Abstract：
BACKGROUND: Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types.
METHODS: Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices.
RESULTS: The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks.
CONCLUSIONS: Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.
METHODS: Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices.
RESULTS: The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks.
CONCLUSIONS: Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.
摘要：
背景：2型糖尿病（T2D）是一种越来越占主导地位的疾病。当在有组织的系统-综合护理（IC）模型中由准备好的主动团队进行干预时，干预会更有效。慢性护理模式(CCM)为其实施提供指导，但是IC的规模扩大是具有挑战性的，这阻碍了T2D护理的结果。在本文中,我们使用CCM调查了佛兰德斯(比利时)初级保健中IC的实施现状及其在不同执业类型中的差异.
方法：比利时包含三种不同的初级保健实践类型：单学科收费服务实践，多学科收费服务实践和多学科人头制实践。在三个佛兰德地区，使用不成比例的抽样方法为每种类型选择最多10种做法，共有66个实践。该研究采用了混合方法设计，其中对慢性病护理评估（ACIC）进行了补充，并与全科医生进行了访谈。护士和营养师与66种做法有关。
结果：收费服务实践的ACIC评分-包含97％的比利时患者-仅相当于对T2D慢性病护理的基本支持。多学科和基于人头的实践得分远高于传统的单学科收费服务实践。该地区对ACIC评分没有显著影响。有了护士，作为一个人头练习和有秘书在回归分析中产生了显著的影响，这解释了ACIC分数75%的差异。由于明确的角色定义，表现更好的做法是成功的，任务授权给护士，协调,结构化使用电子病历，协商规划和自我管理支持的整合，和行为改变干预(内部或使用社区倡议)。护士在初级保健实践中工作的时间越长，他们执行更高级任务的机会就越高。
结论：除了护士或秘书在场，在一个屋檐下工作的多学科和基于人头的融资系统是系统的重要特征，其中ICforT2D可以成功地扩大规模。比利时决策者应重新考虑护理人员在初级保健中的作用，并使融资系统更加一体化。由于IC的放大在不同的背景下差异很大，在包含多种类型做法的卫生系统中统一推广可能不会成功。
方法：比利时包含三种不同的初级保健实践类型：单学科收费服务实践，多学科收费服务实践和多学科人头制实践。在三个佛兰德地区，使用不成比例的抽样方法为每种类型选择最多10种做法，共有66个实践。该研究采用了混合方法设计，其中对慢性病护理评估（ACIC）进行了补充，并与全科医生进行了访谈。护士和营养师与66种做法有关。
结果：收费服务实践的ACIC评分-包含97％的比利时患者-仅相当于对T2D慢性病护理的基本支持。多学科和基于人头的实践得分远高于传统的单学科收费服务实践。该地区对ACIC评分没有显著影响。有了护士，作为一个人头练习和有秘书在回归分析中产生了显著的影响，这解释了ACIC分数75%的差异。由于明确的角色定义，表现更好的做法是成功的，任务授权给护士，协调,结构化使用电子病历，协商规划和自我管理支持的整合，和行为改变干预(内部或使用社区倡议)。护士在初级保健实践中工作的时间越长，他们执行更高级任务的机会就越高。
结论：除了护士或秘书在场，在一个屋檐下工作的多学科和基于人头的融资系统是系统的重要特征，其中ICforT2D可以成功地扩大规模。比利时决策者应重新考虑护理人员在初级保健中的作用，并使融资系统更加一体化。由于IC的放大在不同的背景下差异很大，在包含多种类型做法的卫生系统中统一推广可能不会成功。
