Implementing integrated care in the daily practice of general practitioners in an urban setting: facilitating collaboration between health and welfare services.

Abstract

Summary: Funded by the city of Antwerp, the 'ZIHP' project wants (1) to implement the existing elaborated Flemish vision on integrated care in the daily practice of general practitioners, (2) to strengthen the network around GP practices by facilitating concrete collaborations and (3) strengthen the network around the patient, ultimately improving the health and well-being of the most vulnerable population in Antwerp.
 Context and problem: Current pressure on primary care is driven by increasing complex and long-term care needs of patients and initiatives in health policy to move care from hospitals to the community. In Antwerp, specific areas contain a large number of inhabitants of diverse ethnicity and low socio-economic status. Given that these socioeconomic factors have a large impact on health outcomes, this poses an additional challenge on primary care. The interrelatedness of somatic conditions and psychosocial problems urges for a strong and structural collaboration between welfare and primary care services in these vulnerable neighborhoods. Because GP practices are seen as central hubs for care coordination, the ZIHP project focuses on the support of GP practices in vulnerable areas through the temporarily employment of a social nurse.
 Workshop: We choose for a workshop because we want to explain the functioning of the ZIHP project and subsequently invite professionals to reflect on their own role and act in the uptake of complex care, starting from the goals of the patients. We use casestudies to:
 
 identify the patients problems, viewed from the patients perspective;
 identify the role of each professional;
 identify the added value from each professional in relation to other professionals;
 search for connection and collaboration between the health and welfare sector.
 
 This workshop is relevant for primary care workers (welfare and medical services) and policy makers.
 Workshop details:
 
 20 min intro and presentation with the results of the ZIHP project
 30 min in different small groups – using the ‘Worldcafé methode’ and asking the groups 3 questions:
 
 oWhich problems do you determine in this case?
 oWhat do you expect from each care worker and the patient
 oWhat’s from the patients perspective the most important problem that should be addressed first
 
 10 min: oral summary of take home messages
 
 ofeedback of the most relevant insights of the groups
 osupplemented with insights from the project
 Engage with the audience: We use the ‘Worldcafé method’ which maximizes the exchange between participants. The group is divided into small groups and each group has a host who leads the discussion. After the group has reflected on the first question, the host moves on to the next group, taking the key messages with them, and the group can answer the second question with their own -and the other group's insights. This is repeated for the third question.
 Summarizing the take home messages: The hosts present orally the most relevant insights of the groups, alongside insights of the ZIHP project.