In-country activities
Piloting an Integrated Care Model for the Elderly Diabetic Patients
Merita Stavileci Mustaf, Embassy of Switzerland, Swiss Cooperation Office in Kosovo
The Accessible Quality Healthcare (AQH) project in Kosovo funded
by the Swiss Agency for Development and Cooperation (SDC) and
implemented by the Swiss TPH and Save the Children. AQH project supports
the implementation of health reform with a focus on Primary Health Care
(PHC) and non-communicable diseases, in 12 municipalities of Kosovo.
The aim of the project is 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.
The AQH project in collaboration with an international
expert aims to develop an integrated care model in the municipality of
Fushe Kosova as a pilot. The evaluation will take place once the
implementation of the integrated care model in the pilot municipality is
implemented for the possibility to expand in other municipalities. 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. The provision of services for
health and social welfare are not fully integrated, even though the
current infrastructure allows for good collaboration of these two
sectors considering that municipal authority is composed of health and
social welfare.
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. The chair
of the WG-Dr. Osman Maxhera as well as the participants of the WG has
showed great commitment towards this intervention considering that the
integrated primary health care services are being piloted for the first
time in Kosovo.
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. The finding of the Municipal
Profile generated valuable data but not very reliable due to
non-functional Health Information System (HIS) in Kosovo. Based on data
from Primary Healthcare facilities in municipality of Fushe Kosova, the
approximate number of patients 65 years old and over with Diabetes
Mellitus type 2 in is 235.
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.
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.
