出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In October 2015, the Belgian Health Ministers launched a joint plan in favour of chronic patients entitled “Integrated Care for Better Health” [1]. Through this plan, they expressed their intention to move from a fragmented system to an integrated care system for patients with chronic diseases. They decided to implement this plan in a bottom-up way: they launched a call for multidisciplinary four-year pilot projects involving field actors in a co-creation process in order to initiate innovation at the local level. Methods : This qualitative and inductive research draws on several data collection methods: interviews N=21, focus groups N=7, direct observation 90.5 hours, documentary analysis operational documents and a literature review. The data, pertaining to two aspiring pilot projects, were collected during the “conceptualisation phase”, i.e. the application writing period. Results : According to the authorities ‘guidelines, pilot project consortia had to identify a pilot zone and include a variety of first-line and second-line care actors together with non-medical actors e.g. social and cultural actors working in this zone. They were asked to identify the needs of their population and the available/missing resources in their pilot zone. On the basis of this, they had to write a loco-regional action plan in which they outlined their common vision, their strategic and operational objectives and the actions they would implement to achieve these objectives. Discussions : During the conceptualisation phase, different actors, who would probably not have met otherwise, came to work together, overcoming the traditional fragmentation between first- and second-line of care. More than that, by including non-medical stakeholders, the pilot project consortia extended to the community. Multidisciplinarity, coconstruction, cooperation, coordination, targeting a community/defined population in a delimited territory, initiatives “driven by community health needs” [2], sharing goals and resources, all these elements characterising the pilot projects also characterise community health care [3]. Conclusions : Opting for implementation through the use of pilot projects has led local actors to engage in the development of what could become “community health microcosms” in the future. Pilot projects appear to be tools supporting the development of “community-based integrated care” [2]. Lessons learned : Building multidisciplinary projects entails that local actors reach an agreement on their common vision and goals, which is a challenging task. This implies dealing with controversies by meeting, understanding their respective roles, exchanging ideas, negotiating and overcoming their personal interests. Becoming a group, a community aware of its existence is a task in itself, which takes time. Besides, co-designing health care with local actors brings unpredictability to the process: the result of local actors’ reflections can be different from the authorities’ expectations. Limitations : Nineteen pilot projects submitted applications. For practical reasons of feasibility, this research focuses only on two pilot projects and, more specifically, on the application file co-construction process of these pilot projects. Suggestions for future research : The selected pilot projects will implement their loco-regional action plans during the execution phase starting in January 2018. Focusing on the concrete execution of their loco-regional action plans seems to be a logical continuation of this research.
关键词：integrated care ; community health ; health system ; policy implementation ; chronic diseases
