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Table 4 Main facilitators and barriers encountered during the implementation process

From: Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience"

Characteristics of the intervention program

 

Facilitators

Barriers

-The program was tailored to the needs expressed by the region. The emphasis was on care coordination and self-management support for patients.

-The engagement of a program manager in the region provided the opportunity to strengthen the network of care providers in the region.

-The program respected and reinforced the role of primary care in chronic care delivery. When new services were introduced in the region (education program, support program for the initiation of insulin therapy), respect for the role of each discipline and interdisciplinary communication were central points in the way of collaboration.

-The program targeted different components of the CCM. This resulted in a complex intervention. The complexity of the intervention hampered the information campaign and some components of the intervention negatively affected each other.

-The program was not clearly defined at the start of the project. It was the intention to develop the program in collaboration with the region. This led to some confusion about the aims of the project among care providers.

-Some aspects of the program increased the administrative burden on GPs (regional audit, informed consent procedures).

Characteristics of the professionals

 

Facilitators

Barriers

-The project could rely on a group of well trained and motivated care providers from different disciplines to collaborate with the project.

-Specialists from both hospitals were prepared to contribute to the project. They were involved in the decision making process in the region through their representation in the steering group.

-Care providers had no tradition of working with an interdisciplinary care protocol. Neither did they had the tradition to commit to agreements made by their representatives.

-Care providers expressed their fear of losing patients to the education program. GPs feared to lose control over their patients and also feared loss of income. A nurse's' organization considered education as a job for their nurses working in home care.

-The threshold to start insulin therapy was still high among some GPs. Lack of knowledge and fear for hypoglycaemia were the most important barriers.

-Some care providers didn't participate in the social network and were difficult to reach in information campaigns.

Characteristics of the patients

 

Facilitators

Barriers

-Patients who did participate in the education program, expressed their satisfaction with the content of the program.

-Patients who did participate in the education program, considered their GP as the central care provider.

-According to the GPs, some patients were hard to motivate to participate in the education program.

-Motivating patients to participate in the education program required extra time during the consultation.

- According to the GPs, resistance against starting insulin therapy was still high among patients needing insulin therapy. This resistance disappeared usually once insulin therapy was started.

Characteristics of the social context

 

Facilitators

Barriers

-Senior leaders in the region gave their commitment to the project from the start. Their support to the program was visible during the whole study time.

-Care providers were dissatisfied with the current health policy. The fact that the National Institute for Sickness and Disability funded the project retained some care providers from participating in the project.

-Participation in the different components of the program increased gradually. Care providers and patients needed time to trust the new initiatives. This was in contrast with the commissioners who expected results in a short time.

Characteristics of the economic, administrative and organisational context

Facilitators

Barriers

-The government has invested in guideline development. A national guideline on type 2 diabetes was in preparation at the start of the project. The guideline was used to develop the program.

-Clear legal national task profiles were available. These profiles were used as a guide for the development of the interdisciplinary care protocol.

-There was already some degree of regional organization in place: a network of home care providers (representatives of GPs, nurses and home care) and the professional organizations (GPs, nurses, pharmacists)

-At the start of the project figures about the quality of diabetes care in the region were not available. As a consequence a regional audit was organised although this was not expressed as a priority by the region.

-When the project started care providers worked in relative isolation. It was not clear who was involved in diabetes care in the region. There was no central registration point for care providers.

-The organizational structures present in the region at the start of the project had only limited authority and lacked adequate financial support.

-Most GPs had no support staff in practice.

-The continuation of the program was unsure. The commissioners hesitated to extend funding after the study period. This uncertainty negatively influenced the participation of the region and was a constant point of concern in the local steering group during the last year of the study.

Characteristics of the implementation method

 

Facilitators

Barriers

-Senior leaders were involved in the project from the start. Their support was made visible through their participation in the local steering group.

-The existing network of care providers was used and strengthened.

-The program was the result of a consultative process in the region and targeted the needs expressed by the region.

-Priorities for change were formulated in consultation with the study groups.

-The engagement of a program manager facilitated the implementation of the program in the region.

-An information campaign was designed addressing care providers and patients on a regular basis.

-The information campaign at the start of the project was experienced as confusing. This was partly because of the strategy of involving the region in the development of the program, partly because the program included different components.

-The program targeted different components of the CCM. As a consequence too many priorities were formulated.

-There was no tradition of asking care providers for official commitment to agreements made in the region. The project decided not to break with this principle.

-The scientific evaluation of the study was time consuming and interfered with the daily work in the region.