چکیده (انگلیسی):

Background:Even though previous research has demonstrated improved outcomes of integrated care initiatives, it
is not clear why and when integrated care works. This study aims to contribute to filling this knowledge gap by
examining the implementation of integrated care for type 2 diabetes by two Dutch care groups.
Methods:An embedded single case study was conducted including 26 interviews with management staff, care
purchasers and health professionals. The Context + Mechanism = Outcome Model was used to study the relationship
between context factors, mechanisms and outcomes. Dutch integrated care involves care groups, bundled payments,
patient involvement, health professional cooperation and task substitution, evidence-based care protocols and a shared
clinical information system. Community involvement is not (yet) part of Dutch integrated care.
Results:Barriers to the implementation of integrated care included insufficient integration between the patient
databases, decreased earnings for some health professionals, patients’ insufficient medical and policy-making expertise,
resistance by general practitioner assistants due to perceived competition, too much care provided by practice nurses
instead of general practitioners and the funding system incentivising the provision of care exactly as described in the
care protocols. Facilitators included performance monitoring via the care chain information system, increased earnings
for some health professionals, increased focus on self-management, innovators in primary and secondary care, diabetes
nurses acting as integrators and financial incentives for guideline adherence. Economic and political context and health
IT-related barriers were discussed as the most problematic areas of integrated care implementation. The implementation
of integrated care led to improved communication and cooperation but also to insufficient and unnecessary care
provision and deteriorated preconditions for person-centred care.
Conclusions:Dutch integrated diabetes care is still a work in progress, in the academic and the practice setting.
This makes it difficult to establish whether overall quality of care has improved. Future efforts should focus on areas
that this study found to be problematic or to not have received enough attention yet. Increased efforts are needed to
improve the interoperability of the patient databases and to keep the negative consequences of the bundled payment
system in check. Moreover, patient and community involvement should be incorporated.