Abstract
Why did we do it? (background): The growing number of people with chronic care needs is putting pressure on general practice. Coping with this pressure while keeping care accessible demands a transition to a more proactive and integrated chronic care. General practitioners and practice nurses do want to organise their care more integrated, but the hectic pace of everyday life does not make change evident.
What did we do? During four regional blended training days GPs and practice nurses where supported in the change process towards more integrated care for persons with chronic diseases. The main goal was to make attendees ‘Aware’ of the need for change, establish the ‘Desire’ for change, provide them with the ‘Knowledge’ and ‘Ability’ they need to achieve change, and to ‘Reinforce’ that attendees continue to work on their change. This ‘ADKAR-change model’ formed the backbone of our training program: In preparation attendees watched a short clip in which we clarified the concept of integrated chronic care and assessed to what extent their practice already provides integrated chronic care using the ACIC questionnaire based on the chronic care model. The training kicked-off with reflections on and best practices of integrated chronic care by local key figures. Then participants were divided in four workshops, each of which zoomed in on a different element of integrated chronic care: self-management support, clinical information systems for population management, interprofessional collaboration and community oriented care. The workshops were asset-based according to the method of appreciative inquiry: Led by a moderator and local expert attendees in each group identified what aspects of integrated care they are already doing, what they aspire to do further and how they can realise this ambition in their practice. Participants got acquainted with tools helpful in the process of setting up a quality improvement project. We supported participants to continue to work on their project by sending them tips and tools on a regular basis in the weeks after the training.
What is the learning for the international audience? By starting from energy, strength and opportunities, participants reached a perspective of possibilities, rather than impossibilities. In addition to new insights and tools they went home with an eagerness to get started with their change towards integrated chronic care.
What are the next steps? We aim to organise a follow-up training day for all participants from the different regions, where participants can share their experiences and learn from each other. Furthermore, we will use the insights from the training days to align new training programs with the needs of GPs and practice nurses.
Who did we engage with? This program is unique as it is a cocreation between research project 'SCUBY Belgium' of the University of Antwerp and Domus Medica, the scientific professional organisation of family doctors in Flanders. We realised the local character of the study days by collaborating with key figures from the region as well as experts from both the Flemish universities and colleges.