial in reducing or stabilizing depression, burden, stress and role strain. Group support has a positive effect on caregivers' coping ability, knowledge, social support and reducing depression. Technology-based interventions can reduce caregiver burden, depression, anxiety and stress and improve the caregiver's coping ability. Conclusion: Integrated support packages where the content of the package is tailored to the individual caregivers' physical, psychological and social needs should be preferred when supporting informal caregivers of frail elderly. It requires an intense collaboration and coordination between all parties involved. [ABSTRACT FROM AUTHOR]

The Belgian government Integreo program (www.integreo.be) aims at a nationwide whole-system change in health and social care towards more Integrated Care (IC), by means of geographically defined integrated care projects (ICPs). Starting in early 2018, the twelve ICPs are implementing their action plan to change the organization of their regional network, covering up to 150.000 inhabitants, towards more IC. They receive limited financing: one FTE coordinator. As the final goal of the national plan is to anchor successful changes and scale-up best practices, FAITH.be (Federated consortium for Appraisal of Integrated care Teams in Health in Belgium) developed a mixed methods realist evaluation framework which aims at responding to the questions if, how, for whom and why the implementation of the ICP is successful or not so far, and learn lessons to help the ICPs to adjust their governance to support successful implementation of a whole-system change in their region. We will present preliminary insights of the implementation analysis, describing the main difficulties ICPs struggle with and how they address them. We use participative action and realist methods following RAMESES II standards (http://www.ramesesproject.org/). Data collection tools are chosen in consultation with stakeholders: coordinators, partners of and policy makers. Intermediate results are fed back and discussed with the stakeholders. Two methods are combined: qualitative enquiry for all ICPs and case study methods for three selected ICPs. Normalization Process Theory (NPT) is chosen to guide the analysis. First observations show that ICPs struggle with divergence in vision about priorities and timelines between ICPs, Governmental agencies at both federal and regional level. After postponement of crucial policy decisions and delivery of promised ICT-tools, ICPs are forced to adapt their action plan, which impedes their coherence. Moreover, due to the limited financing, ICPs are expected to pre-finance their actions towards IC, which impedes the involvement of key stakeholders, such as GPs' and social care workers' organisations and raises tensions between care providers, e.g. working in a fee-for service system versus those working in bundled payment systems. Hence, this hinders collective action and participation. These preliminary results will be further discussed and extended with the stakeholders. By the time of the conference, we will present the main issues for each social mechanism as described by NPT and explain why, how and for whom these difficulties occur and describe observed strategies to cope with them. First results show how the divergence of visions between policy makers and stakeholders in ICPs, hinder ICPs to implement innovative actions towards IC. Even though co-creation is considered an important pillar of the Integreo Plan, the lack of convergence of visions between policy agencies and ICPs hinders the implementation of innovative actions towards IC. The results only reflect the views of ICPs, not the policy makers. The results of the implementation analysis will be linked to the outcome and cost analysis of the ICPs. [ABSTRACT FROM AUTHOR]

Background: The Belgian government program "Integrated Care for better health" www.integreo.be aims at a Nationwide Whole System Change in health and social care. This implies change in its structures, finances, processes and paradigms towards more Integrated Care IC. It concerns geographically defined pilot projects that should cover in 'full implementation" more than 3.670.000 people, about one third of the total Belgian Population. Pilot projects are both large-scale implementation projects and test cases. Each pilot aims at changing the organization of their loco-regional area network covering up to 150.000 inhabitants towards more IC. Changes are directed at 14 components, structured at three levels: 1 the patient level e.g. case management; 2 the inter-professional collaboration level e.g. shared medical file; and 3 the inter-organizational collaboration at loco-regional level e.g. quality culture The ultimate goal is to improve the 'Triple Aim' quality of care, equity and the work life of healthcare providers 'TA2+'. A scientific team was appointed to: design and implement an evaluation framework alongside the pilot-projects-in-development. function as a support mechanism to the pilot projects in assisting and accompanying them with their self-evaluation process. function as a support mechanism for the government agencies who induced and guide the change management program. Existing research on achieving sustainable change of loco-regional networks towards more IC and Triple Aim within a nation-wide program is scarce. Moreover, existing research is highly context specific. This need to be taken into account in the generalization process. Aim: To reflect with the target audience on the necessity of changing research paradigms towards theory driven appraisals when engaging into Whole System Change evaluation in healthcare. Format: Interactive workshop with both 'teasing' questions to the target audience and presentation of our lessons learned Speakers: Geert Goderis, Jean Macq, Nathan Charlier, Elien Colman. Target Audience: Researchers and professionals active in the field of IC and system change. Learnings: - System change towards IC cannot be conceived as a delineated intervention, but as a complex strategy or even a policy to innovate and implement long-lasting change. This complexity often manifests as shifting and unpredictable contexts, deep differences among perspectives, and even conflict among stakeholders. Scientific evaluation is necessary and imposes a paradigm change for the involved scientists. 'Laboratory like' methodologies type 'Randomized Controlled Trials' are unfit and must be replaced by theory driven approaches, describing the processes and contextual factors leading to desired outcomes. The evaluation should transcend the question 'what works?' towards questions on how, why, for whom and in what circumstances the program brings the desired outcomes, in order to allow upscaling of the program to a system change covering entire Belgian territory. - Scientists engage in a co-creative process producing new knowledge, in partnership with all other involved stakeholders like e.g. health professionals and government agents. This cocreation process disables the possibility to plan a fixed endpoint: the design is tribute to multiple issues that evolve over time. Meanwhile, the whole program serves as a leverage to create breakthroughs in these issues. [ABSTRACT FROM AUTHOR]

Background: The Belgian government program "Integrated Care for better health" (www.integreo.be) aims at a Nation-wide Whole System Change in health and social care towards Integrated Care (IC), by means of geographically defined pilot projects. Each of the +/- 20 pilot projects will implement IC in a loco-regional area covering up to 150.000 inhabitants. The ultimate goal is to improve the 'Triple Aim' quality of care, equity and healthcare professional work life ('TA2+'). Pilot projects will run for several years serving both as large-scale implementation projects and test cases. Successful projects will be upscaled to cover - ultimately - the entire Belgian territory. A scientific team was appointed for evaluation of the projects. A priority task for this team is to set up sustainable monitoring tools that can evaluate the projects in a longitudinal way. To evaluate the impact of Integreo on TA2+, both content (outcome indicators) and methods of data collection must be defined. However, the scale of the projects - both concerning the number of included persons and the duration of the project - is incompatible with the usual approach of data collection and analysis. Aim: To reflect with the target audience on the process and dynamics of selecting outcome indicators and data collection methods for such large-scale projects. Format: Interactive workshop with 'teasing' questions to the target audience combind with presentation of the lessons learned. This workshop follows Part I and - if necessary - both can be given in one workshop. Speakers on behalf of the research group: Elien Colman, Elias Van Deun, Jean Macq, Geert Goderis Target Audience: Researchers and professionals active in the field of IC and system change. Learnings: 1- On the indicator selection - Define their utility: the quantitative evaluation of the indicators alone will not allow to determine causal relationships, but must be part of a global analysis, including qualitative research methods and implementation evaluation. - Set goals: first define the indicator set by evaluating the added value for measuring the change objectives. - Find an equilibrium between ambition and feasibility. The impossibility to use usual data collection methods has a direct impact on the indicator selection itself. - Define transversal indicators first as a common base for all projects. Afterwards, add project-specific indicators in full co-creation. 2- On the research methodology - The methods of data collection must be routinely applicable and sustainable in the long running. - The collected data from hospitals, General Practice, Patient Reported Outcomes, etc., must also be as much as possible routinely collected and automatically merged with claims data at patient level. - Plan with a clear time line: -- Evolving technological, legal and practical issues determine the data collection possibilities -- Each new database adds complexity to an already complex project: therefore, start small, plan expansion at the appropriate moment. 3- On the co-creation process - It requires time and organization to involve all necessary actors, allowing them to review and process the data. - Moving from existing logics of intra-organisational data-analysis (e.g. in hospitals), towards inter-organisational data-analysis. [ABSTRACT FROM AUTHOR]

Introduction: Continuity of care is essential when trying to avoid untimely institutionalization of the frail elderly. Either continuously or occasionally, multiple care providers are involved in the integrated care for a community-dwelling frail older person. In this coming and going of care providers over time, the informal caregiver usually remains the constant factor. In 2009 the Belgian Federal Government launched a call for innovative projects that aim at maintaining the community-dwelling frail elderly at home for as long as possible. That call resulted in 66 projects that offer a variety of innovative interventions. Aims: The aim of this study is to describe to what extent these projects involve the informal caregivers in the organization of care for the frail elderly. Methods: Data are collected through the projects initial application files, yearly questionnaires, interviews and focus groups. We performed a descriptive analysis of the data and compared subgroups of projects based on the type of interventions. Results: First results show that in most projects involvement of the informal caregiver in the care process is not well established. A minority of projects describe how they plan to implement caregiver involvement in their application files. Caregiver involvement mainly occurs sporadically, when important decisions about an individual client have to be made. Conclusion: The projects lack a structured approach to implement informal caregiver involvement in the care process of frail elderly. [ABSTRACT FROM AUTHOR]

Purpose/objectives: The Belgian National Institute for Health and Disability Insurance (NIHDI) is interested in delaying institutionalization of older persons. Informal caregivers play an important role in maintaining the health, well-being, functional performance and quality of life of older people living at home. The aim of this paper is to identify whether innovative projects in home care are statistically associated with decreasing the informal caregiver's perceived burden. Background/Methods: The study uses the interRAI HC instrument and a shorter version of the original 22-Zarit Burden Interview. In this ongoing study we have a population of 4346 frail older persons who have an informal caregiver and who are benefiting from innovative projects in home care. Through multivariate logistic regression researchers analyze the effect of the projects in the burden of caregivers. This method enables researchers to take into account factors such as the older person's cognitive functioning, ADL performance, depressive symptoms, as well as the informal caregivers' characteristics. Conclusions: This research will provide knowledge on perceived burden and will show whether some types of interventions may have a positive effect on decreasing the burden in giving care. This is important information for home care agencies but also useful information for policy makers at a societal level. [ABSTRACT FROM AUTHOR]

Background: The twelve Integrated Care Program pilot projects (ICPs) created by the government plan 'Integrated Care for Better Health' aim to achieve four outcome types (the Quadruple Aim) for people with chronic diseases in Belgium: improved population health, improved patient and provider experiences and improved cost efficiency. The aim of this article is to present the development of a mixed methods realist evaluation of this large-scale, whole system change programme., Methods: A scientific team was commissioned to co-design and implement an evaluation protocol in close collaboration with the government, the ICPs and several other involved stakeholders., Results: A protocol for a mixed methods realist evaluation was developed to gain insights into the mechanisms that foster successful results in ICPs. The qualitative evaluation proposed will be based on the document analysis of yearly ICP progress reports, selected case studies and focus group interviews with stakeholders. Processes and outcomes of all the projects will be monitored using indicators based on administrative data on population health and the quality and costs of care. A yearly survey will be organized to collect data on patient-reported outcomes and experiences and on provider-reported measures of inter-professional collaboration and proper wellbeing. Using both quantitative and qualitative data, we will develop theories about the mechanisms and the associated contextual factors that lead to integrated care and the Quadruple Aim outcomes., Discussion: The objective of this study is to deliver policy recommendations on strategies and best practices to improve care integration in Belgium and to implement a sustainable monitoring system that serves both policy makers and the stakeholders within the ICPs. Some challenges due to the large scale of the project and the multiple stakeholders involved may impede the successful implementation of this proposal., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2020 The Author(s).)

Although current guidelines recommend collaborative care for severely depressed patients, few patients get adequate treatment. In this study we aimed to identify the thresholds for interdisciplinary collaboration amongst practitioners when treating severely depressed patients. In addition, we aimed to identify specific and feasible steps that may add to improved collaboration amongst first and second level Belgian health care providers when treating depressed patients. In two standard focus groups (n = 8; n = 12), general practitioners and psychiatrists first outlined current practice and its shortcomings. In a next phase, the same participants were gathered in nominal groups to identify and prioritise steps that could give rise to improved collaboration. Thematic analyses were performed. Though some barriers for interdisciplinary collaboration may seem easy to overcome, participants stressed the importance of certain boundary conditions on a macro- (e.g., financing of care, secure communication technology) and meso-level (e.g., support for first level practitioner). Findings are discussed against the background of frameworks on collaboration in healthcare and recent developments in mental health care.