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Introduction: Non-communicable diseases, such as arterial hypertension (HTN) and type-2 diabetes (T2D), pose a global public health problem. Integrated care with focus on person-centred principles aims to enhance healthcare quality and access. Previous qualitative research has identified facilitators and barriers for scaling-up integrated care, however the lack of standardized terms and measures hinder cross-country comparisons. This paper addresses these gaps by presenting a generic codebook for qualitative research on integrated care implementation for HTN and T2D. Description: The codebook serves as a tool for deductive or deductive-inductive qualitative analysis, organizing concepts and themes from qualitative data. It consists of nine first level and 39 second level themes. First level codes cover core issues; and second level codes provide detailed insights into facilitators and barriers. Discussion: This codebook is more widely applicable than previously developed tools because it includes a broader scope of stakeholders across micro, meso, and macro levels, and the themes being derived from highly diverse health systems across highand low-income countries. Conclusion: The codebook is a useful tool for implementation research on integrated care for HTN and T2D at global scale. It facilitates cross-country learning, contributing to improved implementation, scale-up and outcomes. [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]

The shift from institution-based mental healthcare system toward integrated care system is - not only but also- a question of organisation. Recognising the organisational dimension of this shift is a pre-requisite for improving the design of mental healthcare researches. In Belgium, the shift toward integrated care follows a change strategy inspired by the WHO: it is stimulated through pilot projects encouraging the transformation of mental healthcare delivery at the local level. Scientific evaluations of these projects evidenced that, despite the development of innovative practices, the shift is still not complete. The question of how innovative practices are arising and how to support their generalisation nevertheless remained overlooked. Theory: In this paper, we argue for reconsidering the design of scientific research on mental healthcare reforms, by integrating key learnings from organisational theories. Organisation theorists showed that talks are constitutive of organising process, particularly in complex environments where multiple interests, ideologies, and types of expertise are coexisting. The importance of talk in re-organising work processes, particularly interprofessional meetings, has been particularly emphasised in mental health services. We analysed the impact of inter-professional meetings on the reorganisation of mental healthcare in Belgium by relying on qualitative methods and the principle of triangulation: inter-professional meetings n=72 were observed as part of two scientific researches[1]; the meeting participants were interviewed n=57 and interview and observation data were confronted to documents linked to the observed meetings. Results: Based on excerpts of interviews and transcripts of observation, the paper evidences that: - meetings most of the time fail to reach their expected outcomes; - the meeting context and leadership style of the chair importantly influence their real outcomes; - despite the feeling that meetings are useless, they bring about changes in mental health professionals' representations and ways of working. Discussions: Mental healthcare researches have underestimated the influence of interprofessional meetings on mental healthcare services' transformation. Designing scientific researches integrating meeting as a research object to understand how the transformation occurs and instrument to experiment with different meeting techniques might help to address this gap. Conclusion: Two factors explaining the meeting contribution to innovation are: - the level of connectedness/separateness between the meeting context and institutional environment: increased separateness means increased possibilities to experiment with new roles and representations; - the management of meeting conversation: the meeting contribution to innovation is related to the level of ambiguity afforded by the conversation. Lessons: if meetings are supposed to bring solution to complex problems, they have first to be carefully prepared and managed, thus both researchers and practitioners might consider that meeting is a problem before being a solution. Limitations: the research was limited to the Belgian context and the results have not been generalised and tested in other countries and based on quantitative methods. Perspectives: Testing the results in other contexts and designing experimentation with meeting techniques for stimulating innovation in mental healthcare systems. [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]

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]

Information about the National Institute for Health and Disability Insurance (NIHDI) 50th Anniversary event meeting that was held in Brussels, Belgium on April 2, 2014 is presented. Topics include the vision of the health care system and assessment of chronic diseases in Belgium. The meeting featured several policy-makers, managers, health care worldwide including Jo De Cock of Belgium, Hans Kluge of Europe and Hans Vlek of the Netherlands.

Introduction: Multidisciplinary interprofessional, interorganizational and intersectoral collaboration is considered key to meet the complex needs of persons with an autism spectrum disorder (ASD). However, the "institutional field" potentially challenges the integration of care for persons with ASD in Flanders. This contribution explores how regulations affect adequate trajectories of care for persons with ASD. Methods: An inventory was made of publicly accredited and funded organisations providing (early) detection, diagnostics, treatment and care for children, adolescents and adults with ASD. A qualitative thematic analysis was done of the criteria put forward by Federal and Flanders' Community/Regional regulations for organisations. This analysis was validated and complemented with information from an expert panel in order to understand barriers and facilitators for collaboration. Results: The inventory learns that more types of organisations in different policy domains provide services for children and adolescents with ASD compared to adults. The regulations setting the criteria for target group, type of ASD related activity, the professional team, access (financial and by referral or not) and organizational characteristics differ according to the sector (health, welfare, persons with disability). The regulations also differ in the level of detail of criteria. Some organisations (and regulations) are dedicated for persons with ASD, while other organisations provide services for a wider range of disorders, including ASD. Discussion: After the 6th state reform in Belgium, Flanders is seeking for an interorganizational collaboration model providing ASD services. This project studies the possibilities for a "mandated interorganizational network" in which general and specialized care are provided in an effective and efficient way, including an accessible regional system of care for persons with ASD. Therefore we need to understand the newly emerging institutional field. At this stage we only performed a rather formalistic thematic analysis of the regulatory conditions. This needs be complemented with a more in depth understanding the cultural-cognitive and the normative characteristics of the field impacting on real life practices of collaboration. Many indications are found that, if any, collaborations are mainly informal and rely very much on the personal social network of the professionals involved in ASD. Conclusion: At this stage, regulatory frameworks setting the criteria for organisations providing services in ASD trajectories are not entirely aligned, which will hamper to develop a framework for a mandated network. Further reflections are needed to set the scope of a mandated ASD network Lessons learned: Regulatory frameworks of different policy fields within a complex political organisation affect how a model can be developed to implement a mandated network. Regulatory frameworks do not explicitly define if services are "general" or "specialized and dedicated" for ASD. Further reflections are needed on how to regionally organize a balanced and integrated model of care. Limitations: This paper is limited to a rather formalistic thematic analysis of formal regulations. Suggestions for future research: More "realistic evaluation" is needed on the hampering and facilitating factors of interprofessional and multidisciplinary collaboration. [ABSTRACT FROM AUTHOR]

Belgium contracted 12 pilots for implementing quadruple aim in social and health care. 'more value for the same money' is supported by a guarantee that benefits for the health insurance are available for financing higher value services not yet covered by health insurance. Observed expenditure is compared with risk adjusted expected expenditure for a predefined population in each project. The paper explains theoretical background and practical consequences. Fragmentation in health and social care goes with avoidable costs and suboptimal quality of care. Belgian authorities started a journey towards integrated care through pilots in 12 locoregional territories, covering 2,5 million inhabitants. Pilots commit to realise quadruple aim. Consortia of local communities, authorities, social and health care and insurers have defined action plans. They contracted from 2018 with the National Health Insurance (NHI) for implementation. Except for integrator function, projects do not get additional money. A budget guarantee warrants health insurance expenditure for the pilot population to be maintained for 4 years at its predicted level when real expenditure is lower by avoiding low value care. These 'efficiency gains' can be reinvested in high value activities not yet covered bij NHI. This 100% shared saving will support innovation including shifting from fee for service to population based financing. Not for profit insurers administrate reimbursment of claims. A national database contains detailed information at individual level, both on characteristics of the insured as on service utilisation. Yearly calculation is made of the expected expenditure at pilot population level, derived from national observed expenditure. By regression, for each pilot, the mean expenditure per individual in a national reference population is calculated taking into account a set of individual characteristics (age group, sex, morbidity, ...) and applied to the size of population in the pilot region. Outlier individuals and expenditures are excluded from calculation. Pilots target primarily people with chronic conditions and global population at a longer run. Pilots choose if budget guarantee pertains to the entire population or to a subset of people with chronic conditions. Pilots also define if the guarantee pertains to the full extent or to a restricted set of expenditure. Methodoligical problems have arisen when using a claims based risk adjustment for identifying savings. Some of them were unknown when the program has been defined. Project contracts have no provisions to deal with problems like outlierformulas, morbidity factors that cannot be derived from claims data, absence of claims data for social care and confidence intervals. The timeline of datagathering and accounting creates a delay in paying out savings. The budget guarantee is paid out in the fiscal year following the one in which the saving was realised. These problems call for solutions before considering the structural use of claims based data to define population based care financing. Conclusions: There are limits in using risk adjustment based on claims for defining global budgets for integrated care, although the principle seems attractive in a fee for service reilbursment system. Pilots will be a source of precious information on caveats. [ABSTRACT FROM AUTHOR]

Introduction: Community pharmacists are accessible primary care providers and therefore in a good position to detect unmet psychosocial needs of their patients and pharmacy visitors. Description: A collaboration between pharmacists and psychosocial work was set up in Flanders, Belgium. Community pharmacists were trained to discuss psychosocial needs, to inform patients about possible help and refer them to a Center for General Wellbeing if needed. During the pilot of the project between October 2021 and January 2022, the feasibility and potential of this collaboration were examined. Discussion: A total of 79 patient contacts about psychosocial wellbeing were reported using an online registration form, the majority of which concerned women. Family problems and mental health problems were most often reported. Focus group discussions with 28 participating pharmacists showed that they experience their role in psychosocial care as fulfilling and of valuable. Patient satisfaction was mentioned to be a major motivating factor, while time and privacy are barriers. Adequate training in psychosocial wellbeing and care was considered crucial. Conclusion: Pharmacists can be valuable partners in the recognition and referral of patients with unmet psychosocial needs. Structural collaborations between community pharmacy and psychosocial care should be further supported. [ABSTRACT FROM AUTHOR]

Introduction: In the past years, governments from several countries have shown interest in implementing integrated health information systems. The interRAI Suite of instruments fits this concept, as it is a set of standardised, evidence-based assessments, which have been validated for different care settings. The system allows the electronic transfer of information across care settings, enabling integration of care and providing support for care planning and quality monitoring. The main purpose of this research is to describe the recent implementation process of the interRAI instruments in seven countries: Belgium, Switzerland, France, Ireland, Iceland, Finland and New Zealand. Methods: The study applied a case study methodology with the focus on the implementation strategies in each country. Principal investigators gathered relevant information from multiple sources and summarised it according to specific aspects of the implementation process, comparing them across countries. The main implementation aspects are described, as well as the main advantages and barriers perceived by the users. Results: The seven case studies showed that adequate staffing, appropriate information technology, availability of hardware, professional collaboration and continuous training are perceived as important factors which can contribute to the implementation of the interRAI instruments. In addition, the use of electronic standardised assessment instruments such as the interRAI Suite provided evidence to improve decision-making and quality of care, enabling resource planning and benchmarking. Conclusion: In practice, the implementation of health information systems is a process that requires a cultural shift of policymakers and professional caregivers at all levels of health policy and service delivery. Information about the implementation process of the interRAI Suite in different countries can help investigators and policymakers to better plan this implementation. This research sheds light on the advantages and pitfalls of the implementation of the interRAI Suite of instruments and proposes approaches to overcome difficulties [ABSTRACT FROM AUTHOR]

Introduction: The use of emergency department (ED) services has known a significant rise in the past decade. Organizational factors, such as the models of after-hours primary medical care services, and the shortage of general practitioners (GPs) could explain this phenomena. But also demographic and societal elements combined with the problem of patient's 'inappropriate visits to the ED. In order to ensure continuity of care for patients, collaboration between GPs and EDs becomes increasingly essential. Not to mention the benefit of this collaboration for the healthcare system in terms of efficacy and efficiency. This papers explores positive experiences of collaboration between GPs and ED teams in Brussels and the French speaking regions of Belgium, with the objectives of 1) identifying the main concepts related to IC that are highly valued by actors; and 2) analyzing forces and opportunities of the Belgian context in terms of IC. Focusing on positive experiences is inspired from the Appreciative Inquiry (AI) philosophy which is based on the assumption that every organization has something that works well and these strengths can be the starting point to create a positive change. Methods: A series of eight focus groups (FG) with GPs and ED teams was conducted in Brussels and different French speaking regions between September 2014 and December 2015. FG lasted one and a half hours on average. Participants' number varied between 6 and 12 per FG. They were audio recorded and transcribed verbatim. An interview guide was designed based on the first two phases of AI, "discovery and dream". Transcripts were analyzed thematically using an inductive content analysis technique. Results: Findings showed that a positive experience of collaboration is mainly related to a high level of communication. Both GPs and EDs attach great importance to clear, timely, and accurate written reports, but also to oral communication. Phone calls are highly valued as they allow actors to interact directly, and negotiate the patient plan of care. Mutual acquaintanceship is another component of IC. Actors agree that knowing each other and being able to put a face to a name optimizes contact, enhances relationships and strengthens trust. Trust is also the result of previous experiences. It is manifested by seeking advice from each other and making joint decisions. Another finding is about power. A positive experience of power is mainly characterized by a relationship of equality without any dominance behavior. It shows in respectful and professional attitudes towards each other. Role clarification is also of particular importance. Knowing one's own role and that of others and fulfilling that role is considered as a valuable lever for collaboration. It supposes that actors are aware of each other training, thus more confident in the competencies of the others. It also improves the referral process. The patient himself plays a major role in enhancing IC and can be the driving force in communication between actors. As for the political environment and the healthcare system in general, they don't seem to play a significant role in promoting collaboration between GPs and EDs. With the absence of integration policies, data and information exchange system remains poorly developed; there are no incentive measures to encourage collaboration; no gatekeeping process; the out of hours GPs services are problematic for both parties; and the fee-per-service payment and the legislation on both parties financing encourage competition. Finally, actors' priorities, in order to achieve better collaboration, include better communication and mutual acquaintanceship. Discussion: Opportunities for enhancing IC in the Belgian context include a recent report from the Belgian healthcare knowledge center addressing the organization and payment of ED services in Belgium and highlighting the necessity of increased collaboration between EDs and GPs. Although controversial, the report is definitely a starting point of negotiation toward better IC. Also the recent federal plan aiming at developing integrated and patient centered care for chronic patients by developing pilot projects which experiment and evaluate models of integration. As for the forces, they lie in the fact that mutual acquaintanceship happens informally, despite the lack of organized activities, and that actors are aware of the benefits of IC and ready to engage in a better relationship. Conclusion: In terms of cost-efficiency, the performance of the Belgian healthcare system remains poor. Several initiatives aiming at coordinating care between hospitals and primary care have been established. But until today, only rare strategies target the ED specifically. In the future, strategies to enhance collaboration should be seriously investigated if we aspire to integrating efficiently the different healthcare providers. [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: Healthcare authorities worldwide search for ways to develop integrated care and interprofessional collaboration. In Belgium, Medical-Pharmaceutical Concertation (MPC) was introduced as a format to promote constructive dialogues between GPs and community pharmacists (CPs) with a focus on pharmacotherapy. Objective: To evaluate the implementation of MPC from the perspective of healthcare authorities and GPs/CPs. Methods: Mixed-methods approach, including semi-structured interviews with stakeholders and service users, observations of MPC meetings and surveys in GPs/CPs. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed inductively. Results: The implementation of MPC took a slow start. Parties involved had divergent views on the goals of the MPC: stakeholders focused on measurable results, while service users aimed on improving interprofessional communication. Additionally, service users felt that the lack of local structures hindered consensus building and implementation of agreements in daily practice. Support from professional associations was considered indispensable for the implementation of MPC. In order to organize this efficiently, the establishment of an independent institution, coordinating the MPC initiative, was highly recommended. Conclusion: The study confirms that a thorough context assessment prior to implementation of a complex project is needed and that a step-wise approach should be respected to achieve effective interprofessional relationships. [ABSTRACT FROM AUTHOR]

The article discusses the proposals for reform on the implementation of strategic plan and health care innovations for chronic diseases in Belgium. It states that the Belgian health care system is governed by the National Institute for Health and Disability Insurance (NIHDI) social security agency of the country's Minister of Social Affairs. It also emphasizes the several sectors of that financed the healthcare system including the national, social security based and health insurance system.