Facilitating integrated primary healthcare: an instrument to develop tailored and integrated care pathways

Laurent Desmet, Eva Goossens, Peter Van Bogaert, Katrien Danhieux

Keywords: Integrated care, care pathways, interdisciplinary, chronic care

Setting:

The prevalence of chronic conditions like diabetes and cardiovascular diseases is increasing, underscoring the need for integrated, interdisciplinary primary healthcare. However, establishing such care organizations poses a complex challenge for primary care practices. While the chronic care model provides an organizational framework, its implementation remains low. Primary healthcare professionals often cite the lack of tangible, concrete tools to apply this model in daily practice.
In response to this gap, the four-year JACARDI project aims to develop a practical instrument or program to assist general practices in creating and implementing integrated care pathways.

Target group:

Primary healthcare professionals, including physicians, nurses, and physician assistants.

Description of the innovative practice or project:

The initial phase focuses on developing the intervention. First, information will be collected through interviews with healthcare providers, analysis of existing practice protocols and a scoping literature review. Next, the intervention will be designed during co-creation workshops with stakeholders at various levels.

The second phase involves implementing the intervention, with the strategy chosen based on insights from the initial phase. Possible strategies include coaching , teaching packages and toolboxes on topics such as practice vision, teamwork and task delegation. Subsequently, an evaluation will be conducted, followed by another co-creation session, refinement of the intervention and a second round of implementation.

Evaluation:

Evaluation will be guided by the framework proposed by Proctor et al., which assesses implementation outcomes, service outcomes, and patient outcomes. This structured approach ensures a comprehensive evaluation of the project's effectiveness and impact.

Next Steps:

Sustainability is a core value, with efforts focused on developing a practical, user-friendly instrument tailored to the needs of the target population. Involving key stakeholders from project inception aims to integrate project results into existing structures, facilitating scalability and long-term impact.

Lessons learned:

Insights gained from this project will facilitate the organization of integrated care for patients with chronic conditions, ultimately enhancing the quality of care provided.

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