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Background: Little is known about the prevalence of people with chronic wounds cared for at home and their care integration needs in Belgium. In high-income countries, chronic wounds are associated with ageing processes, chronic diseases and social and financial vulnerability, resulting in multiple needs. To meet these needs, many health care providers (with nurses figuring prominently) are involved. This can lead to fragmented health care trajectories and the need to strengthen care coordination. Objectives: This study aims to estimate the prevalence of people with chronic wounds cared for at home in Belgium. It also seeks to explore their health care trajectories and the risk of fragmentation of care to inform policy makers, care providers and research. Design: Cross-sectional. Setting(s): Home care. Participants: Routinely collected data of reimbursed care of 3467 people with a chronic wound cared for at home in 2018. Methods: We applied a stratification method to our sample based on health care trajectories. First, we constructed individual sequences of care received during the year. Then we summarised the health care events using a K-mers approach. Finally, a multinomial mixture model was used on the previously obtained summary to cluster individuals according to their health care trajectories. Afterwards, other epidemiological, socioeconomic and health care use indicators were calculated for each health care trajectory group. We also estimated the prevalence of people with chronic wounds treated at home. Results: We constructed six health care trajectory groups for two age categories (<65 and ≥65 years) showing different intensity of care use and type of care. In some health care trajectory groups, generalist care was found to be predominant. In others, specialist care appeared more prevalent. Depending on the health care trajectory group, a significant proportion of people had multiple care providers involved (mainly nurses, medical specialists and GPs), and

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

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

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

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

The eastern Democratic Republic of Congo (DRC) has experienced decades-long armed conflicts which have had a negative impact on population's health. Most research in public health explores measures that focus on a specific health problem rather than overall population health status. The aim of this study was to assess the health status of the population and its predictors in conflict settings of South Kivu province, using the World Health Organization Disability Assessment Schedule (WHODAS). Between May and June 2019, we conducted a community-based cross-sectional survey among 1440 adults in six health zones (HZ), classified according to their level of armed conflict intensity and chronicity in four types (accessible and stable, remote and stable, intermediate and unstable). The data were collected by a questionnaire including socio-demographic data and the WHODAS 2.0 tool with 12 items. The main variable of the study was the WHODAS summary score measuring individual's health status and synthesize in six domains of disability (household, cognitive, mobility, self-care, social and society). Univariate analysis, correlation and comparison tests as well as hierarchical multiple linear regression were performed. The median WHODAS score in the accessible and stable (AS), remote and stable (RS), intermediate (I) and unstable (U) HZ was 6.3 (0-28.6); 25 (6.3-41.7); 22.9 (12.5-33.3) and 39.6 (22.9-54.2), respectively. Four of the six WHODAS domain scores (household, cognitive, mobility and society) were the most altered in the UHZs. The RSHZ and IHZ had statistically comparable global WHODAS scores. The stable HZs (accessible and remote) had statistically lower scores than the UHZ on all items. In regression analysis, the factors significantly associated with an overall poor health status (or higher WHODAS score) were advanced age, being woman, being membership of an association; being divorced, separated or widower and living in an unstable HZ. Armed conflicts have a signi

Background: The eastern Democratic Republic of Congo (DRC) has experienced decades-long armed conflicts which have had a negative impact on population’s health. Most research in public health explores measures that focus on a specific health problem rather than overall population health status. The aim of this study was to assess the health status of the population and its predictors in conflict settings of South Kivu province, using the World Health Organization Disability Assessment Schedule (WHODAS). Methods: Between May and June 2019, we conducted a community-based cross-sectional survey among 1440 adults in six health zones (HZ), classified according to their level of armed conflict intensity and chronicity in four types (accessible and stable, remote and stable, intermediate and unstable). The data were collected by a questionnaire including socio-demographic data and the WHODAS 2.0 tool with 12 items. The main variable of the study was the WHODAS summary score measuring individual’s health status and synthesize in six domains of disability (household, cognitive, mobility, self-care, social and society). Univariate analysis, correlation and comparison tests as well as hierarchical multiple linear regression were performed. Results: The median WHODAS score in the accessible and stable (AS), remote and stable (RS), intermediate (I) and unstable (U) HZ was 6.3 (0–28.6); 25 (6.3–41.7); 22.9 (12.5–33.3) and 39.6 (22.9–54.2), respectively. Four of the six WHODAS domain scores (household, cognitive, mobility and society) were the most altered in the UHZs. The RSHZ and IHZ had statistically comparable global WHODAS scores. The stable HZs (accessible and remote) had statistically lower scores than the UHZ on all items. In regression analysis, the factors significantly associated with an overall poor health status (or higher WHODAS score) were advanced age, being woman, being membership of an association; being divorced, separated or widower and living in an unstable HZ, SCOPUS: ar.j, info:eu-repo/semantics/published

Realist and developmental evaluation approach The policy plan “integrated care for better health”, and more specifically its first action line, the implementation of 12 integrated care pilot projects (ICPs) since 2018, has provided very promising results over the two first years. This is an ongoing process: the endeavour should be sustained by different stakeholders acting at different levels in order to yield fruitful results in the near future. The opposite would represent a considerable loss of investment and of knowledge “in the making” to integrate care in Belgium. The scientific team FAITH.be, in charge of evaluation of the Plan, was able to (1) create and apply to iCPs a monitoring framework for development of integrated care based on a whole population management within a geographical area (see p 30 to 48 of executive summary), (2) identify several promising practices (see in main report and specific annex) that should be further developed, and (3) identify specific conditions that can help reaching the overall goals of the Plan. This work of the realist and developmental evaluation initiated by FAITH.be (including triple aim + 2 indicators) should be used to strengthen the process of integrated care development. Indeed, the authorities should acknowledge the complex nature of the changes taking place via this ambitious system reform, involving many stakeholders at many levels who do not have a definitive vision about the choices to be made or how to proceed. All the involved stakeholders can contribute to knowledge production about these complex processes: this is a key goal of the policy Plan. This part summarizes the main lessons learned in the form of “recommendations” addressed to the policy makers at federal and federated level, and to the stakeholders involved in ICP development. More information about why these recommendations are developed, how they were identified and concrete examples can be found in the body of the executive summary, the full rep

and its covariates at primary healthcare level in DR Congo. METHOD: We conducted a community-based cross-sectional study in adults with diabetes or hypertension, mother-infant pairs with child malnutrition, their informal caregivers and randomly selected neighbours in rural and sub-urban health zones in South-Kivu Province, DR Congo. We used the WHO Disability Assessment Schedule 2.0 (WHODAS) to measure functional, cognitive and social disability. The study outcome was health status clustering derived from a principal component analysis with hierarchical clustering around the WHODAS domains scores. We calculated adjusted odds ratios (AOR) using mixed-effects ordinal logistic regression. RESULTS: Of the 1609 respondents, 1266 had WHODAS data and an average age of 48.3 (SD: 18.7) years. Three hierarchical clusters were identified: 9.2% of the respondents were in cluster 3 of high dependency, 21.1% in cluster 2 of moderate dependency and 69.7% in cluster 1 of minor dependency. Associated factors with higher disability clustering were being a patient compared to being a neighbour (AOR: 3.44; 95% CI: 1.93-6.15), residency in rural Walungu health zone compared to semi-urban Bagira health zone (4.67; 2.07-10.58), female (2.1; 1.25-2.94), older (1.05; 1.04-1.07), poorest (2.60; 1.22-5.56), having had an acute illness 30 days prior to the interview (2.11; 1.24-3.58), and presenting with either diabetes or hypertension (2.73; 1.64-4.53) or both (6.37; 2.67-15.17). Factors associated with lower disability clustering were being informally employed (0.36; 0.17-0.78) or a petty trader/farmer (0.44; 0.22-0.85). CONCLUSION: Health clustering derived from WHODAS domains has the potential to suitably classify individuals based on the level of health needs and dependency. It may be a powerful lever for targeting appropriate healthcare service provision and setting priorities based on vulnerability rather than solely presence of disease.

Background: Optimizing the organization of care for community-dwelling frail older people is an important issue in many Western countries. In Belgium, a series of complex, innovative, bottom-up interventions was recently designed and implemented to help frail older people live at home longer. As the effectiveness of these interventions may vary between different population groups according to their long-term care needs, they must be evaluated by comparison with a control group that has similar needs. Methods: The goal was to identify target groups for these interventions and to establish control groups with similar needs and to explore, per group, the extent to which the utilization of long-term care is matched to needs. We merged two databases: a clinical prospective database and the routine administrative database for healthcare reimbursements. Through Principal Component Analysis followed by Clustering, the intervention group was first stratified into disability profiles. Per profile, comparable control groups for clinical variables were established, based on propensity scores. Using chi-squared tests and logistic regression analysis, long-term care utilization at baseline was then compared per profile and group studied. Results: Stratification highlighted five disability profiles: people with low-level limitations; people with limitations in instrumental activities of daily life and low-level of cognitive impairment; people with functional limitations; people with functional and cognitive impairments; and people with functional, cognitive, and behavioral problems. These profiles made it possible to identify long-term care needs. For instance, at baseline, those who needed more assistance with hygiene tasks also received more personal nursing care (P < 0.05). However, there were some important discrepancies between the need for long-term care and its utilization: while 21% of patients who were totally dependent for hygiene tasks received no personal nursing care