Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience".
BACKGROUND
Most research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered.


METHODS
Process evaluation of an action research project (2003-2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process.


RESULTS
The overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding.


CONCLUSIONS
Guided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure. The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers. Currently primary care providers lack the opportunities to take up full responsibility for chronic care.


BACKGROUND
ClinicalTrials.gov Identifier: NCT00824499.
Sunaert
Patricia
P
Department of General Practice and Primary Health Care, Ghent University, Belgium. patricia.sunaert@ugent.be
Bastiaens
Hilde
H
Feyen
Luc
L
Snauwaert
Boris
B
Nobels
Frank
F
Wens
Johan
J
Vermeire
Etienne
E
Van Royen
Paul
P
De Maeseneer
Jan
J
De Sutter
An
A
Willems
Sara
S
D001530:Belgium; D002908:Chronic Disease; D003625:Data Collection; D003695:Delivery of Health Care / Q000458:organization & administration*; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D005260:Female; D006284:Health Plan Implementation / Q000379:methods*; D006761:Hospitals; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000458:organization & administration
Qual Saf Health Care. 2002 Jun;11(2):148-52
12448807
BMC Health Serv Res. 2005 Aug 24;5:56
16117836
Diabet Med. 2008 Feb;25(2):179-85
18290859
JAMA. 2003 Apr 16;289(15):1969-75
12697800
Ann Fam Med. 2007 May-Jun;5(3):233-41
17548851
Health Serv Res. 2002 Jun;37(3):791-820
12132606
Implement Sci. 2006 Oct 18;1:23
17049080
Diabetes Care. 2007 Jun;30(6):1630-7
17526822
Qual Health Res. 2006 Mar;16(3):377-94
16449687
J Eval Clin Pract. 2005 Oct;11(5):417-29
16164582
Eff Clin Pract. 1998 Aug-Sep;1(1):2-4
10345255
Int Clin Psychopharmacol. 2001 Apr;16 Suppl 3:S5-13
11459330
Qual Saf Health Care. 2003 Feb;12(1):40-6
12571344
Milbank Q. 2004;82(4):581-629
15595944
BMC Health Serv Res. 2008 Aug 27;8:181
18752660
Lancet. 2003 Oct 11;362(9391):1225-30
14568747
Ann Fam Med. 2006 Jul-Aug;4(4):317-26
16868235
Prim Care Diabetes. 2009 May;3(2):103-9
19264568