Organisation of care for chronic patients in Belgium
Authors: Paulus Dominique , Van Den Heede Koen , Mertens Raf 
Published: January 2025

SCIENTIFIC REPORT 11 -- 1. THE CHALLENGE OF CHRONIC CARE 11 -- 1.1. CHRONIC CARE: A GROWING BURDEN FOR THE HEALTH CARE SYSTEMS. 11 -- 1.2. OBJECTIVE: DEVELOPMENT OF A POSITION PAPER FOR CHRONIC CARE IN BELGIUM 11 -- 1.3. SCOPE: FROM CHRONIC DISEASE TO CHRONIC CARE BASED ON THE PATIENTS NEEDS 13 -- 1.3.1. Chronic disease: official definitions based on a listing of diseases 13 -- 1.3.2. The patient with chronic disease: frequently in the plural 13 -- 1.3.3. Chronic care as an answer to the patients needs 13 -- 1.3.4. on care (versus primary prevention and health in all policies) 15 -- 1.4. EPIDEMIOLOGY AND COSTS OF CHRONIC DISEASES 15 -- 1.4.1. Epidemiology 15 -- 1.4.2. Costs 16 -- 2. HIGHLIGHTS FROM THE INTERNATIONAL PERSPECTIVE 18 -- 2.1. VIEWPOINTS OF THE EUROPEAN UNION, THE UNITED NATIONS AND THE WORLD HEALTH ORGANIZATION 18 -- 2.1.1. Data sources 18 -- 2.1.2. International frameworks: calls for integrated care 18 -- 2.1.3. Shift towards integrated care: advocacy for organizational changes 21 -- 2.1.4. Role of primary care: hub of coordination 22 -- 2.1.5. Summary and conclusions 24 -- 2.2. CHRONIC CARE MODEL 26 -- 2.2.1. Elements of the chronic care model 26 -- 2.2.2. Evidence underlying the chronic care model 27 -- 2.3. HIGHLIGHTS FROM 4 COUNTRIES 28 -- 2.3.1. Methods 28 -- 2.3.2. Stakeholder collaboration: shared vision and leadership 29 -- 2.3.3. Information technologies and performance measurement. 31 -- 2.3.4. Engaging consumers 31 -- 2.3.5. Improving Health Care delivery: translation of the national/regional strategy at local level 32 -- 2.3.6. Aligning finance /insurance: incentives 32 -- 2.3.7. Outcomes 33 -- 2.3.8. Barriers in redesigning chronic care management 33 -- 2.3.9. Key points: lessons learned 33 -- 3. REASONING FRAMEWORK FOR A HEALTH SYSTEM ORIENTED TOWARDS CHRONIC CARE 34 -- 3.1. OBJECTIVE OF THIS CHAPTER 34 -- 3.2. DEVELOPMENT OF A VISION FOR A REFORM OF CHRONIC CARE IN BELGIUM 35 -- 3.2.1. General shape of the vision or root definition 35 -- 3.2.2. Core purpose 36 -- 3.2.3. Additional qualifications 36 -- 3.2.4. Expanded vision/root definition 38 -- 3.3. CONCEPTUAL MODEL: FUNCTIONAL ACTIVITIES REQUIRED FOR A CHRONIC CARE SYSTEM 39 -- 3.3.1. Plan, provide and co-ordinate routine care 40 -- 3.3.2. Provide acute episode response and specialized services 41 -- 3.3.3. Conduct early identification 42 -- 3.3.4. Support patient/informal caregiver empowerment (including self-management) 43 -- 3.3.5. Conduct health promotion and prevention activities 44 -- 3.3.6. Implement and follow-up a dynamic care model 45 -- 3.3.7. Six requirements for each activity 45 -- 3.4. CONCLUDING REMARKS 47 -- 4. CHRONIC CARE INITIATIVES IN BELGIUM 48 -- 4.1. OBJECTIVE OF THIS CHAPTER 48 -- 4.2. METHODS 48 -- 4.2.1. Data sources 48 -- 4.2.2. Data collection 48 -- 4.2.3. Inclusion and exclusion criteria 48 -- 4.3. NATIONAL PLAN: PRIORITY TO CHRONIC PATIENTS! 49 -- 4.4. DESCRIPTION OF THE INITIATIVES FROM THE FEDERAL PUBLIC SERVICE HEALTH, FOOD CHAIN SAFETY AND ENVIRONMENT AND FROM THE SICKNESS FUNDS 49 -- 4.4.1. Inventory of initiatives that target patients with a chronic illness 49 -- 4.4.2. Discussion: initiatives from the Federal Public Service Health, Food Chain Safety and environment and from the Sickness Funds 55 -- 4.5. DESCRIPTION OF INITIATIVES FROM THE NATIONAL INSTITUTE FOR HEALTH AND DISABILITY INSURANCE 56 -- 4.5.1. Health care system level 56 -- 4.5.2. Plan, provide and coordinate care in the primary care setting 57 -- 4.5.3. Self-empowerment of the patients 63 -- 4.6. KEY POINTS: CHRONIC CARE INITIATIVES IN BELGIUM 64 -- 5. RECOMMENDATIONS IN RELATION TO CHRONIC CARE: ANALYSIS OF KCE REPORTS 65 -- 5.1. OBJECTIVE OF THIS CHAPTER 65 -- 5.2. METHODS 65 -- 5.3. TAILORED DELIVERY SYSTEM DESIGN 65 -- 5.3.1. Strengthening primary care: illustration of type 2 diabetes care 66 -- 5.3.2. Organizational models that streamline transition between primary, secondary and tertiary care 67 -- 5.3.3. Organization of services for the older persons 67 -- 5.3.4. Organization of Palliative care services 69 -- 5.3.5. Organization of Mental Health Care Services 70 -- 5.3.6. Organization of rehabilitation services 70 -- 5.4. APPROPRIATE WORKFORCE 71 -- 5.4.1. Physician workforce planning 71 -- 5.4.2. Attractiveness, recruitment and retention of the GP profession 71 -- 5.4.3. Differentiated Nursing Practice 72 -- 5.4.4. The right function for the right health professional: physiotherapists and pharmacists 72 -- 5.4.5. Important role for the occupational physician and the advisory physician from the sickness funds 73 -- 5.4.6. Role for informal caregivers 73 -- 5.4.7. Curricula and continuous education based on needs 73 -- 5.5. APPROPRIATE FINANCING 74 -- 5.5.1. Financial accessibility 74 -- 5.5.2. Financing system for home care nursing 75 -- 5.5.3. Comparison of two financing systems for primary health care 76 -- 5.5.4. Financial initiatives for quality 76 -- 5.6. QUALITY PROCESSES 77 -- 5.7. DECISION SUPPORT 78 -- 5.7.1. Seamless care with regard to medications 79 -- 5.7.2. Self-empowerment in chronic dialysis 79 -- 5.8. CLINICAL INFORMATION SYSTEMS 79 -- 5.9. KEY POINTS: EVIDENCE AND RECOMMENDATIONS FROM KCE REPORTS 80 -- 6. FOCUS ON PATIENT EMPOWERMENT AND NEW PROFILES/ FUNCTIONS IN THE FIRST LINE OF CARE 82 -- 6.1. OBJECTIVE OF THIS CHAPTER 82 -- 6.2. METHODS 82 -- 6.3. HOW TO FOSTER THE PATIENT SELF-EMPOWERMENT ? INSIGHTS FROM A SYSTEMATIC REVIEW OF THE LITERATURE 82 -- 6.3.1. Scope of the literature review 83 -- 6.3.2. Methods 84 -- 6.3.3. Results of the search strategy 84 -- 6.3.4. Effectiveness of the interventions: results by disease 88 -- 6.3.5. Summary of the findings: analysis by type of intervention 94 -- 6.3.6. Conclusion: what elements make up successful interventions? 97 -- 6.3.7. Strengths of this review 98 -- 6.3.8. Caveats in the interpretation of results 98 -- 6.3.9. Key points: interventions to foster patient empowerment 99 -- 6.4. NEW PROFILES AND FUNCTIONS IN THE HEALTH CARE SYSTEM 99 -- 6.4.1. Objective: analysis of the possible changes within the workforce to tackle the future challenges of chronic care 99 -- 6.4.2. Methods 100 -- 6.4.3. New roles in health care: examples from the UK, Canada and The Netherlands 100 -- 6.4.4. Situation in Belgium 110 -- 6.4.5. Discussion: implementation of new functions and professions in the Belgian health care system 114 -- 6.4.6. Key points: new functions and roles in primary health care 115 -- 7. ORGANIZATION OF CHRONIC CARE IN BELGIUM: STAKEHOLDERS ANALYSIS 116 -- 7.1. OBJECTIVE OF THIS CHAPTER 116 -- 7.2. METHODS: CONSULTATION OF STAKEHOLDERS FROM DIFFERENT LEVELS 116 -- 7.2.1. Micro and meso levels: four brainstorming sessions and semi-structured interviews 116 -- 7.2.2. Macro level: two meetings with stakeholders 117 -- 7.3. RESULTS: STAKEHOLDERS VIEWS ON THE ORGANIZATION OF CHRONIC CARE IN BELGIUM 118 -- 7.3.1. Theme 1: continuum of care within lines of care and between lines of care calls for coordination 118 -- 7.3.2. Theme 2: Redefining the roles of health professionals and training 121 -- 7.3.3. Theme 3: Empowerment and support of the patient and his/her informal caregiver 124 -- 7.3.4. Theme 4: Payment system influences care 125 -- 7.3.5. Theme 5: Clinical information systems and e-Data 127 -- 7.3.6. Theme 6: Accessibility of care 129 -- 7.3.7. Strengths and limitations of this SWOT analysis 130 -- 7.4. KEY POINTS: HIGHLIGHTS FROM THE SWOT ANALYSIS WITH STAKEHOLDERS 131 -- 7.4.1. Lack of efficiency 131 -- 7.4.2. Coordination at micro level: a multidisciplinary primary care team is at the centre of a system designed for people with chronic care needs 131 -- 7.4.3. Coordination at the meso level: mid-level scale initiatives to improve seamless care between hospital and home care 131 -- 7.4.4. Task delegation and new functions in the health care system: the added value of medical assistants and qualified nurses 131 -- 7.4.5. Preventing institutionalization: importance of respite care and coaching the informal caregivers 132 -- 7.4.6. Patients and Informal care givers. Roles of their organizations 132 -- 7.4.7. Balancing payment systems 132 -- 7.4.8. Information systems 132 -- 7.4.9. Accessible care 133 -- 8. ANALYSIS OF COORDINATION STRUCTURES AND PROGRAMMES IN BELGIUM 134 -- 8.1. OBJECTIVE OF THIS CHAPTER 134 -- 8.2. BACKGROUND: HEALTH CARE SYSTEM, A COMPLEX ADAPTIVE SYSTEM 135 -- 8.3. COORDINATION STRUCTURES AND PROGRAMMES IN HEALTH CARE 135 -- 8.3.1. Coordination structures 135 -- 8.3.2. Coordination programmes 136 -- 8.4. KEY FEATURES OF COORDINATION STRUCTURES AND PROGRAMMES 136 -- 8.4.1. Coordination structures at micro level 136 -- 8.4.2. Need for a geographically integrated system at meso level 138 -- 8.4.3. Towards a uniform vision at macro level 138 -- 8.5. EVOLUTION OF COORDINATION STRUCTURES IN BELGIUM 139 -- 8.5.1. Micro level: from single-handed practices towards more collaboration 139 -- 8.5.2. Meso level: from home care coordinating centres (SIT/CCSSD) to Integrated Primary Care Systems (GDT/SISD) 140 -- 8.6. CARE PROGRAMMES: FIT WITHIN MICRO OR MESO HORIZONTAL STRUCTURES 142 -- 8.6.1. Local multidisciplinary Networks 143 -- 8.6.2. Alternative forms of care for older persons 143 -- 8.6.3. Palliative care platforms and teams 143 -- 8.7. FROM LESSONS LEARNED TO FUTURE PERSPECTIVES 144 -- REFERENCES 146