Abstract
In Flanders, the prevalence of chronic diseases is high and still increasing partially due to aging of the population and partially due to other reasons like surviving acute diseases or cancer. The aim of the Zorgzaam Leuven project is to test the impact of the implementation of a complex intervention based on the principles of integrated care for a well defined population of approximately 100.000 inhabitants in Belgium.
To realize this aim an regional plan created based on integrated care principles and co-creation started in 2016. This plan results in a portfolio of actions for different types of patients with elements of disease management, case-management and proactive care. An integrator and open networks structure was created to make this happen within a learning network.
The building blocks of this project are:
1. Gathering of data on the whole population.
2.Implementation of communications tools.
3 enhancing Teamwork by coaching and the use of PDCA cycli to increase quality.
4. Local care networks
5. Sharing of expertise.
6. Adaptation of different financial mechanism
7. Collaboration with research units to implement interventions with existing proof of concept
8. Scientific evaluation