Problem: High prevalence of type 2 diabetes; suboptimal patient education on diabetes for self-monitoring and lifestyle adaptations; growing dissatisfaction of primary care providers regarding their weak gatekeeping function.
Solution highlights: Primary care nurse-physician teams were introduced to lead new diabetes health networks, with the aim of connecting providers across sectors and strengthening primary care gatekeeping; collaboration with stakeholders in the early design stages of the initiative encouraged multistakeholder buy-in from the outset; updated evidence-based care pathways published in a guidebook helped streamline and standardize care; extensive patient education and coaching on self-management skills enabled patients to engage in their own care; pragmatic intermediary solutions were found to address pressing challenges; for example, implementing paper medical records carried by the patient to counter poor communication between providers in the absence of an electronic information system.
Description of practice
Since the early 2000s, Andorra has faced a high and rising burden of noncommunicable diseases, particularly type 2 diabetes. The largely-reactive and specialist-driven model of service delivery left the health system struggling to provide the coordination across providers and continuity of services needed to effectively respond to changing health pressures. Patient care-seeking patterns favoured direct entry to specialist care and dissatisfaction among general practitioners was growing due to their strained gatekeeping role. Time and resources necessary to fully engage patients in their diabetes care were found to be lacking, despite the known complex nature of diabetes and close links to individual lifestyle factors.
The Andorran Ministry of Health and Welfare has prioritized a transition from an acute, reactive health system orientation to a more integrated service delivery model, as evidenced in the national Strategic Health Plan 2010-2015. The newly-launched pilot for an integrated type 2 diabetes care model is one of the most recent efforts to realize the aims of the Strategic Health Plan. Working closely with key stakeholders, the pilot has been designed to strengthen the gatekeeping role of primary care. Nurse-physician care teams have been established as the central managers for type 2 diabetic patients. Coined ‘diabetes health networks’ these nurse-physician teams are responsible for all patient referrals to other providers, including those previously not recognized by the public system for diabetes care, such as podiatrists and social workers. Evidence-based care pathways and protocols have been updated and made available to providers to help guide and standardize care. Additional patient education is also given as a means to encourage greater self-management by patients. While participation in the pilot is voluntary, financial incentives encourage engagement and reward performance. Participating patients have lower co-payment responsibilities for diabetes care and access to providers not typically covered by the standard care package. Participating general practitioners receive a fixed payment per patient and service, plus an additional performance-based incentive. The pilot successfully secured the enrolment of 85% of general practitioners. Following training for providers, the pilot was officially launched on World Diabetes Day 2014 and is set to run for one year. The pilot will be monitored against a set of 20 performance indicators. Results from this evaluation will inform the future implementation of the initiative and its potential for scale-up in the context of Andorra’s new integrated health care model.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The initiative is being steered by the government, but efforts to include a wide range of actors have been made. Plans for the pilot took shape through an iterative process involving regular meetings with representatives from multiple stakeholder groups, including the Council of Ministers, general practitioners, nurses and other health professionals, the Diabetic Association, the Andorran Office of Social Security and the Andorran National Health Service. An appointed project coordinator is overseeing the development of the diabetes pilot, under guidance from a newly-established multidisciplinary steering committee.
As the diabetes pilot is still in the early implementation stage, outcomes are not yet available. Evaluation of the pilot will be based on a series of 20 performance indicators measuring processes, outcomes and satisfaction.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Anna Nerin
- Ministry of Health