Mechanisms of integrated care in Flanders: A bottom-up perspective

Abstract

Background

For some time now, integrated care has been put forward to create a more demand-driven, patient-centred and cost-effective care system. Various conceptual frameworks have been developed to shed light on the complex concept. However, they lack insight into the mechanisms driving integrated care in practice. The aim of this paper is to gain insight into how integrated care is realised in practice.

Methods

Six cooperation projects in Flanders were compared on five integration mechanisms. A content analysis of secondary sources on each of the cases and semi-structured interviews with representatives of these cases was conducted. The data were analysed using comparison tables.

Results

Six cases representing five cooperation models in the Flemish health and social care were analysed for the presence of integrated care mechanisms. Six of the 22 mechanisms are present in all case examples. Half of the identified mechanisms concern the integration of professionals. Integrated care in these Flemish cases refers mainly to organising a case meeting, appointing a case manager and dividing the tasks between care professionals. Integration of support is less developed.

Conclusions

The bottom-up approach to study the practical implementation of mechanisms is a fruitful approach, since it brings into light the complex realities and practicalities of the mechanisms of integration and how they are shaped by local actors in local contexts. The approach shows how Flemish and Belgian policy makers are struggling to scaling up these integration models, whilst at the same time responding to local conditions and needs.

Keywords

Integrated care chronic disease case-comparison study

Introduction

Worldwide, integrated care is being put forward to create a more demand-driven, patient-centred and cost-effective care system.¹ This has been the response to the changing needs placed on the care system, mainly because of the expansively growing prevalence of people with (multiple) chronic conditions.² The traditional care systems often fail to sufficiently meet the increased complex, long-term and fluctuating needs of people with chronic diseases.³

But when is integrated care successful and how? To understand how integrated care should be organised optimally given a certain setting, several researchers have tried to gain insights into the core and common characteristics of care integration during recent years.^3–10 The result of this is a variety of conceptual frameworks which distinguish between the degree of integration,¹¹ the scope of integration^4,5,12 and the level of integration (macro, meso, micro⁸). Yet, current research still does not clearly give insight into the mechanisms to achieve the successful implementation of integrated care¹⁰ neither into the concrete realisation of each of the mechanisms driving integrated care in practice. With mechanisms, we refer to the type of integrated care intervention, distinguishing the mechanisms of integrated care from their context on the one hand and their outcomes on the other hand.¹³ Many researchers have analysed case examples of integrated care.^9,14–16 Yet, the main conclusion to be reached is that, whilst we have come a long way in being able to define the key building blocks of integrated care, the interplay between them is so complex and intertwined that it seems an impossible challenge to create any simple implementation model.¹⁷

Therefore, the aim of this article is to gain insight into how integrated care is realised, based upon a bottom-up analysis of specific integrated care projects and practices in Flanders, the Dutch-speaking region of Belgium. We show which types of integration dominate in Flanders, which mechanisms are used to reach integrated care, what mechanisms are neglected, and how they are implemented in practice. The limited number of studies focusing on integration mechanisms supports more attention to the use of these mechanisms.

Methods

Integrated care is a relatively new policy concept in the Belgian context.¹⁸ Van den Heuvel¹⁹ shows how Flemish and national policy initiatives have initiated 12 cooperation models in the health and social care system, focusing on different target groups (e.g. vulnerable children, persons with chronic psychiatric problems, frail elderly). For this article, we selected five types of these cooperation models. The selection of these models was based on three selection criteria (Table 1): they should focus on care for (adult) individuals with a chronic illness; the cooperation models should not only focus on one part of the disease process, such as prevention or palliative care; and the cooperation models must have been active at the time of the data collection (September, 2014). Table 1 contains an overview of the selected cooperation models. For four models, one practical case is selected. For the fifth (Protocol 3 projects), we select two cases, because of the greater accent on innovation and the lesser impact of national regulations.

Table 1.

Selected integration models

Integration model	Selected case
Cooperation initiatives primary care (CPC)	Health Consultation District Leuven, (CPC HCDL)
Mental health care networks	Article 107 Leuven-Tervuren
Protocol 3 projects	TCP+Menos
Neighbourhood health centres	WGC The Ridderbuurt, Leuven
Local Multidisciplinary Networks (LMN)	Care trajectory (diabetes) Leuven

In order to analyse how integration is organised in the cases in a uniform way, this study distinguishes between four types of integration:¹⁰

Integration between organisations: the relationship between organisations in a network, such as cooperation agreements and contractual agreements;

Integration of professionals: the relationship between care professionals within and between organisations;

Integration of services: the coordination of services and the integration of the care process in order to optimise the service for the patient and

Integration of supporting systems: the degree to which supporting systems are collectively coordinated or provided by initiatives, and have financial incentives to promote integrated care, such as bundled-payments.

Based on a systematic review, Van der Klauw et al.¹⁰ identified 22 mechanisms to reach these types of integration (Table 2). We use these mechanisms to compare the selected Flemish cases which mirror the specific Flemish and Belgian policy initiatives.

Table 2.

Overview of types and mechanisms of integrated care¹⁰

Type: Integration of organisations

• Formal connections between organisations

• Care pathways or pre-described patient trajectories

• Organisational policy, culture and leadership style focused on chronic care

Type: Integration of professionals

• Multi-, inter-, transdisciplinary teams

• Division of roles and tasks between care professionals

• Training for caregivers/professionals aimed at cooperation and integration

• Sharing information in organised meetings

• Professional attitude aimed at integrated care/broad perspective concerning patients’ problems

Type: Integration of service delivery

• Shared/collectively build infrastructure

• Evidence-based guidelines

• Involving patients’ and volunteers’ caregivers (family and friends)

• Care plans in which patients and care professionals determine goals together

• The role or function of a case manager

• Supporting self-management and education of the patient

• Paradigm shift from acute to chronic care and from reactive to proactive care giving

Type: Integration of support systems

• IT system enabling digital communication with other professionals

• IT system for exchanging registered information, such as records and care plans

• IT system for patients that is accessible to them throughout the entire care trajectory

• Database with patient characteristics to use for risk stratification

• Monitoring performance in order to support, guarantee and maintain (integrated) care

• Financial incentives that support, guarantee and maintain (integrated) care

• Digital support tools for patients that supports active involvement with self-management

For the selected cases, we used a two-step approach to data collection and analysis. The first step was a content analysis of secondary sources, that is, online accessible documentation, websites, and scientific evaluation reports about the cases. Two researchers each coded the data from these secondary sources. The mechanisms of integration constituted the codes. For each mechanism, the researchers scored whether it was present (yes/no) and briefly summarised the representation of the specific mechanism. The result of step 1 was a score list of mechanisms applied per case and scores of both researchers were compared. There was a high degree of consensus between the researchers. Disagreement was primarily due to a lack of information.

In the second step, we interviewed six coordinators from the cases in order to validate the information from the secondary sources and to gather missing information. These interviews were semi-structured; the topic list was based on the set of 22 mechanisms of integrated care. The case coordinators were asked to assess each mechanism for their own case. The interviewer compared this score to the result of step 1 and asked supplementary questions in case of discrepancies between the scores of step 1 and the answers of the case coordinators or when there had been disagreement between the researchers in step 1. Finally, this discussion paper was presented to the coordinators of the cases who were interviewed for verification and confirmation.

Description of the six selected cases

Belgium has an elaborate, but complicated and fragmented health and social care system that differs between regions. Health policy in Belgium is a responsibility of both the federal authorities and the federated entities (regions and communities). The federal authorities are responsible for the regulation and financing of the compulsory health insurance; the determination of accreditation criteria (i.e. minimum standards for the running of hospital services); the financing of hospital budgets and of heavy medical care units; the legislation covering different professional qualifications; and the registration of pharmaceuticals and their price control. Federated entities are responsible for health promotion and prevention; maternity and child health care and social services; different aspects of community care; coordination and collaboration in primary health care and palliative care; the implementation of accreditation standards and the determination of additional accreditation criteria; and the financing of hospital investment. The Belgian health care system is characterised by a high level of coverage (99% of the population is covered) with a relatively high patient contribution (circa 18% of total costs). People with disabilities make use of regular health and social care and of specialised services for people with disabilities. During the last 15 years, the federal as well as the Flemish authorities have initiated a lot of policy measures to realise integrated care for different target groups such as vulnerable children, persons with chronic psychiatric problems, and frail elderly. In this article, we focus on care for (adult) individuals with a chronic illness.

Cooperation initiative primary care actors: CPC HCDL

In 2010, the Flemish Government corroborated the cooperation initiative of primary care actors (CPC) whose main goal is to improve the cooperation between the various professional care services within a specific region.¹⁹ They bring together the representatives of various organisations to enhance cooperation and they are also responsible for the organisation of multidisciplinary meetings (MDMs) between different caregivers around a specific patient. The CPC HCDL (Health Consultation District Leuven) is one of the 15 CPC and consists of nine sub-regions. One of the tasks of CPC HCDL is to monitor the MDMs. Two MDMs are distinguished; MDM for patients or clients with a decreased physical independence and an MDM PSY for patients or clients with complex and enduring psychiatric problems. The goal of a MDM is to facilitate the cooperation between care professionals and to improve care by tailoring it to patients’ needs and expectations.²⁰ This is done in a ‘round table conversation’. An acknowledged and independent consultation organiser plans the MDM, ensures moderation and chairmanship. The follow-up of patients or clients is organised by appointing a care intermediary and by using an electronic care plan.²⁰

Mental healthcare: Care circuits and – networks mental health

In 2009, Article 107 of the Federal Law on hospitals and residential care services was changed to implement community mental health care. With the revision, hospitals were able to use their budget for beds for organising other care functions, such as multidisciplinary ambulatory teams.¹⁹ For example, a transition from residential care to community care is now being implemented within Flemish care networks and care circuits.²¹ In order to realise this transition, five key functions were defined: prevention, early detection, screening and diagnoses (function 1); a treatment team within the home environment (function 2); psychosocial rehabilitation (function 3); intensifying residential specialised care (function 4) and specific ways of living (function 5). The mobile teams have a central role and focus on supporting adults (from the age of 18 until the age of 65) with psychiatric problems living at home (function 2). After this reform, the care-network from the district of Leuven and the care region Tervuren was initiated in 2011. It entails among other things five multidisciplinary mobile teams and one crisis team. The network mainly operates between organisations (meso-level).

Elderly care: Care-innovation project – ‘tailed cooperation creates a plus’ (TCP+)

Given the growing group of elderly, Belgium is searching for alternative ways to prevent early residential admission such as the care-innovation- or protocol 3-projects. The National Health Insurance Organisation (INAMI-RIZIV) launched their first call for innovative projects aimed at supporting autonomy among elderly and preventing early admission to a residential care facility.²² One of those protocol 3 projects that was established is TCP+. TCP+ is available for every individual older than the age of 60, living within a defined area. The goal of TCP+ is to enable elderly people to continue living at home by providing support that matches the needs of the elderly and their potential caregivers.²³ In order to realise this, TCP+ has nine cooperation partners: several residential care facilities, home-care organisation such as services for family care and home nurses and an insurance company.²⁴

Elderly care care-innovation projects – Menos

A second protocol 3 project is Menos. Menos was started in 2008 as a local initiative in order to increase knowledge about dementia and mental health care programs. Menos focuses on elderly individuals with mental health problems or dementia and their caregivers. Menos is a cooperation initiative between the Public Centre for social welfare (Openbaar Centrum voor Maatschappelijk Welzijn - OCMW), one organisation for home care, two mental health organisations, a hospital and a general practitioners’ association.²⁵ Menos offers a multidisciplinary trajectory that starts with a specialised diagnosis followed by an MDM in which next steps are discussed, such as group education for the individual with dementia and the family care giver, individual support for the elderly with mental health problems and/or the family care giver and tailored home care. Menos mainly focuses on direct care for individuals with dementia (micro-level), but also takes the initiative to the meso-level (between organisations), such as education.

Neighbourhood health centres – WGC (Wijkgezondheidscentrum) The Ridderbuurt, Leuven

Neighbourhood centres in Belgium were established in the 1970s in order to provide multidisciplinary primary care at the level of a city neighbourhood.²⁶ The neighbourhood health centres employ a system of fixed-price reimbursement in which patients choose for a permanent registration with a team of health care professionals. Since 1 May 2013, a fixed amount per patients is reimbursed each month to the centre. This amount is calculated based on certain characteristics (age, gender, social status, presence of a disability, chronic illness or medical conditions that require a lot of care) from patients that are registered at a certain centre. In Flanders, there are currently 25 neighbourhood health centres.²⁷ These centres are interdisciplinary: a general practitioner, (home) care, kinesiotherapy, dietitian and a social worker. They focus on prevention, health promotion and patient participation.

WGC De Ridderbuurt was founded in 1995 in a relatively poor neighbourhood in the city of Leuven. Health promotion, patient participation, integrated care, continuity of care, accessibility, a multidisciplinary approach and a community orientation are the guiding principles.

Local multidisciplinary networks – care trajectory (diabetes) Greater Leuven

Care trajectories focus on the treatment and follow-up of patients with chronic conditions and are established by the federal government. These care trajectories are organised on a regional level and focus on patients with specific forms of diabetes type 2 and kidney insufficiency.²² Local multidisciplinary networks (LMNs) support these trajectories. The LMNs are an initiative from general practitioners’ circles and Integrated Services for Home care (ISHs). A care trajectory starts with a cooperation agreement between a patient, a general practitioner and a specialist.¹⁹ The objectives of a care trajectory concern the coordination and planning of a specific situation, stimulating the dialogue with patients by using a personal care plan, aiming for optimal cooperation between general practitioner, specialist and other care professionals and optimise the quality of care. The care trajectory operates at the micro-level and is concerned with care delivery to the patient. Conversely, the LMN deals with the meso-level, that is, support between organisations. LMN Leuven consists of all primary care actors and is coordinated by two general practitioners. They focus on one specific chronic disease, namely diabetes.

Comparison of the cases

Overview of the used mechanisms

Table 3 demonstrates that professional integration was the most prevalent type of integration in the Flemish cases, found in 90% of the examples. The integration of supporting systems (38%) and services (45%) were less common. Furthermore, the results show that six mechanisms of integration were present in all cases: division of roles as tasks among care professionals, education aimed at cooperation and integration, sharing of information during organised meetings, care plans in which patients and care professionals determine goals together, the role of a case manager and financial incentives aimed at (integrated) care. Four other mechanisms were found in four or five of the cases: formal connections between organisations, multi-, inter-, and trans-disciplinary teams, a professional attitude aimed at integrated care and involving caregivers and volunteers. Additionally, three mechanisms were not found in any of the cases: self-management support and education, digital resources and working according to evidence-based guidelines. Finally, looking at the individual cases, WGC implemented the highest number of mechanisms (15 of 22 mechanisms) and care trajectories the lowest number (8 of 22 mechanisms).

Table 3.

Presence of type and mechanisms of integrated care within six Flemish selected cases

	CPC HCDL	Article 107 network Leuven-Tervuren	Care innovationproject TCP+	WGC	Care trajectories	Care innovation project Menos	Total (1)
Type: Integration of organisations							9/18 (50%)
• Formal connections between organisations	x	x	x	o	x	x	5/6
• Care pathways or pre-described patient trajectories	o	o	o	o	x	x	2/6
• Organisational policy, culture and leadership style focused on chronic care	x	o	o	x	o	o	2/6
Type: Integration of professionals							27/30 (90%)
• Multi-, inter-, transdisciplinary teams	x	x	x	x	o	x	5/6
• Division of roles and tasks between care professionals	x	x	x	x	x	x	6/6
• Training of caregivers/professionals aimed at cooperation and integration	x	x	x	x	x	x	6/6
• Sharing information in organised meetings	x	x	x	x	x	x	6/6
• Professional attitude aimed at integrated care/broad perspective concerning patients’ problems	x	o	x	x	o	x	4/6
Type: Integration of service delivery							18/42 (45%)
• Shared/collectively build infrastructure	o	o	o	x	o	o	1/6
• Evidence-based guidelines	o	o	o	o	o	o	0/6
• Involving patients’ and volunteers’ caregivers (family and friends)	x	x	x	o	o	x	4/6
• Care plans in which patients and care professionals determine goals together	x	x	x	x	x	x	6/6
• The role or function of a case manager	x	x	x	x	x	x	6/6
• Supporting self-management and education of the patient	o	o	o	o	o	o	0/6
• Paradigm shift from acute to chronic care and from reactive care giving	o	o	o	x	o	o	1/6
Type: Integration of support systems							16/42 (38%)
• IT-system enabling digital communication with other professionals	x	o	x	x	o	o	3/6
• IT- system for exchanging registered information, such as records and care plans	x	o	x	x	o	o	3/6
• IT-system for patients that is accessible to them throughout the entire care trajectory	x	o	o	o	o	o	1/6
• Database with patient characteristics to use for risk stratification	o	o	o	x	o	o	1/6
• Monitoring performance in order to support, guarantee and maintain (integrated) care	o	o	x	x	o	o	2/6
• Financial incentives that support, guarantee and maintain (integrated) care	x	x	x	x	x	x	6/6
• Digital support tools for patients that supports active involvement with self-management	o	o	o	o	o	o	0/6
Total	14/22	9/22	13/22	15/22	8/22	11/22

x = characteristic is present within the case, 0 = characteristic is absent in the case (a characteristic is considered to be present if it was mentioned in the documents or interviews in any form).

(1) For each type, a sum is made of characteristics present; for each mechanism, a sum is made at the row level of the characteristics present. (The type is the sum of the separate mechanisms.).

Integration between organisations

Integration between organisations was not very common in our cases. When present, it primarily concerned ‘formal connections between organisations’(reported in five of the six cases). The agreements concerned legal protocols on relations to unite activities between the organisations. The case examples varied as to the use of signed contracts between organisations. Two cases reported ‘Care pathways or prescribed patient trajectories’ (care trajectories Great-Leuven and Menos) mainly through care pathways. In both cases, this concerned a distinct patient trajectory, delivered by several organisations. In the other cases, the cooperation agreements did not have their own distinct care pathway. Next, we conclude that two organisations had an ‘organisational policy, culture and leadership style focused at chronic care’. They had a specific improvement policy for the cooperating partners. Important to note is that interviewees in all cases pointed out that it is not easy to identify this specific mechanism and that changing policy, culture and leadership between organisations is difficult to achieve, because, e.g. employees are not well acquainted at the start of a project, individuals make or break a culture change, or logistics are deemed more important than policy, culture and leadership.

Integration of professionals

Integration of professionals was often present, yet varied largely in mechanisms reported. First, ‘Multi-, inter- and transdisciplinary teams’ could be found in five cases. The cases were similar in determining distinct roles within the team such as the role of a care intermediary or case manager. We observed differences in the configuration of the teams. Two cases had fixed teams of professionals, whilst in other cases individual care professionals were in the lead and met each other to divide tasks. Next, ‘division of roles and tasks between professionals’ recurred in every initiative and was formalised. However, the way of formalisation was different. The multidisciplinary cooperation in the context of the MDM and article 107 networks was regulated by a legal framework to which specific tasks and financial compensation were linked. The care trajectories described roles in specific contracts for stakeholders and WGC The Ridderbuurt worked with interdisciplinary protocols describing agreements concerning care substitution. The TCP+ project described the role of the trajectory supervisor. And at Menos, the division of tasks and roles was described in the contract with the financing body. Third, all cases offered different forms of ‘Training of care professionals aimed at cooperation and integration’. Some trained professionals in information communication technology (IT) skills and tools. Others trained in dealing with elderly with dementia, project management for a care trajectory promoter or team responsibility for patients. Fourth, all cases reported some form of ‘Information sharing within meetings’. In three cases, patients or family members were present at these meetings to establish goals and divide tasks. Fifth, ‘Professional attitude aimed at integration of care/holistic perspective on problems of patients’ was present in four cases. However, interviewees indicated that this mechanism is difficult to identify because the attitude of professionals evolves as they start and continue to cooperate and because the attitude should cover a broad perspective on patients’ care needs.

Integration of service delivery

Integration of service delivery received limited attention within the case examples and was not based on evidence-based practices, the use of patient participation and their informal networks, or prevention. What mechanisms did we see? First, ‘Shared/commonly built infrastructure’ was only found at WGC The Ridderbuurt where professionals worked in one building. Other cases had agreements about the sharing of buildings for specific functions, such as team meetings, training or night-time care, short stay or day activities in a residential care facility. Second, none of the cases used formal ‘evidence-based guidelines’ even though aspects of the service delivery were evidence-based and different cases make the use of scientific research explicit. WGC The Ridderbuurt, for instance, developed folders and protocols concerning care substitution and health promotion based on scientific research and the care trajectories Great-Leuven and TCP+ used an evidence-based screening instrument (BELRAI). Cases also worked according to legislation or guidelines drawn up by the Flemish government or the INAMI-RIZIV. Third, ‘Involving family or friends’ was a mechanism in four cases, through inviting patients’ family and friends to a meeting in which the patient, care professionals and caregivers discuss the care process. Cases varied in the extent to which this was a central aspect of the care approach. Fourth, all cases are ‘Establishing care plans in which patients and care professionals determine goals’. The cases had in common that care plans were used to simplify the patient’s administration. Differences in content were also observed, e.g. three cases established an individual care trajectory, tailored to the specific needs of the beneficiaries whilst two others focused their care plans on medical consultations and follow-up. Fifth, all cases had an explicit ‘role or function of the case manager’ which was always the professional nearest to the patient or client. The case manager was a point of contact for all those involved, who monitored the agreed upon tasks against the needs and expectations of patients/client and his or her caregivers. However, the practical role or function of a case manager varied between cases. In some cases, a case manager was a separate function or always the same professional, whereas in other cases, for each patient or client, a case manager was appointed. Sixth, ‘Supporting self-management and education of patients’ was not a structured mechanism in any of the cases. Five cases, however, provided information or offered voluntary education at the individual level or in a group. Finally, the ‘Paradigm shift from acute to chronic care and from reactive to proactive care giving’ was only observed at one case, WGC The Ridderbuurt. Focal point was the interplay between acute and chronic care, but working proactively received much attention. Interviewees from other cases did notice a change as to how care for individuals with a chronic condition was seen.

Integration of supporting systems

The cases showed very little integration of supporting systems. Most cases developed their own IT-systems in an ad-hoc fashion. The communication between professionals and with patients, but also the possibility for patients to participate by means of IT, received little IT support within the cases. We will now describe how each mechanism was represented in the cases.

First, in three cases an ‘IT-system enabling digital communication with other professionals’ was implemented. In these cases, the system was exclusive and could not be implemented in other cases. The degree of maturity of the systems varied. The three other cases did not use any technology for communication between care professionals. All these cases had, at their start, the ambition to develop an IT system themselves, but the development turned out to be too difficult and so professionals still communicated by phone, (sometimes unprotected) e-mail or face-to-face meetings. Second, three cases implemented an ‘IT-system for exchanging registered information, such as records and care plans’. These systems were also used for communication between professionals. Another case took the initiative to exchange messages and records but failed due to double registration requirements. And the two other cases were waiting for the government to take initiative for such a system. Third, only one case had an ‘IT-system for patients that is accessible to them throughout the entire care trajectory’, namely, the e-care plan of CPC HCDL. Here, patients could access and/or add information. In the other cases, patients had some access to (paper) version of their records or care plan.

Database with patient characteristics that can be used for risk stratification

Only WGC The Ridderbuurt actively used health predictors in order to act proactively, such as medical and social-demographic information, care-dependency and lifestyle. Within the article 107 network Leuven-Tervuren and only in cooperation with hospitals’ emergency rooms, there was a database for suicide prevention. Three other cases did not use a database with patient characteristics for risk stratification. They did register for evaluation research in which they participated (care trajectories Great-Leuven and Menos) and the legally required yearly report (CPC HCDL). Menos used the KATZ scale for risk stratification, but did not create a database based on the results. TCP+ used the BELRAI instrument, but only for determining individual requests for care and scientific research, not for risk stratification.

Monitoring performance that support, guarantee and maintain (integrated) care

The WGC The Ridderbuurt was actively working on monitoring performance in order to support the quality of care. For instance, they used statistics for overall consultation, asked patients how satisfied they were with the care and organised audits based on existing instruments (European Practice Assessment and Failures, Accidents and Almost Accidents instrument). TCP+ facilitated a report tool for retrieving data from the registered information, such as the average cost per day per patient. Menos and the care trajectories Great-Leuven monitored performance in favour of scientific research, but they were not able to directly use it for improving their care delivery because they only had access to clustered information. CPC HCDL, Menos and the article 107 network Leuven-Tervuren monitored processes, but not performance.

Financial incentives that support, guarantee and maintain (integrated) care

All cases used financial incentives in order to stimulate integrated care. This concerned reimbursement for performing specific tasks or taking up certain roles. We observed different incentives for different stakeholders or goals. CPC HCDL had two incentives. The first one concerned a reimbursement aimed at professionals for participating in an MDM. The second incentive was a reimbursement for the role of care mediator and organiser of meetings. The article 107 network Leuven-Tervuren, TCP+ and Menos used a project reimbursement, potentially supplemented with other subsidies. At the care trajectories, the general practitioner and the specialist received a fixed reimbursement for every patient who participated. The patient could count on a (higher) reimbursement for specific consultations in the program (podologist, dietician and diabetes educator). Finally, WGC The Ridderbuurt used a capitation fee. That is, a fixed, pre-arranged monthly payment, determined for each registered patient as opposed to patients paying for each treatment.

Digital support tools for patients that facilitate active involvement with self-management

None of the case example offered patients digital tools that facilitated active involvement with self-management and education. The article 107 network Leuven-Tervuren experimented with digital tools, but these were not part or the care process. There was also no place for (digital) tools at TCP+ and Menos at this time. WGC The Ridderbuurt lend out blood pressure monitors so they could fill out a form, but did not use digital tools. The care trajectories in Great-Leuven also did not use digital tools.

Discussion

In this article, we identified the type of integration and the used mechanisms to reach integration in six integrated care projects in Flanders for persons with a chronic illness. The regional as well as the federal government has initiated 12 cooperation models for vulnerable groups in the last 15 years. Our analysis shows that 6 of the 22 integration mechanisms are present in all case examples and thus in all integration models: division of roles and tasks between care professionals, sharing information in organised meetings, training for professionals aimed at integration, financial incentives that support integrated care, the use of individualised care plans and case managers. In other words, integrated care in Flanders refers mainly to organising a case meeting, appointing a case manager and dividing the tasks between care professionals. Four mechanisms are present in the majority of the cases: formal agreements between organisations, multidisciplinary teams, professional attitudes aimed at integrated care and involving patients and volunteers. Half of the identified mechanisms concern the integration of professionals. Integration of support is less developed. The high degree of formalisation in most of the case examples may be explained by the role of national and regional policies. More generally, the studied integration models make use of those mechanisms such as co-location, case management and multidisciplinary teams, which are identified as the most successful in achieving positive health outcomes and service user satisfaction.²⁸

The high degree of formalisation in most of the case examples may be explained by the role of national and regional authorities which are important drivers into the direction of integrated care. At the same time, given the diversity of policy initiatives, the coordination of these various coordination strategies and policies based on a system-wide approach remains a challenge, especially from the perspective of health and social care organisations and services who are stimulated to participate in these various integration models. As is the case in other European countries analysed by Nolte et al.,²⁹ the Flemish and Belgian policy makers are struggling with the challenge of scaling up these models, whilst at the same time ensuring that they are sufficiently responsive to local conditions and needs. Three mechanisms are absent in all of the case examples: the use of evidence-based guidelines, supporting self-management of the patient and digital tools for self-management. Five mechanisms are present in only one case. They concern mechanisms of integration of service delivery, namely shared infrastructure, integration of support systems and are ‘soft mechanisms’ of integration such as a ‘paradigm shift to chronic care’ and leadership. Especially, ‘the latter are more and more considered as the drivers of integrated care’.¹⁷ In other words, such ‘high-tech’ mechanisms can’t be decoupled of ‘high-touch’ personalised care based on a patient-oriented vision on integrated care.⁹

Using a bottom-up perspective, it becomes clear that operationalising and validating these mechanisms remain difficult, especially because their concrete implementation in specific cases differs considerably and because there is no consensus yet about the appropriate methods to study them. For instance, what do we mean by a multi- or transdisciplinary team, how can we measure or analyse the extent of cooperation within the team? In addition, the differences between the levels of integration remain sometimes arbitrary. For instance, information technology is currently considered as a separate mechanism of integrated care. However, IT could also be regarded as a tool for exchanging information, communication or self-management rather than a separate mechanism. The bottom-up approach to study the practical implementation of mechanisms is, however, a fruitful approach, since it brings into light the complex realities and practicalities of these mechanisms and how they are shaped by local actors in local contexts. It aligns with the realist evaluation approach³⁰ which is more and more used in the field of integrated care (see for instance).¹³ This approach focuses not only on the question if it works but also on how and why it works, given the fact that integrated care cannot be reduced to one specific intervention and that mechanisms need to be translated to fit local contexts and conditions.

Finally, this study has some limitations. The first limitation is that we only selected six cases from the five cooperation models. However, there is a large diversity of examples for each integration model. The insights of the approach presented in this article could be enhanced by including more case examples for each model. The second limitation is that the results are based on one momentary recording in time. The cases that are described here already had taken many steps and will continue to evolve in the future. By using several sources of information and discussing the results with a coordinator of a case, we developed a clearer view on this subject. However, using a longitudinal approach would provide insights into the evolution of the integration of care across time. The third limitation is that the description of the cases is based on the available documents and an interview with a coordinator. In order to gain a more comprehensive view on whether and why mechanisms are present, other sources of information or stakeholders such as patients could be included in the research. Finally, due to time restrictions, it was not possible to determine the effects of the used mechanisms on financial sustainability (cost-effectiveness). Follow-up research, or combining the insights from evaluations from different projects, could shed light on this issue and could also generate knowledge about direct relationships between specific characteristics and outcomes and costs. In other words, the present analysis does not allow us to determine whether the presence of an integration mechanism, or lack thereof, predict better outcomes and a reduction of costs. Such relations have been found abroad.^31–33 This highlights the need for future research to determine which characteristics within the Belgian context will result in better health outcomes and a reduction in costs.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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References

Dessers

Vrijhoef

HJM

Annemans

et al . Towards a comprehensive research design for studying integrated care. Int J Care Coord 2014; 17: 105–115.

WHO. Global status report on noncommunicable diseases 2014. Geneva: WHO, 2014.

Nolte

and McKee

Integration and chronic care: a review. In: Nolte

and McKee

(Eds.). Caring for people with chronic conditions: a health system perspective. Oxford, UK: University Press Oxford, 2008, pp. 64–91.

Kodner

DL.

All together now: a conceptual exploration of integrated care.

Healthc Q 2009; 13: 6–15.

Shaw

Rosen

and Rumbold

What is integrated care. London, UK: The Nuffield Trust, 2011.

Singer

Burgers

Friedberg

et al . Defining and measuring integrated patient care: promoting the next frontier in health care delivery. Med Care Res Rev 2011; 68: 112–127.

De Bruin

Versnel

Lemmens

et al . Comprehensive care programs for patients with multiple chronic conditions: a systematic literature review. Health Pol 2012; 107: 108–145.

Valentijn

Schepman

Opheij

et al . Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. Int J Integr Care 2013; 13: e010.

Goodwin

Dixon

Anderson

et al . Providing integrated care for older people with complex needs. Lessons from seven international case studies. London, UK: The King’s Fund, 2014.

10.

Van der Klauw

Molema

Grooten

et al . Identification of mechanisms enabling integrated care for patients with chronic diseases: a literature review. Int J Integr Care 2014; 14: e024. 2014.

11.

Leutz

WN.

Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Q 1999; 77: 77–110.

12.

Fulop

Mowlem

and Edwards

Building integrated care: lessons from the UK and elsewhere. London, UK: The NHS Confederation, 2005.

13.

Busetto

Luijkx

and Vrijhoef

HJM.

Advancing integrated care and its evaluation by means of a universal typology. Int J Care Coord 2017; 20: 41–44.

14.

Alderwick

Ham

and Buck

Population health systems: going beyond integrated care. London, UK: The King’s Fund, 2015.

15.

Goodwin

Sonola

Thiel

et al . Co-ordinated care for people with complex chronic conditions. London, UK: The King’s Fund, 2013.

16.

Hong

Siegel

Ferris

TG.

Caring for high-need, high-cost patients: what makes for a successful care management program? Report no. 19, August 2014. New York, NY: The Commonwealth Fund, 2014.

17.

Goodwin

Understanding integrated care. Int J Integr Care 2016; 16: 6.

18.

Paulus

Van den Heede

and Mertens

Organisation of care for chronic ill in belgium: development of a position paper. Brussels, Belgium: Belgian Health Care Knowledge Centre, 2012.

19.

Van den Heuvel

Networked care: a new organisational concept for persons with a complex, longterm care and support need [Netwerkzorg: Een nieuw organisatieconcept voor personen met een complexe, langdurige zorg-en ondersteuningsvraag]. Leuven, Belgium: Uitgeverij Acco, 2014.

20.

CPC HCDL (SEL GOAL). Multidisciplinary negotiation, www.selgoal.be/mdo/ (2015, accessed 26 October 2015).

21.

Nicaise

Dubois

and Lorant

Mental health care delivery system reform in Belgium: the challenge of achieving deinstitutionalisation whilst addressing fragmentation of care at the same time. Health Pol 2014; 115: 120–127.

22.

INAMI-RIZIV. Care trajectories, www.zorgtraject.be/NL/Professioneel/default.asp (2009, accessed 26 October 2015).

23.

TCP+ (SOM+). Region Waas & Dender (Regio Waas & Dender). SOM+, http://sintjozefmoerzeke.be/wp-content/themes/wzc/doc/folder_SOMplus.pdf (2012, accessed 26 October 2015)

24.

TCP+ (WZC Sint-Jozef). Cooperation agreement: Tailed Cooperation creates a Plus! [Samenwerkingsakkoord: Samenwerken op maat levert een plus op!] (SOM+). Ruiselede, Belgium 2010.

25.

Menos

Partners, www.menosgenk.be/organisatie2.html (2015, accessed 26 October 2015).

26.

De Maeseneer

De Roo

and Willems

Community health centers in Flanders. In: Dierckx D, Oosterlynck, S, Coene J, et al. (eds) Poverty and social exclusion yearbook 2012. Leuven – Den Haag: Acco, 2012, pp. 233–245.

27.

VWGC. Concept community health care center [wijkgezondheidcentrum], www.vwgc.be/index.php?page=4 (2015, accessed 25 October 2015)

28.

Nolte

et al . Evidence supporting integrated care. In: Amelung

Stein

and Goodwin

. (eds) Handbook integrated care. Cham, Switzerland: Springer Verlag, 2017, pp. 25–38.

29.

Nolte

Corbett

Fattore

et al . Understanding the role of community hospitals: an analysis of experiences in five countries. Eur J Pub Health 2016; 26: ckw164.069, https://doi.org/10.1093/eurpub/ckw164.069.

30.

Pawson

Greenhalgh

Harvey

et al . Realist review – a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy 2005; 10: 21–34.

31.

Elissen

Nolte

Hinrichs

et al . Evaluating chronic disease management in real-world settings in six European countries: lessons from the collaborative DISMEVAL project. Int J Care Coord 2014; 17: 25–37.

32.

Elissen

Steuten

Lemmens

et al . Meta-analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes. J Eval Clin Pract 2013; 19: 753–762.

33.

Lemmens

Boom

et al . Chronic care management for patients with COPD: a critical review of available evidence. J Eval Clin Pract 2013; 19: 734–752.

34.

Ahgren

and Axelsson

A decade of integration and collaboration: the development of integrated health care in Sweden 2000-2010. Int J Integr Care 2011; 11: 1–8.

35.

Busetto

Kiselev

Luijkx

et al . Implementation of integrated geriatric care at a German hospital: a case study to understand when and why beneficial outcomes can be achieved. BMC Health Serv Res 2017; 17: 180.

36.

Christian

and Curtis

(eds). Introduction to integrated care. Integrated care applying theory to practice. New York, NY: Routledge, 2012, pp. 3–19.

37.

Darzi

and Howitt

Integrated care cannot be designed in Whitehall. Int J Integr Care 2012; 12.

38.

Evans

Baker

Berta

et al . The evolution of integrated health care strategies. Adv Health Care Manag 2013; 15: 125–161.

39.

Gillam

Integrated care: final objective or fortuitous by-product?.

Br J Gen Pract 2012; 62: 456–457.

40.

Glasby

If integration is the answer, what was the question? What next for English health and social care. Int J Integr Care 2016; 16: 11.

41.

Gomes

Weber

Brown

et al . Mergers, acquisitions and strategic alliances: understanding the process. Basingstoke, UK: Palgrave Macmillan, 2011.

42.

Gröne

and Garcia-Barbero

Integrated care: a position paper of the WHO European office for integrated health care services. Int J Integr Care 2001; 1: e21

43.

Howarth

and Haigh

The myth of patient centrality in integrated care: the case of back pain services. Int J Integr Care 2007; 7.

44.

Richters

Nieuwboer

Perry

et al . Evaluation of DementiaNet, a network-based primary care innovation for community-dwelling patients with dementia: protocol for a longitudinal mixed methods multiple case study. BMJ Open 2017; 7: 8.

45.

Strandberg-Larsen

Measuring integrated care: an international comparative study. Copenhagen, Denmark: University of Copenhagen, 2011.

46.

Vargas

Mogollón-Pérez

De Paepe

et al . Do existing mechanisms contribute to improvements in care coordination across levels of care in health services networks? Opinions of the health personnel in Colombia and Brazil. BMC Health Serv Res 2015; 15: 213.