Piloting an Integrated Care Model for the Elderly Diabetic Patients

Introduction : The Accessible Quality Healthcare AQH project in Kosovo funded by the Swiss Agency for Development and Cooperation SDC aims to improve the health status of the Kosovar population through strengthening healthcare providers and managers to meet the needs of the patients, and making patients more aware of their rights. In addition to poor quality of health services and the lack of appropriate responses to client demands, services are not well integrated and inter-sectoral collaboration between health, social welfare, education, and civil society is limited. The AQH project in collaboration with an international expert aims to develop an integrated care model in one pilot municipality. Contrary to other countries, Kosovo has a very young population, hence services for older people are not a high priority. Therefore, this intervention aims to concentrate on integrated services for older people. The diagnosis of Diabetes type 2 is used as an entry point for a more holistic organization of services, including the introduction of a geriatric needs assessment to strengthen the collaboration between health, social and community services. Methodology and Discussion : A participatory approach based on action research principles ensures that the model addresses the needs of patients, providers and policymakers. The iterative process, combining literature reviews, primary and secondary data collection, analysis and feedback sessions, allows for contextualization of international evidence according to the data and feedback collected during workshops. For this purpose,a multi-sectoral working group WG at the municipal level was established with representatives from health, social services, education and local NGOs, including the Association of Retired People. A first workshop introduced the principles and key elements of integrated care and defined the target group for the intervention. A rapid review of the international literature synthesized existing evidence on integrated diabetes care for older people, and formed the basis for the draft model. Following, WG members wrote the Municipality Profile, which informed the contextualization and feasibility of the integrated care model. In a second workshop the draft for the integrated diabetes care model was presented, and the notion of a geriatric needs assessment GNA as a tool to support integrated care planning across sectors introduced. Taking into account local resources, population needs and feedback from the WG, the next steps are to develop and roll-out education and training programmes on various topics, and use the GNA to collect missing data. Conclusion : The regular involvement of the multi-sectoral WG is a huge asset which ensures that there is a clear commitment to integrated care and the development of the pilot model. While the international expert brings the experience and evidence to the project, the WG ensures feasibility, sustainability and commitment to change.  Early on it was realized that the timeframe for piloting the model needed readjustment due to limited data. By Mid-2018, the analysis of the baseline data from the GNA, the education and training programmes and the development of integrated patient pathways will be available for discussion.