Improving quality of chronic care by integrating the primary care setting

PURPOSE: One of the main barriers for further improving the quality of chronic care was the absence of performance-based financing. With the introduction of a Diagnosis-Based Costing method (DBC) within primary care, a new organisational model is implemented in the region Maastricht. This integrated care model includes all relevant stakeholders, such as GPs, district nurses, dieticians, nurse practitioners, practice assistants, physiotherapists and hospital-based specialists. Aim is to optimise the quality of fragmented primary care for chronically ill within the existing budget restraints or, if even possible, to diminish the present costs for chronic care. CONTEXT AND DATA SOURCES: Increasing prevalence of chronic illnesses, an ageing society and the observation that existing care systems approach mostly insufficiently to specific health problems and patients' needs asked for redesigning the existing healthcare system. We started by focussing on primary diabetes and COPD care. For the delivery of diabetes and COPD care within the entire primary care setting health care insurance companies contract with GPs only. GPs act as gatekeepers and coordinate the delivery of care within the primary care setting. Evidence-based medical guidelines and evidence about the organisation of respectively integrated diabetes and COPD care were used to outline care in multidisciplinary protocols. Referral criteria for secondary care are formulated as well. Within this protocol hospital-based specialists deliver specialized care while working in the GPs electronic patient file. CASE DESCRIPTION: In 2007 and 2008, respectively 6390 and 6700 diabetes patients, derived form 87 GPs, have been included in the DBC-cohorts. The DBC COPD has been implemented in October last year, until now 2253 patients are registered. DBCs for cardiovascular diseases and for depression and anxiety are under construction and will be implemented by the end of this year. All healthcare givers register their delivered care into the same electronic patient file. PRELIMINARY CONCLUSIONS/DISCUSSION: Based on the preliminary data it can be concluded that the integrated care model has been adopted by professionals in the primary care setting, patients and the health care insurance companies. Moreover, agreement has been reached in the process of care delivery, the indicators for performance-based costing and the collection of data for care and research purposes. Matches and gaps between the actual delivered care and the protocol are explained by the Chronic Care Model and the Management Control Theory (an article is accepted for international publication). Patient outcomes, cost-effectiveness and benefits of these programmes are now subject of investigation. The main challenge for the future is to answer the question whether such disease-specific driven approaches remain suitable for patients suffering from more than one chronic disease (multi-morbidity).