Position paper
Authors: Paulus Dominique , Van Den Heede Koen , Mertens Raf 
Published: January 2025

POSITION PAPER 2 -- TABLE OF CONTENTS 2 -- 1. CHRONIC DISEASES: A CHALLENGE FOR THE HEALTH CARE SYSTEM 5 -- 1.1. CHRONIC DISEASES REMAIN A PRIORITY FOR THE BELGIAN HEALTH AUTHORITIES 5 -- 1.2. CHRONIC DISEASES: A CHALLENGE FOR ALL HEALTH CARE SYSTEMS 5 -- 1.2.1. Strategies proposed by international organisations 5 -- 1.2.2. Prevalence of chronic diseases in Europe 6 -- 1.3. PREVALENCE OF CHRONIC DISEASES IN BELGIUM. 6 -- 1.4. IMPORTANCE OF MULTIMORBIDITY 6 -- 1.5. A BURDEN FOR THE FRAILEST PATIENTS 6 -- 1.6. ESCALATING COSTS OF CHRONIC DISEASES 7 -- 2. WHAT IS A CHRONIC DISEASE? FROM A DISEASE-ORIENTED TO A NEEDS-BASED -- CONCEPT 8 -- 2.1. MULTIPLICITY OF PATIENTS NEEDS 8 -- 2.2. NEEDS-BASED APPROACH FOR CHRONIC CARE 8 -- 3. IMPORTANCE OF PATIENT EMPOWERMENT 9 -- 4. SCOPE AND METHODS 10 -- 4.1. SCOPE OF THE POSITION PAPER: FOCUS ON CHRONIC CARE AND SUPPORT -- DELIVERED BY THE HEALTHCARE SYSTEM 10 -- 4.1.1. Importance of health in all policies 10 -- 4.1.2. Scope of the position paper: focus on care and support delivered by the healthcare -- system 10 -- 4.2. COMBINATION OF METHODS 11 -- 5. A VISION ON THE FUTURE ORGANISATION OF CHRONIC CARE IN BELGIUM 11 -- 5.1. VISION OF THE PROVISION OF CHRONIC CARE IN THE BELGIAN HEALTH CARE SYSTEM 11 -- 5.1.1. Sources 11 -- 5.1.2. Core vision 12 -- 5.1.3. Additional qualifications 12 -- 5.1.4. Expanded vision of the provision of chronic care within the health care system 13 -- 5.2. CONCEPTUAL MODEL: ACTIVITIES TO IMPLEMENT THE VISION OF CHRONIC CARE 13 -- 5.2.1. Module 1: plan, provide and coordinate routine care 14 -- 5.2.2. Module 2: provide acute episode response and specialized services 14 -- 5.2.3. Module 3: conduct early identification 14 -- 5.2.4. Module 4: support patient/informal caregiver empowerment (including self-management) 14 -- 5.2.5. Module 5: conduct health promotion and prevention activities 14 -- 5.2.6. Module 6: implement and follow-up a dynamic care model 15 -- 5.2.7. Requirements for the above mentioned activities 15 -- 5.2.8. Overview of the conceptual model proposed for a health care system oriented -- towards chronic care 15 -- 5.3. FROM ACTIVITY MODEL TO POLICY RECOMMENDATIONS 16 -- 6. POLICY RECOMMENDATIONS 16 -- 6.1. PLAN, PROVIDE AND COORDINATE ROUTINE CARE IN THE PRIMARY CARE SETTING 16 -- 6.1.1. Individualized care plan 16 -- 6.1.2. Provide routine care and support for the chronic patient 19 -- 6.1.3. Monitor and evaluate progress and quality of care 23 -- 6.1.4. Provide care coordination 26 -- 6.2. PROVIDE ACUTE EPISODE RESPONSE AND SPECIALISED SERVICES 28 -- 6.3. CONDUCT EARLY IDENTIFICATION 30 -- 6.4. SUPPORT PATIENT AND INFORMAL CAREGIVER EMPOWERMENT 31 -- 6.4.1. Develop provider skills and tools for patient empowerment 31 -- 6.4.2. Provide patient empowerment services and support 33 -- 6.5. CONDUCT HEALTH PROMOTION AND PRIMARY PREVENTION ACTIVITIES 34 -- 6.6. IMPLEMENTATION AND FOLLOW-UP OF A DYNAMIC CARE MODEL 34 -- 7. REFERENCES OF THE POSITION PAPER 39 -- APPENDIX OF THE POSITION PAPER 49 -- APPENDIX 1. RECAPITULATIVE INVENTORY OF THE MAIN ACTION FIELDS AND OF THE -- ACTORS INVOLVED 49 -- APPENDIX 1.1. EDUCATION 49 -- APPENDIX 1.2. DEVELOPMENT OF PROTOCOLS AND TOOLS FOR COMMUNICATION 50 -- APPENDIX 1.3. DEVELOPMENT OF INFORMATION AND COMMUNICATION TECHNOLOGY -- APPLICATIONS 50 -- APPENDIX 1.4. QUALITY IMPROVEMENT INITIATIVES 50 -- APPENDIX 1.5. EMPOWERMENT 51 -- APPENDIX 1.6. MANPOWER 51 -- APPENDIX 1.7. ORGANIZATIONAL REFORMS 52