/ policy vision
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Table of contents
1
1.1
1.2
2
2.1
2.2
2.3
2.4
2.5
3
3.1
3.1.1
Introduction
Adopting one line for strong primary care
Bending lines into circles
Chapter 1: Why change?
Who or what is Primary Care?
Why reform?
Paradigm shift
Public authorities in one line
Policy phase already undertaken
Chapter 2: What do we change?
The person with a care and support need at the centre
Control in their own hands
3.1.1.1
3.1.1.2
3.1.1.3
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
3.1.7
3.1.8
3.1.9
3.1.10
3.1.11
3.1.12
3.1.13
3.1.14
3.1.15
Integrated approach
Self-management
Health skills and empowerment
Informal care
Framing care and support aims
The informal caregiver is a fully-fledged partner in care
Primary care players also have a role in prevention
Signposts in care
More care in the neighbourhood
Local social policy
The care providers in primary care
The residential care players are structurally part of primary care
Family care
Residential care centre
Social work services
More mental health care in primary care
Complex care
3.1.15.1
3.1.15.2
3.1.15.3
3.1.15.4
3.1.15.5
3.2
3.2.1
3.2.2
3.2.3
3.3
3.3.1
3.3.2
3.3.3
3.3.4
16
16
16
18
18
18
20
21
22
23
23
26
27
27
28
29
31
Complex Care: good digital registration and collaboration
Complex care: the multidisciplinary care team and care coordination
Complex care: case management in action
Primary care opts for digital care coordination
Primary care is the requesting party for good coordination with the hospitals
31
33
34
37
38
Support of the care providers
Primary care area
The regional care area (at regional-urban care region level)
The Flemish level: From Partnership Platform to a Flemish Institute for Primary Care
Preconditions
Initial training and on-going training
Care capacity in primary care
Support of primary care practice forms
Funding of primary care
40
40
44
46
48
48
49
50
53
3.3.4.1
3.3.4.2
3.3.4.3
3.3.5
3.3.6
3.3.7
4
4
5
8
8
9
11
12
12
16
16
16
Funding from the federal government
Funding from the Government of Flanders
Communicating budgets in closed barrels
A digital primary care
Innovation and entrepreneurship
Quality policy
53
56
56
57
58
60
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4
4.1
4.2
4.3
5
CHAPTER 3. Transition
Preparing regulations
Reallocation of staff and resources
Sharing ownership of the reorganisation
Summary
62
62
63
64
65
6
6.1
6.2
Appendices
Lexicon
Division of power Flemish - federal government
71
71
76
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1
1.1
Introduction
ADOPTING ONE LINE FOR STRONG PRIMARY CARE
In this country, a lot of work has been done by many generations to create a well-founded,
accessible, high-quality and affordable care system.
The Flemish care landscape is still characterised by well-trained, well-intended and hard-working
partners who want to alleviate, with their head, heart and hands, the suffering and needs of our
fellow countrymen and women and, where possible, to prevent it inflicting them. But that takes
place in a fragmented way and from too many different structures. The citizen no longer sees the
wood for the trees and has insufficient grasp of the organisation of hiscare1 and support. The care
providers and care workers, too, see too much of their time consumed by administration and
meetings. It must become simpler, more effective and more transparent, whereby the care seeker
has the maximum control over the organisation of his care.
The Flemish Coalition Agreement 2014-2019 includes a simplification of the primary care structures
and the strengthening of primary care. Over the years, a broad consensus has grown concerning the
necessity for fundamental reforms in primary care in order both to increase the satisfaction of
persons with a care need and their informal caregivers, and to improve the performance of the care
as a whole. Furthermore, a unique historic momentum presents itself in which a reform of the
hospital sector in this country coincides with the implementation of the sixth state reform and, in
particular, with the acquisition of new levers at the level of the Government of Flanders which will
facilitate a better alignment between the healthcare sector and the welfare sector.
The Flemish Coalition Agreement also concurs with the principle that this also implies that the
individual patient/customer must be more involved in decisions concerning his/her own care, that
we recognise him/her as expert in his/her own medical condition or support need.
Together, people with a care need, the healthcare providers and the healthcare practitioners, the
institutes that offer care, the healthcare insurers and the government, must now grasp the
opportunity to implement a broadly supported reform. In mutual respect and in a participatory and
transport process, but in full realisation that we may perhaps never regain such momentum in the
future. This text therefore outlines the evolutions and policy direction for primary care in Flanders
between now and 2025. This will demand a process that must be evaluated at regular intervals and,
if necessary, be adjusted.
In this text we use the term ‘healthcare provider’2 as a collective term for healthcare providers,
healthcare practitioners and services offering care, in compliance with the terminology of the
primary care decree3. The GP will, in the future organisation of primary care, (continue) to play a
1
For the sake of readability, we use the masculine from throughout the text for citizens/care seekers and care providers. Obviously, we mean both male
and female citizens and care providers.
2
When, in the text, the term “professional healthcare provider” or “healthcare provider” is used, we should understand that this means both the healthcare
providers in the healthcare and welfare sectors. Sometimes only the term “healthcare provider” is used, sometimes both terms are used in
conjunction with each other. In the first case, this is to aid readability, in the second to underline the importance of both sectors.
3
Decree of 3 March 2004 concerning primary healthcare and collaboration between the healthcare providers, art. 2:16° healthcare provider: a healthcare
practitioner as intended in 19°, and also an organisation, agency or person that provides professional care or services to users and thus facilitates, enables or
supports primary healthcare, with the exception of the organisation, service or person with a more specialised care provision,
19° healthcare practitioner: a pharmacist, doctor, dietician, physiotherapist, speech therapist, dentist, nurse, midwife or professional practitioner of another
discipline determined by the Government of Flanders, working in primary healthcare, with the exception of a doctor-specialist, including actual or legal entities
who group these in a mono- or multi-disciplinary connection.
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crucial role, although collaboration with other disciplines will be encouraged. Integrated care implies
an integrated approach regarding the person with a care and support need4. A keen sense of
enterprise is reflected in a large variety of independent healthcare providers, services and
organisations with an extensive range of care services. The citizen has complete freedom of choice in
this wide spectrum. That varied care landscape calls for a clear horizon. A clear horizon where the
aim is well-defined as a collective quest by care and support users, healthcare providers, healthcare
insurers and the government. That aim is the best possible quality of life for and autonomy of our
citizen. The citizen must be able to dictate as far a possible that best possible quality of life. Those
who are young and strong doe not lie awake at night thinking of that quality of life because it seems
so self-evident to them, but they must realise that unrelenting risk behaviour can undermine that
quality of life in the future.
Those who are old or in need of care run the risk of a life with limitations, but nevertheless want to
keep control over their care in their own hands. That is why the person with a care or support need is
central in the thinking and actions of everybody who is professionally or in some other way involved
in healthcare and welfare.
1.2
BENDING LINES INTO CIRCLES
The Flemish care landscape with its wealth of players and organisations has thus become confusing
and fragmented. And consequently, the person with a care need may not always know how to keep
control of his care need in his own hands. The healthcare and welfare sectors have for too long
assumed their own compartmentalised organisational system, which allows everything to be neatly
allocated to primary, secondary and tertiary healthcare, or placed in the compartment of healthcare,
or of welfare, each with its own models and procedures. Everybody realises that the boundaries are
blurring and that the position of the person with a care need has irreversibly taken a central position
in the care and support model.
Let us bend the lines into circles in a concentric model. In the plans for future care and welfare
provision, the objectifiable needs of our population must also take a central place in our thinking and
acting. The WHO model positions the informal caregiver, the volunteers and the neighbourhood as
the first protective and supporting skin around the person with a care need, who takes central place.
When care needs become more complex, primary care must be activated. Considering the increasing
care needs of an ageing population, it is of vital important to be able to rely on strong, well
developed primary care. This can relieve the more expensive specialised care and contribute to a
considerable extent to an accessible, effective and high-quality care system for everybody. Wellorganised primary care can also reduce social inequalities in the area of healthcare by optimising the
accessibility of care and assuming a signal function.
4
The term ‘person with a care or support need’ signifies the person as a whole, with needs in the area of welfare, housing, work, mobility, health. In the text,
the term will be shortened and we talk of ‘person with a care need’. This is deemed to cover the complete term.
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It is now time to recognise this model consistently in the policy, and to align our structures with it. In
this way we will be working on simplification, integration and greater efficiency of organisations and
structures.
There is no international travel guide for this collective journey to that new horizon. Those journeys
can vary from country to country and are of course dependent on the nature and structures of the
care and welfare system already in place, and the care culture that has grown there.
The World Health Organisation does, however, give us a number of tips:
 Make sure the journey is participatory and is developed with the stakeholders;
 Impose a mandatory public accountability on the players and organisations concerning the
resources deployed and the quality of care and services provided;
 Confidence cannot grow without transparency in the operation of the organisations and services;
 Watch over integrity and good governance;
 Provide supporting arguments for policy choices and ensure capacity to take decisions based on
sound data, experience and intelligence.
Nobody has ever claimed that planning and undertaking this journey would be easy. Nobody will
applaud spontaneously when we leave familiar things behind. Nevertheless, we have a duty to the
ever-growing group of largely elderly people with a care and support need to undertake this quest
for a new system of collaboration.
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In Flemish primary care, we have a tradition of socially inspired enterprise, both individually and
collectively. We want to acknowledge, stimulate and appreciate the dynamism this generates. We
want to support the innovation that the practical training seeks to achieve during our quest. It is
certainly not our intention to impose collaborative models from above. We do, however, want to
find the right balance between the very important responsibilities of the players in the field and the
role of the government which wants to act in a supportive and effective way, but which can also lay
down the main lines, using the WHO recommendations as a compass.
We should also realise that primary care is a shared area of competence of federal, Flemish and local
authorities. Without mutual collaboration and agreements, it will never work.
Primary care and hospital care are also linked in terms of budget. A shift of activities and volumes
from in-patient care to the home situation also implies a shift of budget from the hospitals to primary
care and vice versa. For example, a shortened stay in the maternity ward will imply higher budget
requirements for maternity care at home, or less in-patient psychiatric care will result in more homecare psychiatric teams.
It will not be easy, but if we all roll up our sleeves and put our backs into this reorganisation, it will
succeed. Thus we will turn fragmented primary care into strong primary care.
You are invited to join us on our journey to convert a number of visions in the near future into
change and achievements that will eventually benefit all the stakeholders, and not least the persons
with care and support needs.
Thank you for your contribution and interest, which is greatly appreciated.
Jo Vandeurzen
Flemish Minister for Welfare, Public Health and Family
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2
Chapter 1: Why change?
A primary care conference calls for a number of agreements on the terminology used in order to
avoid confusion and unnecessary discussion. For this reason, we first present the terminology of
‘primary care’. The motives for embarking on a change process must be clear from the very start for
every participant.
2.1
WHO OR WHAT IS PRIMARY CARE?
Primary care can be defined as follows5:
 Refers to directly accessible, ambulatory, general care for non-specified healthcare or welfare
(related) problems, whether physical, psychological or social in nature;
 Generally represents the first contact with professional care;
 Can offer diagnostic, curative, revalidation and palliative care provision for the large majority of
problems;
 Offers prevention for individuals and risk groups in the indigent population;
 Takes into account the personal and social context of people;
 Ensures continuity of care over time and between care providers;
 Supports the informal care available to the patient/client.
Internationally, much is changing in primary care6. The European office of the World Health
Organisation published, as a sequel to the World Health Rapport ‘Primary Health Care: now more
than ever!’7 , the report ‘Health 2020: European Policy Framework and Strategy for the 21st
century’8, in which primary care is presented as the corner-stone of a modern healthcare policy:
"The primary care must be a cornerstone in every care system in the 21st century. That
remains the focus for Health 2020. How can primary care anticipate the current needs? By
creating a favourable climate for partnerships and by encouraging people to participate in
new ways in their care and to take better care of their own health. Better and more costeffective care is possible by making the best possible use of 21st-century instruments and
innovations, such as communication technology - digital documents, telemedicine / ehealth and social media. Viewing the patients as a partner and a source for input and being able to
give accountability for what it means to the patient: those too are important principles.”
The academic chamber of reflection also states that primary care today must contribute to achieving
the “Quadruple Aim”9. This concept formulates 4 aims for care:
1. improvement of care as it is experienced by the individual;
5
SAR WGG, Primary Care Reflection Memorandum. Contribution in response to the Flemish conference on Primary Healthcare, 4 November 2010,
p. 6-7.
6
Verlinde, C., De Maeseneer, J. et.al., The reform of primary care in Flanders: we’re working on it together! Abstract of the academic chamber of
reflection for the Primary Healthcare Conference of 16 February 2017. 10 January 2017 https://www.zorg-en-gezondheid.be/conferentiereorganisatie-van-de-eerstelijnszorg-in-vlaanderen
7
Anonymous. Primary Health Care: now more than ever ! Available via : http://www.who.int/whr/2008/en/
8 Anonymous. Health 2020 : European Policy Framework and Strategy for the 21st Century. Available via:
http://www.euro.who.int/en/publications/policy-documents/health-2020.-a-european-policy-framework-and-strategy-for-the-21stcentury-2013b
9
Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2004 ;12:573-576.
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2. improvement of health at population level with special attention to accessibility and social justice;
3. achieving added ‘value’ for the patient in the area of health with the resources deployed;
4. ensuring that professionals in healthcare are able to do their work in a good and sustainable
manner.
The care providers that are active in primary care in the healthcare sector include: pharmacists,
dieticians, general practitioners, physiotherapists, psychologists, dentists, speech therapists, (home
care) nurses, midwives, care specialists, occupational therapists, podologists, carers, social workers
(list not exhaustive)10.
We consider the following players in primary care in the welfare sector to be indispensable: the
residential care players (services for family care and additional residential care, services for logistic
help, services for minders, services for home care [recognition], social welfare services of the health
insurance fund, local service centres, services for foster care, day care centres, convalescent centres,
centres for short stay, groups of assisted dwellings, residential centres and associations for users and
informal caregivers), centres for general welfare (CAW) and public centres for social welfare
(OCMW), community work and associations where the poor have their say. Naturally, the youth
services and the persons with a disability (VAPH) sector, as well as the Child and Family Agency
(K&G), play an important role in primary care. They are part of the policy council that meets monthly
with the Flemish Minister for Welfare, Health and Family, where coordination and policy orientation
are discussed.
2.2
WHY REFORM?
The challenges that make a change process necessary are described below and are based on the
abstract11 from the academic chamber of reflection, which has assisted in the preparation process for
this conference:

Demographic and epidemiological developments: we are getting older (in 2016, the average life
expectancy for men was 84.6 years and for women 89.1 years). The prevalence of cancer is
increasing, as a consequence of this ageing. Partly thanks to improved therapy, cancer is
becoming a chronic disease. There is an increase in chronic conditions, with a particular rise of
‘multi-morbidity’ (having several chronic conditions): recent research shows12 that half of those
older than 75 have two or more chronic conditions, while two in every five people older than 75
have four or more chronic conditions. Care processes that focus on one condition are not
sufficient here. In order to care properly for the patient, there is a need for a paradigm shift from
illness-oriented care to care that takes the aims and preferences of the patient as its starting
point13. This means an important role for primary care in avoiding the fragmentation of
healthcare. Primary care must, with the citizen and patient, adopt the role as ‘integrator’ of the
care. The increase in numbers of vulnerable people sets new demands for quality and interprofessional collaboration.
10
EXPH (EXpert Panel on effective ways of investing in Health), Report on Definition of a frame of reference in relation to primary care with a special emphasis
on financing systems and referral systems, 10 July 2014
11‘The reform of primary care in Flanders: we’re working on it together!’ Abstract from the academic chamber of reflection for the Primary
Healthcare Conference of 16 February 2017, 10 January 2017, Brussels.
12 Barnett K, Mercer SW, Norbury M et al. Epidemiology of multi-morbidity and implications for healthcare, research, and medical education: a
cross-sectional study. The Lancet 2012;380:37-43. doi:10.1016/s0140-6736.
13
Boeckxstaens P. Multimorbidity: a quantitative and qualitative exploration in primary care. Ghent, General Practice and Primary Healthcare
department. Ghent University, 2014.ISBN: 9789491125089.
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
A second challenge is formed by scientific and technological developments and their implications
for the affordability of healthcare. Scientific progress offers the perspective of new preventive
and curative possibilities in the area of genetics, cardiovascular disease, neuroscience, cancer
care and mental health care. It is no longer possible to imagine daily practice in healthcare
without IT and communications technology. The stay in hospital is becoming ever shorter, and
hospitals are seeing an increase in out-patient admissions. More technology is finding its way
into home care. A clear vision must be developed concerning this and adequate strategies for
dealing with it. Primary care has a role in translating new insights into the approach to health
problems, and this with attention for the ‘relevance’ of the care and avoidance of medicalisation
of daily life. Many of these new technologies and pharmaceuticals have an important impact on
the healthcare budget, which implies responsible scientific and social choices.

Globalisation and social-cultural developments imply that diversity in society is increasing and
that people now look internationally for solutions to their health problems. This means that care
providers must have a broader spectrum of forms of interaction if they are to approach every
person with a care demand appropriately. With higher education and increasing accessibility of
medical information via the internet, some ‘patients’ are evolving more and more into ‘critical
consumers’. They are well-informed and expect to enter into a dialogue with the care providers,
to assess options together and to reach decisions that best suit their lives. People who belong to
ethnic-cultural minorities bring considerable diversity to care situations, and we must deal
appropriately with this. The changing social context (more people are working longer and seeking
a new work/life balance) has an important impact on informal care (decline in the availability of
volunteers, informal care, etc.). There is also a clear change in opinions on quality care at the end
of life.

The existential aspect of being human is growing in importance. In addition to the physical and
psychological problems with which people are confronted, each of us also wants to invest in
quality and significance of life and add meaning to the activities in which we are engaged14.
People present themselves (in care) differently, are more assertive and are increasingly aware of
the role they must and want to play - also at an existential level. Control of the care takes the
individual’s right of self-determination and living situation as its starting-point, and these indicate
aspects of care and welfare.

In the social-economic area, there are major health differences between countries, but also
within social groups in a specific country: “poverty makes you ill and illness makes you poor”
remains a reality. There is a social health gap in our country. The financial and economic crisis
has also had an effect on social inequality in the area of health. Primary care offers opportunities
in the area of accessibility of care, and has a strong signalling function for recognising, together
with other sectors, the ‘social determinants’ of health (living and work situation, education,
social cohesion, etc.) and proposing corrective measures.
Social-economic factors, such as unemployment, being single, having a lower level of education
and a low income, increase the risk of mental disorder, depression and suicide. At the same time,
factors such as unemployment, poverty and loneliness are also often the result of depression or
other mental problems. The KANS study by the Support Centre WVG15 showed a strong
relationship between the severity of depressive feelings and the financial problems among users
of primary healthcare facilities in Flanders (CAW, social work agencies of the health insurance
funds and OCMW).
14
Thomas A et al (1999). Population-based study of social and productive activities as predictors of survival among elderly Americans. BMJ
319,478-483.
15
DeSmet et al, 2010, https://steunpuntwvg.be/publicaties/rapporten/publicaties-nieuw#KANS
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In addition to the conclusions and evolutions that science offers as important reasons why a reform
is imperative, we would again like to stress the opportunity offered by both the sixth state reform
through a shift of several important powers to the regions, and also the observation that at this same
time a reform of the hospital landscape is presenting itself.
This has already been referred to in the introduction. This momentum is a unique historic
opportunity for a fundamental reform for which we must today lay out the roadmap.
2.3
PARADIGM SHIFT
In order to address these challenges, a paradigm shift is necessary in the policy around the
organisation of care, from supply-directed to demand-directed care. In order to be able to offer
people-centred and integrated healthcare services, the World Health Organisation proposes five
strategies16.
1.
2.
3.
4.
5.
Empowerment and involving persons with a care need;
Clear direction and accountability;
Reorientation of the care model;
Care provision oriented to the needs of persons;
Making it possible to bring together diverse stakeholders in order to realise the reform.
This paradigm shift does not only apply to the level of policy implementation, but also to that of the
help and care providers in the field. The strategic Advisory Council for Welfare, Health and Family 17
“Integrated care and support takes as its starting-point the needs, demands and aims of the
person with care needs (and his immediate circle). Striving for a good quality of life for and by
every citizen must be the ultimate ambition of integrated care and support.
It is essential that professional (care and support) systems only come into action when they are
needed and only there where they are needed. In a caring society, professional care is not the
solution for everything, but acts rather as support and supplement to the social network and
people’s own ability. Integrated care and support focuses strongly on preventive action and on
mobilising cohesive forces in society.
This integrated care and support can only be achieved by strengthening accessible primary care
across the sectors and policy areas. The discussion on the organisational preconditions and the
inter-sectoral deployment of resources must not be confused with the aim of an integrated
approach: the best possible alignment of care and support with the demands and needs of
citizens who, temporarily or permanently, find themselves in a vulnerable situation. "
Everybody realises that no single individual care provider is in a position to cover on its own the
complexity of care and support and that collaboration has become a conditio sine qua non for
providing efficient and effective care. This is reflected in multi-disciplinary collaboration: care
providers look over the wall of their practice or facility and, together, adjust the care to the needs of
the person with a care need.
16
WHO, WHO global strategy on people-centred and integrated health services. Interim report, 2015
17
SARWGG, Vision memo Integrated care and support in Flanders. 7 December 2012
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2.4
PUBLIC AUTHORITIES IN ONE LINE
In Belgium and Flanders, the responsibilities concerning primary care are, as mentioned earlier,
dispersed over three levels: the federal level, the level of the Government of Flanders (community)
and the local administration level (cf. appendix power distribution Flemish-federal).
This means that they must coordinate the policy together, in order to make it transparent for the
care players and for the citizen, and to avoid counter-productive or contradictory policy measures.
Ideally, a synergy will arise through good coordination of the policy measures at various public
authority levels. The federal government and the Government of Flanders can also use the InterMinisterial Conference on Public Health as a forum where the ministers involved can lend each other
insight into policy intentions, but can also reach agreements that translate into consensus strategies,
protocol agreements or cooperation partnerships if a common legal basis appears necessary (e.g.
ehealth). Since 2009, 33 protocol agreements, 18 amendments and 12 joint statements have been
approved. Joint action plans, such as the eGezondheid plan18, the plan for chronic illnesses, the
protocol agreement on prevention and the guide concerning the reform of mental health care,
BelRAI, hospital reform, hospital emergency planning, etc., were approved in the past 2 years by
inter-ministerial conferences. In Flanders, we ensure in this way that Flemish and federal initiatives
complement each other to the maximum.
Consultation with the federal government is also appropriate, to ensure that the powers resting with
it after the Sixth State Reform in the area of care provision (reimbursement of the primary care
providers and the prescribed pharmaceuticals), the performance of health professions and the
continuity of care (standby duty, out-of-hours surgery) are in line with the organisation and support of
primary care in Flanders.
The sixth state reform has also provided the possibility of developing an Institute for the Future. Such
an institute could give the policy makers a strong foundation for taking decisions that are relevant to
both government levels.
The autonomy of local authorities and recognition of their management role in primary care call for
sound agreements between the Government of Flanders level and the representative of the local
authorities, the Flemish Association of Cities and Municipalities (VVSG). Currently, this consultation is
too often ad hoc.
A structural dialogue between the various public authorities and primary care is important. That is why
they will have a place in the future Institute for Primary Care (see later).
2.5
POLICY PHASE ALREADY UNDERTAKEN
In the run-up to, during and after the previous conference for primary care in 2010, thought was
given to a better operation and less fragmentation of that primary care. The aims of that conference
were:
 To improve the quality of primary healthcare through better and more professional collaboration
between the various care providers;
 A better guarantee of the quality of life and work of the care providers by supporting and
facilitating collaboration and by organising them in such a way that the administrative burden is
18
http://www.plan-egezondheid.be/
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reduced for all involved.
Following the example of this conference, considerable emphasis was placed on the development of
ICT support for the primary care. Vitalink was set up, and the project éénlijn.be for the support of
primary care in the use of ICT was started. Projects for primary care in the psychological field were
also initiated. A ‘Care Ambassador’ was appointed to tackle the problem of capacity in care. The
Collaboration Platform for Primary Care was set up. Thought was given to multi-disciplinary
collaborations at practice level, and there is a growing awareness that the supportive, so-called
meso-level needs restructuring.
On 7 December 2013, an interim symposium was held on primary healthcare, reviewing the state of
affairs regarding the relevant policy.
The Sixth State Reform offers the possibility and opportunity to think carefully about the
reorganisation of primary care, both in structure and content. In the Coalition Agreement of the
Government of Flanders and the policy memorandum 2014-2019 the following was therefore stated:
“The Government of Flanders is convinced that expanding and strengthening primary
healthcare, certainly in light of the growing need for good chronic care, continuity of care,
elderly care and mental health care, is crucial. We want to use the strengths of our care
services, with their diversity of forms in which front-line care providers are active, as the
starting-point.
This also implies that the individual patient/customer must be involved in the decisions
involving his or her care and that we also recognise him or her as an expert in his or her
condition or need for support. To reinforce this we will develop a charter that clearly defines
the customer/patient’s (collective) rights.
Various primary care network structures are currently in operation. In consultation with the
stakeholders we will work on an operational plan to strengthen, align, simplify and integrate
primary care structures. The sixth state reform creates the momentum for this challenge with
the transfer of the support of the health professions in primary care and the organisation of
primary health care (out-of-hours surgeries, Local Multidisciplinary Networks, Integrated
Service Home Care, the palliative networks and the palliative multi-disciplinary teams).”
The change process must correspond with other current reforms, or those that are yet to be
initiated, namely: development of Flemish Social Protection, development of a new organisational
and financing model for elderly care, implementation of person-linked financing for persons with a
disability, integration of the new powers, the new action plan concerning mental health care,
broadening of the concept of care-strategic planning (currently limited to hospitals) and the reform
process around social work. Thus the Coalition Agreement states:
We will transform our health landscape into a care system that better reflects the needs of
citizens and that allows it to better respond to (changing) care demands. We will do this by
expanding the scope of strategic care planning for hospitals as an instrument for
development (redevelopment). Obtaining a planning permit or approval will shift from an
institution’s individually enforceable right to a process that is subject to collective
responsibility. In this context, we will encourage the development of new/alternative forms of
care (care hotels, rest homes, rehabilitation stays, etc.)
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Due to a wave of mergers in recent decades the average Flemish hospital is characterised by
significant redeployment. A framework must be created that slows down the further
duplication and unnecessary diffusion of high-tech and highly specialised services. The
concentration of complex pathology with a clear link between volume and outcome must be
encouraged and monitored using (outcome) indicators. We will strive for networks in which
cooperation between hospitals is encouraged on the one hand and horizontal networks with
partners in the region involved in care and welfare are encouraged on the other. Integrated
care will only be achieved if hospitals, general practitioners and also the ‘residential care’
partners in primary care involve themselves in a horizontal care continuum or ‘horizontal’
network.
We will work on a new organisational and funding model for (residential) care for the elderly
and thus encourage the development of innovative models. The new powers related to price
control will also be embedded in this new approach. Before applying radical changes to
existing financing systems, we will test concepts of person-linked financing in elderly care. We
will study the possibilities of reconverting residential capacity and available previous permits
to other suitable care forms.”
A preparatory process was started at the end of 2016 around the future of social work, and will
culminate in a conference in the autumn of 2018. Seven working groups were put together. These
working groups each have social workers employed in various sectors: primary care, youth care,
socially weaker persons with a disability, justice, work and integration. Using their wide range of
perspectives and expertise, they jointly formulate proposals around five themes: fundamental rights,
emancipation versus disciplining, the purpose of social work in networks, individual support versus
structural operation, diversity in society. Considering the important task of social work in primary
care, we will follow this reform closely.
Integrated care must be achieved across the professional areas. That is why coordination must also
be sought with the federal initiatives around the new hospital networks, the reform of hospital
financing and the revision of RD 78 concerning the care providers.
The federal government and the federated states will also work together to further develop the
mutual plan for integrated care for the chronically ill. In implementation of action line 1 of this
mutual plan, a maximum of 10 pilot projects will be launched in Flanders. These projects will develop
further the various components of integrated care. ‘The aim of the pilot projects in the Plan
“Integrated care for better health” is to test and develop integrated care for chronic patients within a
geographically prescribed region with respect for the Triple Aim thinking and with attention for the
equity principle and the life quality of the healthcare professionals.’19
To ensure that the proposed reform of primary care in Flanders is tackled with broad support, 6
working groups have been set up in preparation for this conference. Each working group had a
balanced representation of, among others, players in primary care organisations and provisions,
professional groups, experts from the sector, users, etc. Each working group was given a number of
objectives which are briefly explained below, and, during various work sessions, they formulated
answers to the questions posed:

19
Working group 1 - Task and structural integration (led by Roel Van Giel)
GUIDE Pilot projects Integrated care for the chronically ill. Via http://www.integreo.be/sites/default/files/public/content/gidspp.pdf
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The allocation of clearly defined functions and tasks necessary for achieving an integrated care
approach at the levels that support the practical implementation level and drawing up a proposal
for a support structure (or structures), based on the proposal from the ‘task’ exercise.

Working group 2 - Geographic definition of the care regions (led by Joris Voets)
Drawing up a proposal for care regions based on the results of working group 1.

Working group 3 - Models for integrated care (led by Ilse Weeghmans)
Developing further a Flemish model of integrated care, based on existing models, with an eye to
coordination with the federal process of integrated care for the chronically ill.

Working group 4 - The patient/citizen at the centre (led by Guy Tegenbos)
Developing a vision and scenario to give a leading role to the citizen and the person with a care
need in integrated care, in all aspects of that care in which that person must be involved.

Working group 5 - Data sharing and quality of care (led by Dirk Ramaekers)
Developing a model for evaluating the quality of care within an integrated care approach.

Working group 6 - Innovation and entrepreneurship in care (led by Johan Hellings)
Achieving solutions for rolling out those innovative and innovation projects in care that have
been positively assessed.
Each working group drew up a final report. The essential ideas from these final reports were bundled
in an abstract. This abstract contributed to the basis for developing this policy text.
The complete process is supported by a steering committee. The members of this committee were
the chairs of the working groups, various members of the Minister's Office and the Care and Health
Agency and the external process supervision that had been awarded to Möbius. In addition, input
was also requested from academics from various disciplines, who met and entered into a dialogue
with each other and with the Minister in an ‘Academic Chamber of Reflection’ (composition as
appendix).
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3
Chapter 2: What do we change?
3.1
THE PERSON WITH A CARE AND SUPPORT NEED AT THE CENTRE
3.1.1
Control in their own hands
3.1.1.1
Integrated approach
Each person is entitled to care and support that allows the best possible quality of life. Every person
also has a responsibility to avoid recognised risk factors in the area of health and welfare as far as
possible or to reduce them. Helping people achieve the best possible quality of life they personally
desire is the ultimate aim of our care and support. To achieve this goal, an integrated approach is
necessary. Care and support in which lines, levels and sectors are subordinate to this aim and
whereby care is offered in an integrated way. Care in which the person takes the central position and
where the care providers, together with the person, map out the path to the best possible and
attainable quality of life and help him achieve it. The term ‘help him achieve it’ is very important
here. It suggests that the autonomy of the person is the starting point and the role of director is
assumed by the person concerned, or his informal caregiver. For the time being, the care
coordination will also be assumed by the person or his informal caregiver.
3.1.1.2
Self-management
We call the assumption of control by the person himself self-management. The care process that is
built up always take this self-management into account. If autonomy and willingness for autonomy
are present, this self-management is not in question. If the person shows reduced autonomy to
assume the role, the care process gives priority to regenerating that autonomy. The control can
temporarily be assumed by somebody chosen by the person with a care need, such as the informal
caregiver, or, if that is not possible, by a professional care provider. In an advanced stage of certain
conditions or in complex situations, care coordination may be needed in additional to the role of
control. The care coordination will then, for the time being, be assumed by the informal caregiver. If
that is not possible, the care coordination can be assumed by a professional care provider, always as
chosen by the person with a care need.
3.1.1.3
Health skills and empowerment
How can we guarantee that each person can assume control when a care need arises? That is a
process that must start from an early age. We are talking about a process of health literacy, or health
skills. The European Commission defines health literacy as follows:
“the degree to which people have the ability to obtain, process and understand fundamental
services and information in the area of health, so that they can take decisions to the benefit of
their health”.
The knowledge, skills and attitudes that a citizen needs to approach care with the necessary
confidence and control can be provided through health literacy education. The acquisition of health
skills has two main areas:
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1. Making available reliable and understandable information.
Various players have a role in this: the government, knowledge and education institutes, care
providers and insurers20, patient associations (i.e. prevention of illness), etc. Digitisation can play
a major role here. For example, by entering reliable data in the electronic patient file, the person
with a care need can obtain (scientifically founded) information. Or the person with a care need
can be informed about patient associations, activities etc. in his area.
2. Acquiring basic knowledge and learning skills in order to adopt a specific behaviour.
This is very loosely defined and includes, for example: the ability to read a medication leaflet,
knowing where to find reliable information and how to check it, knowing which service provider
you can approach for which care issue, etc. The Academic Chamber of Reflection states in its
abstract that people with better health literacy arrive at the right care place faster if the right
care question is asked. Investing in health skills is a social task and is a process that can best start
as early as possible. This therefore forms an extremely important challenge for all care players,
but also for the education system.
Good health skills give the person with a care need the possibility of better coordinating his own care
and becoming a fully-fledged partner in care. However, he may sometimes require coaching and
encouragement (empowerment or self-encouragement). This is certainly the case if the person with
a care need can continue to play an active role in his own care process when he is in a situation of
care dependency.
The process of empowerment contains the core elements of autonomy, support, acceptance and
improvement of the living situation21 and is primarily directed at increasing control over one’s own
life and promoting the capacities to undertake independent action and thus raise the quality of life.
Imparting knowledge and information on the condition(s) and the course of the illness, providing
insight into the social and personal functioning, providing insight into support possibilities etc., help
the person with a care need to take decisions in his care himself and is thus a task for every care
provider. But patient associations can also help here: via information sessions, contact with fellow
sufferers, awareness campaigns etc.
Gaining insight into one’s own care and support plan and being able to register and share personal
data are important elements in the process of empowerment. In this way, the personal expertise and
the mental and social functioning of a person with a care need can be exchanged with the care
providers. But also the scientific evidence that care providers have at their disposal can be made
available to the person with a care need via the electronic file.
In addition, it is important that the care provider considers the person with a care need as an equal
partner in the care process. But even then, the person with a care need must be behind the wheel as
much as possible. Several decision and support aids already exist at the moment. These can be
developed further.
20
The insurance institutes have an explicit assignment in this, described on page 10 of the federal pact of insurance institutes. This pact also
points out the interlinkage of powers in this with the federated states. Policy unit Minister of Public Health and Social Affairs (2016,
September). NISDI: http://www.inami.fgov.be/SiteCollectionDocuments/toekomstpact_verzekeringsinstellingen.pdf
21
(2012) Flemish Patient Forum, symposium of patient empowerment. via
http://vlaamspatientenplatform.be/nieuwsbrieven/item/denkdag-patient-empowerment
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Lastly, care providers must be familiar with the core elements of empowerment so that they can
assist the person with a care need at all times. It should thus also be included in the initial and
continuous training of the care providers.
3.1.2
Informal care
Informal care is all care and support that is offered by non-professionals. Informal care assumes a
special and important place in this, next to occasional care and support offered by volunteers. As
more people express the wish to continue to live at home, even when they have a complex care
need, the care provided by family members, friends, neighbours and volunteers assumes an
increasingly important place. If the person with the care need cannot assume control, the informal
caregiver is the next party to which control should be allocated. These informal caregivers do not
only assume many practical aspects in the care process and, where necessary, take over the
coordination of the care, but are also of inestimable value in the health-economic and psychological
area. After all, they support the person with a care need both mentally and socially. But like everyone
else, informal caregivers also occasionally reach their limits. To keep their daily care bearable, we are
working on a support policy that will allow them to continue lending this care for as long as possible.
The informal care holds a position in the care process that is on a par with the professional care
providers. The professional care providers must acknowledge, respect and actively involve the
informal caregivers in every action that is taken around the person with the care need.
3.1.3
Framing care and support aims
Persons with a complex and chronic care need formulate, in consultation with the care coordinator
(see later), the care and support aims22 - in the text, we refer to them from here on as “care aims”.
These are attached to the analysis that has already been made of the life aims and wishes of the
person with care needs. The care aims thus indicate what the desired quality of life is for this person
and are, as far as possible, formulated as SMART aims and translated into specific actions and deeds
that have a place in a care and support plan. For the realisation of the care aims, the person (or his
informal caregiver) chooses his formal and informal care providers who are involved in this.
Action: the Flemish Patients Platform is developing a user-friendly, accessible and robust instrument
that enables people with a chronic condition/complex care need to help formulate life aims.
3.1.4
The informal caregiver is a fully-fledged partner in care
Fully involving informal caregivers as partners in care services, as well as supporting informal
caregivers, is the duty of all the care providers involved. The informal caregiver becomes a partner in
the care and support plan and participates, on condition that the person with a care need agrees to
this. In addition, professional care providers are being encouraged to involve informal caregivers and
to respect their role in the care process and, where necessary, in care coordination. The Informal
Care Plan and “the resolution of the Flemish Parliament concerning the improvement of the support
of informal caregivers”, as adopted by the Flemish Parliament on 1 February 2017 focus strongly on
this. It should be stated here that few people are prepared for their role as informal caregiver.
22
The plan ‘Integrated care for a better health’ (IMC 19 October 2015) used the following description: “Further, a person with a chronic
condition has needs that are not purely medical (diagnostic, structured and evidence-based treatment, combating symptoms, managing
pain, avoiding complications), but also psychological (need for information, emotional support), social (help in day-to-day life, integration
into society) and spiritual in nature. (…) Our healthcare system must be able to satisfy these different needs. This demands a paradigm shift
from illness-oriented care to care that takes the aims and preferences of the patient as its starting point.”
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Providing essential knowledge of the care process and of the range of care forms available is
important, as too is providing information on the conditions (e.g. dementia, diabetes, autism, etc.)
and offering practical tips on how to deal with them.
For many informal caregivers, offering informal care is an enriching experience. The vast majority of
informal caregivers experience providing care as fruitful and would, in the same situation, provide
informal care again. But informal care can also prove a burden and have consequences for the quality
of life. It is thus essential to retain the balance between capacity and burden.
Focusing on this is a social choice that is achieved across and through the policy areas and policy
levels. The informal care plan implements this. The main lines of the informal care plan are:




Social recognition and appreciation of informal caregivers;
Supporting informal caregivers;
Collaboration between informal caregivers and professional care;
Specific attention for the young informal caregiver;
The plan is based on a broad definition of informal care. There is no ideal informal caregiver. Many
informal caregivers work together in an informal care network. Support must then be customised.
We pay particular attention to vulnerable groups, such as the elderly informal caregiver, informal
caregivers with a migrant background, care for people with mental health problems and
underprivileged informal caregivers.
The commitment of the informal caregiver in the care process demands the commitment and
consent of the person with a care need.
Providing information is an essential point in the support of informal caregivers. We are working with
the associations involved on a Flemish expertise point for informal care where all information that
concerns informal caregivers is provided in an accessible and primarily digital manner. This expertise
point will be integrated into the operations of the Flemish Institute for Primary Care, as described
later in the memorandum. It is also important that informal caregivers can find answers to their
questions and needs locally. As described later in the memorandum, this local point of contact will be
embedded in the assignments of an integrated, broad and recognisable service that will include an
accessible, local reception function.
A diverse group of informal caregivers demands a diverse range of support possibilities. Persons with
a care need can also support their informal caregiver through the healthcare insurance. A welldeveloped professional range of care services and attention for neighbourhood-driven support
should provide informal caregivers with sufficient time for themselves.
The majority of informal caregivers are still of an occupationally active age. The combination of work,
family and informal care is not always easy and demands the necessary attention.
The relationship between the informal caregivers and the professional care has a double perspective.
On the one hand we want the informal caregivers to be considered as fully-fledged care partners
within a well-coordinated care plan, and on the other we expect that professional care also has an
eye for the possible needs and support of the informal caregivers. We also want to give informal
caregivers their rightful place in primary care.
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Specific attention is paid to young informal caregivers, primarily children and young people under the
age of 24, who grow up in a family situation with special care needs. We would appeal to the care
providers to recognise this group of young people, to involve them in the care context and to pay
attention for their specific needs and questions.
Actions:
 The primary care decree, the mental health care decree, the local social policy decree and the
residential care decree are being amended, and the principle that the informal caregiver is a
fully-fledged partner in care with specific needs and desires must be included.
 The implementation decrees must be amended and also the agreements with organisations must
take these basic principles as their starting point and explicitly adopt them.
 Consultation is planned with the minister authorised for Education on the inclusion of health
skills in the learning aims of primary and secondary education.
 In collaboration with the associations involved, a Flemish expertise point for informal care will be
founded that will be incorporated into the Flemish Institute for Primary Care (see later). The
intention is make this easy to access and to operate in a mainly digital way.
 The Flemish informal care plan, where the 4 themes are specified in actions for primary care, will
be implemented.
 The “resolution of the Flemish Parliament concerning the improvement of support of informal
caregivers”, as adopted by the Flemish Parliament on 1 February 2017 will be implemented.
3.1.5
Primary care players also have a role in prevention
In aiming for the best possible quality of life, prevention takes an unmistakably important position.
Initiatives and health promotion and sickness prevention in healthcare and beyond, via an intersectoral policy, can provide this. The healthcare aims acting as policy instrument.
A healthcare conference took place on 16 and 17 December 2016, which was held in the light of
framing a new design for healthcare aims around ‘healthy living’. These could replace the elapsing
health aims around nutrition and exercise and tobacco, alcohol and drugs. One of the important
decisions taken is the proposal to work via the life domains in which the citizen is active. The care
and welfare life domain and the neighbourhood are, in the context of the reform of primary care,
important life domains alongside family, recreation, education, work and the citizen.
Helping to achieve the health aims of the preventive health policy is thus an assignment for the
primary care providers. Implementing a proactive policy in care and welfare means that the care
providers also take into account prevention and are supported in applying the methodologies from
the preventive health policy in their practice.
It is also important that there is a local translation of the Flemish health aims through the adoption of
validated methods and of other objectives from the prevention policy. Both the approach by local
authorities (‘Healthy Municipality’ method) and by the players who have a role in the primary care
area (see later) are important.
There are also policy objectives in the area of prevention which are not always explicitly stated in
health aims.
The Government of Flanders wishes to support dentists in preventive oral care, certainly among the
target groups with substandard self-care or care use. Nurses, carers and care workers, pharmacists,
physiotherapists and occupational therapists have an important role in the area of preventing falls.
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Doctors and psychologists can contribute to mental health promotion. Pharmacists have an
important advisory duty concerning appropriate medication use and preventing addiction to
psychotropic drugs. Doctors, midwives and Child and Family nurses make young parents aware of
prevention (cot death, vaccination, breast feeding, etc.). The Huizen van het Kind (children’s centres)
are an important instrument for working on prevention in respect of the target group of young or
future parents and families. They connect and make accessible the services and ensure that the
support of the families, deprived families in particular, is guaranteed in every life area. They have
specific attention in this for social support, group operations, mental health, relationship support,
practical help, etc.
During the conference ‘the future is young’ on 6 October 2016, it was proposed to structure the path
that parents and children from vulnerable groups take into a supervisory ‘care pathway’ that fits in
with the preventive family support. It also describes the expected actions by digital means, so that it
is clear for everybody what is done by whom and when. The basis of this care pathway is laid by what
we now know as the pre and perinatal guidelines of the KCE and the consultation schedules as used
by the Child and Family Agency and the CLBs. The scope of the care pathway is, however, made
broader: not only the medical monitoring but also the following aspects are handled: mental wellbeing, (preparing for) parenthood, development, healthy nutrition and exercise, smoking and drug
use, oral health, social support, practical help, health determinants, ensuring rights and support
possibilities, leisure time activities and health skills.
Every care provider should be sufficiently alert to health, welfare and/or social problems which the
citizen himself does not (sufficiently) consider. In this way, every care provider can make his
contribution to early detection and intervention by discussing them and proposing possible solutions.
The forum on which representatives of primary care find themselves locally is the Care Council (see
later). This Care Council must be supported by the available expertise and the network of the LOGO
involved. The LOGO will be absorbed into the support structure of the regional care area with the
aim, among other things, of strengthening the link with primary carers and of supporting them with
recommendations and information.
Actions:
 A new legislative framework will be written to allow the LOGOs to be absorbed into the support
structure of the regional care area
 The Care Council will be empowered by the Flemish Institute for Primary Care and partner
organisations around prevention (VIGeZ, VAD etc.) and the regional care area (see later) to
monitor the local-regional progress concerning the health aims and to draw fitting conclusions.
 A supervisory care pathway for parents and their children from vulnerable groups is being
mapped out, which to a large degree will be based on digital data sharing.
3.1.6
Signposts in care
Persons with a care need or care demand, or their informal caregivers, often look for information
and an appropriate answer. There is also a need for reachable, easy to access, local reception
functions, both physical and digital, where help-seekers and their informal caregivers can obtain all
the useful, objective information on their support demands: information about and availability of the
services, their rights and possibilities for service provision and benefits and for any substantive
information related to the care demand or care need.
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In Flanders, the General Welfare Centres (CAW), the Public Centres for Social Welfare (OCMW) and
the social services of the health insurance funds have a reception task that has been confirmed by
decree. Each of these organisations has built up specific expertise. We are bundling this expertise in a
partnership for ‘integrated, broad and recognisable reception’. The overall service and social services
to care seekers and their informal caregivers are embedded in the tasks of this integrated broad and
recognisable reception, which means that both welfare and health aspects are approached from a
generalist perspective, aimed at maximum access to care and allocation of rights. The integrated
broad and recognisable reception pays specific attention to vulnerable groups (including people in
poverty) and can be expanded further within the broad concept of the Social House. In every respect,
the Social House is part of the integrated broad and recognisable reception. This is also one of the
actions included in the Flemish Poverty Reduction Action Plan.
The local administration (or collaborating administrations) assumes in this sense the director’s role
and puts a lot of work into the partnership between the players involved.
This reception may not be interpreted in the passive sense of the word, namely just as a front-desk
function. The integrated broad reception organises the ease of access to the care services and acts
with an outreaching and pro-active approach with a focus on vulnerable target groups. It contributes
to the autonomy of the person to assume his self-management. Often, giving information and
direction in the care services with good clarification can help the person to assume the control of his
care and prevent more radical care situations. Experience teaches, however, that the way in which
the reception takes place and potential barriers in the follow-up care must also be given the
necessary attention. This immediately shows the importance of the link between this broad
reception and the care providers. Currently, eleven integrated broad and recognisable reception pilot
projects are under way.
Actions:
 The 11 pilot projects for integrated broad reception that run until 2018 are encouraged to focus
as much as possible on the link between care and welfare.
 For the further implementation of the integrated broad reception, as much focus as possible will
be given to the link between care and welfare.
 Based on the evaluation of these pilot projects, we will assess how the further implementation
can take shape in Flanders.
3.1.7
More care in the neighbourhood
Persons with a chronic care need or reduced self-care ability generally want to stay at home longer.
Achieving this wish is often made possible by a range of support from professional, but also from
informal, care providers. Neighbours who help and volunteers form a valuable link between the
person with a chronic care and support need and the society in which he must be able to participate
for as long as possible. Growing loneliness and social isolation must be combated.
Volunteers and informal caregivers must be able to rely on care and support in their vicinity that makes
their effort more bearable. Local service centres, fewer mobile transport centres, centres for day care
and day activities, services for family care, but also volunteer minders in the home and foster care can
give the informal caregiver some respite and allow them some time for themselves.
Buddy systems with motivated volunteers for people with mental health problems can facilitate their
reintegration into society. Modified residential forms (such as social assistance dwellings) can have
social effects because they make accommodation affordable. Initiatives in the area of occupational
therapy can also be a useful addition for people with a disability who can no longer access the
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regular job market. But other care players are also encouraged to organise themselves with a focus
on the neighbourhood.
Within the children's centres, the focus is on a strong collaboration between local actors and the local
community to design interventions that reduce health inequality and make the services accessible.
Actions:
 The future Flemish Institute for Primary Care will have the assignment to develop and distribute,
together with the VVSG, methods based on good practices for the local administrations to
facilitate initiatives around neighbourhood-driven care.
3.1.8
Local social policy
The organisation of primary care cannot be viewed in isolation from the local social policy. Primary
care and focusing on informal care operates, by definition, at the local or community level. The local
administration’s role of director is unquestionable in this. This will be echoed in a new decree for
local social policy. Local administrations will receive the assignment to include inclusive and
integrated local social policy aims in their long-term plans. The existing instruments will be used for
this, so that it does not involve additional planning tasks for the local administrations. In addition, we
also foresee an important director’s role that translates into the best possible coordination of
services with local needs.
More specifically, the local government will achieve at operational level, possibly in collaboration
with other authorities, the integrated broad recognisable reception. The local administrations are
also the designated partners for assuming the role of director in the context of the socialisation of
care. We refer here to such things as the development of initiatives in the area of community-driven
care. Volunteers, neighbours, family and informal carers of persons with a care need, and players in
the social, welfare and healthcare sector work together in such an environment to keep help and
care accessible, affordable and available to everybody, and to promote social cohesion.
3.1.9
The care providers in primary care
General practitioners, dentists, nurses, midwives, pharmacists, physiotherapists, social workers,
occupational therapists, primary care psychologists, dieticians, speech therapists, podologists, care
workers, etc. form the basis of primary care in Flanders. All play an essential role in the care of the
person with a care need. Each from their own expertise, competencies and capacities. They provide
support and advice from birth to the final days of life.
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The general practitioner provides medical support and advice for both acute and chronic care
needs. From a relationship of trust, sometimes lifelong, with the person with a care need, he is in
an excellent position to listen to the care needs of the person and to offer advice that can
contribute to the prevention of conditions, to early detection and intervention, to the healing
and changing of the person’s lifestyle. From his position, he is ideally placed to detect and treat
physical, mental and social problems and where necessary to make referrals. The medical
responsibility is with the general practitioner. There is no discussion about this.
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The operating area of nurses is formed by the home or alternative home environment of the
person with a care need. The strain from the manipulation of less mobile persons, and the time
pressure on home-care nurses caused by the many journeys in increasingly congested traffic,
form risk factors. More so than the GP, the nurse enters the familiar environment of the person
to perform nursing activities that are aimed at solving his problems or at least opening them up
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for discussion, and thus to support or reactivate the daily activity. Their signalling function is
vital.
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The midwives focus on supporting the pregnant woman and on mother and child after the birth.
There role is becoming gradually more important since perinatal care is becoming less an
inpatient activity.
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Pharmacists make an indisputable contribution to care with their support and advice concerning
the correct use of medication. The polymedication of the elderly and persons with a chronic care
need imposes specific challenges on them concerning therapy loyalty, having insight into the
medication schedule of care users and informal caregivers, and the correct use of the prescribed
medication. Their tasks also include an important social component, since they are an easily
accessible link in the primary care chain. Persons with an acute or chronic care need will
sometimes wish to get things off their chest. The pharmacist is often one of the first contacts
when illness strikes or a point of multiple contact for a chronically ill person. In this way, they
build up a relationship of trust with the person with an ongoing care need or with their informal
caregiver.
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Dentists are the first point of contact in oral care. An increasing number of elderly people have,
thanks to good dental care in the past, been able to retain their teeth until an advanced age. This
demands a specific focus and approach, taking into account the limited mobility and more brittle
tissue and teeth of older patients. Good oral care contributes to general health.
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The physiotherapists also make an important contribution to the person with a care need. Both
in their own practice and in people’s homes, they increase the quality of life of persons with
physical needs. The physiotherapist concentrates largely on human movement in the context of
healthy functioning. Together with the patient, he tries to promote the physical possibilities and
activities of that person. The physiotherapist also contributes to the preventive health aims (e.g.
prevention of falls, combating a sedentary lifestyle). A role that is becoming increasingly
important in an ageing society, in which people exercise less.
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Another profession that focuses on the maintenance or recovery of physical functioning is the
ergotherapist. His support is aimed at regaining, improving or maintaining performance in the
learning, living, working and leisure situations of people of various ages. Together with the
person with a care need, he searches for a way of participating in day-to-day life.
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The social worker directs his activities at normalising, expanding and promoting action
possibilities of the person with a care need in relationship to the environment. Exploring and
achieving entitlements intended to increase access to provisions in all life areas is part of the
core task of social workers. Today the emphasis is rightly placed on the fact that the person with
a care need must take control of his own care. But there are circumstances in which this
demands (not only) changes by the person himself but also from the environment and society.
Social workers shape this from a social signalling function within a provision or agency, but also
via community work and specific participation processes. All this with the aim of also focusing on
structural changes.
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The primary care psychologist23 treats mild psychological complaints, provides short care
(maximum 5 sessions) and works together with the general practitioner. The problem is clarified
during a consultation with the person with a care need and an assessment is made as to how the
23
In Flanders there are currently 7 pilot projects in the primary care psychological function financed by the Government of Flanders.
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problems could be tackled. When more serious psychological problems are detected, the person
is referred to more specialised mental health care. The primary care psychologist mainly focuses
on increasing the self-reliance and resilience of the person with a care need within his or her
context and close to home. He provides (early) clinical psychological, generalist and short-term
support. The primary care psychologist is there for all age groups and must also be accessible for
vulnerable groups.
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The care worker has become indispensable as the care provider who is responsible for personal
care and for the person with a care need functioning well in his home or temporary home
environment. The care worker is also responsible for the home environment of this person, with
whom he can gradually build up a relationship of trust. He carries out the actions autonomously,
in compliance with the residential care decree.
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A nursing care worker is specifically trained to undertake 18 nursing supportive tasks. Those
tasks are delegated by a nurse. The nursing care worker performs this tasks under supervision of
a nurse and is part of a structured team. In addition to the 18 tasks, a nursing care worker also
performs the tasks of a care worker. In a short time, this discipline has developed onto an
indispensable link in primary care.
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The podologists examine persons with complaints of the feet and do this in relationship to the
higher body parts, such as knees, hips and back. The podologist fulfils an key role in the
treatment of persons with conditions such as diabetes and rheumatism. This profession is thus
indispensable in achieving care pathway contracts of persons with diabetes type 2.

The correlation between exercise and nutrition has been identified for some time, for example in
the preventive healthcare policy. An important profession in this area is the dietician. This care
provider supervises and supports persons in adapting nutrition and living habits. They thus fulfil a
role both in health promotion and in the support of persons with a medical condition.
The most important characteristic of the care providers in primary care is their accessibility for the
person with a care need. With their generalist view on the care needs, they deliver the most suitable
care themselves, or they ensure a suitable referral within primary care or to the more specialised
care.
Digital data-sharing is increasingly becoming a condition for qualitative care and the evolution in this
area is progressing so rapidly that the care providers must be supported in it. The project eenlijn.be
attempts to close the unquestionable gap between the young and the older generations, but also
between the disciplines, through adapted training courses. The Government of Flanders wishes to
make eenlijn.be more sustainable and to incorporate the current, project-based operation in the
Flemish Institute for Primary Care.
Care providers in primary care must be supported by all levels that hold or will assume responsibility
in this area (primary care area, regional care area and Flemish level), whereby good task designation
for each level of support and harmonisation of the support forms are essential. Overlap in structures
and tasks must absolutely be avoided. The support must be able to respond to the demand side, and
for articulating the demands concerning support of primary care, an effective Care Council from the
primary care area is very important.
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3.1.10 The residential care players are structurally part of primary care
Based on a vision of socialisation, care is provided in the person’s own living environment where
possible. Informal care and the community are of essential importance here. We can only achieve
this if there are also adequate and accessible professional care services available. A wide range of
customised professional care and support can be offered as soon as it becomes necessary, needless
to say with a focus on the person with his care demand, but equally in support of the informal care.
Residential care players include the home care provisions and residential care forms that are
recognised by Flanders via the Flemish Parliament Act on Residential and Home Care.24
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Family care and supplemental residential care
Services for logistical help
Minder services
Home nursing services
Foster care services
Social work services of the health insurance funds
Local service centres
Regional service centres
Associations of Care users and informal caregivers
Residential care centres
Short-stay centres
Centres for day care
Groups of assisted dwellings
Convalescent centres
The residential care players are a structural partner of primary care and consequently are explicitly
part of the primary care area (see later).
Both residential elderly care and home care are currently in flux. The draft paper ‘Flemish welfare
and care policy for elderly people. Close and integrated. Vision and Agenda for Change’ outlines the
future care and support policy for the elderly people in Flanders. The paper focuses attention on,
among other things, the coordination and integration of assignments and tasks and avoiding overlap
between the various provisions. At the same time, the demands, needs, autonomy, freedom of
choice and quality of life of elderly people are given a central position. The content of this paper is
complementary to the policy vision on future integrated care provision in primary care and the
implementation of the future framework of operations for the services for family care and residential
care centres.
In carrying out this draft memorandum, an updated operational framework is being developed with
the involvement of the sectors.

24
Flemish Parliament Act on Residential and Home Care of 13 March 2009, available via https://www.zorg-en-gezondheid.be/woonzorgdecreet-van-13-
maart-2009
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3.1.11 Family care
The services for family care and supplementary home care offer customised care and support to all
families. At all stages of life, going from maternity care to support in the last stages of life, a claim can
be made on the services for family care. Family care can only be effective if it has a place within an
integrated care and support provision around the person with a care demand, with this person being
in control of his own care. The services for family care work in that sense closely with all the other
professional and informal care players in the care team that is put together by the person with a care
need.
This care team can be broader than the normal primary care services. Providing family care in a
context of, say, persons with psychological problems, persons with a disability, problematic
upbringing or poverty of opportunities demands close collaboration with the specialised care and
welfare provisions.
The aim of family care is that the person in need of care can remain as long as possible in his chosen
living environment, thanks to appropriate care and support. The home environment offers a sense of
security, carries a lot of memories in it, engenders rest and stability. Limits of home care must, here,
be opened up to discussion. The starting point of care and support services is the careful drafting of
the care, support and development objectives. These objectives arise from a needs assessment and
are determined at the indication of the person with a care need. The objectives that family care aims
to achieve are, in other words, objectives that the person with a care demand has in mind within an
integrated, coordinated care and support plan.
When developing the future vision, we want to pay attention to a more community-driven operation
of family care. Making family care flexible is part of this. In addition to the individual support in the
person’s own home, we want to stimulate initiatives to jointly support persons, in consultation with
the person with the care demand, his informal care and surroundings, on a small scale and locally.
This could be possible, from a broad range of residential forms to a centre for collective day care. We
must hereby take into account the mobility of the person with a care need.
3.1.12 Residential care centre
The residential care centre has, in recent decades, undergone many transformations: it has evolved
from old people's home and rest home to residential care centre. The term residential care ‘centre’
refers to the fact that, in addition to 24/7 accommodation, support and care in the centre, a diversity
of residential care forms can also be offered with the aim of achieving customised care and support:
groups of assisted dwellings, centres for short stay and day care, local service centre, night care for
the community, etc.
The residential care centre has literally become the crossroads within primary care from where
support and care in the community can be offered. In this context, the residential care centre is
becoming increasingly important as regards support and care that is offered in the community, the
neighbourhood or town, in consultation with and to reinforce the residential care. The residential
care centre is part of rapidly evolving primary care.
Under the influence of the large social consensus on residential care, the expansion of possibilities
for supporting informal care and the increasing intensity and complexity of care and support
demands, a shift can be identified in the target group of the residential care centre. Where earlier
relatively self-sufficient elderly people lived in a residential care centre for several years, it now
appears that the care profile of the current residents of residential care centres shows an increase in
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the intensity of care and a shorter length of residence. Care and support is visibly multi-layered and
more intensive. In addition, residential care centres are being asked to adopt the care and support of
non-elderly people with a prolonged and intensive care demand (young people with dementia,
persons with a mental or physical disability, persons with a stabilised chronic condition, persons with
a non-congenital brain injury), whether or not in collaboration with specialised provisions
(decompartmentalisation).
The residential care centre secures, together with the persons with a care need and their families,
the community and all other welfare and care partners, a cohesive and community-driven approach
to housing, care and welfare.
The residential care centre does not stand alone. It is a fully-fledged partner in a broad network of
care and support forms within primary care in the region in which it is active. The coordinating,
consultative doctor (CRA) and the general practitioners working in the residential care centre shape,
in consultation with the management and the care staff, a suitable qualitative medical policy. An
assortment of not exclusively care related activities, initiatives or organisations can be linked to the
residential care centre (under its own management or otherwise), such as childcare, activities of
schools, local small businesses, classrooms for associations, companies, library, exhibition space, etc.
It is an integrated part of an age-friendly community, area or village. This should be made possible
via a suitable framework for infrastructural norms and via spatial planning.
3.1.13 Social work services
The social work services provide demand clarification, offer care and pathway counselling in complex
home care situations and have built up expertise in the context of a proactive approach to various
target groups. The social work services of the health insurance funds also form an important bridge
for the citizen between Flemish and federal authorities.25 From their unique position, they have a
good overall picture of the intertwinement of (health) care, welfare and the social administrative
aspects. That is why they are a point of contact for healthcare players such as general practitioners,
hospitals, paramedics, etc.
To address the increasing demand for supervision by social workers, we are reviewing the possibility
for reinforcement.
We also conclude that much synergy is possible between the assignments of the regional service
centres and the social work services of the health insurance funds. We are investigating the
possibility of having the assignments and resources of Regional Service Centres absorbed by other
provisions that are included in the Flemish Parliament Act on Residential and Home Care.
Actions:
 The residential care centre works, together with the persons with a care need and their families,
the community, all other relevant welfare and care partners and local authorities, on a cohesive
and community-driven approach to housing, care and welfare.
25
The federal pact with the insurance institutes ‘the health insurance funds will rapidly evolve from an administrative and benefit payments
institution to a model in which the members are informed, assisted and coached to become familiar with the healthcare playing field, its
players, the rights and obligations of the patient, the financial modalities, etc. Minister of Public Health and Social Affairs Policy Unit (2016,
September). NISDI: http://www.inami.fgov.be/SiteCollectionDocuments/toekomstpact_verzekeringsinstellingen.pdf
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
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The working groups26 started will work further on updating the vision and drawing up an
inventory of obstacles experienced and identified in the operational field in legal, financial and
organisational areas.
In the primary care area, the residential care players have representation in the Care Council of
the primary care area. The primary care decree will be thoroughly rewritten.
Reconversion possibilities are being worked out with the umbrella organisations to reconvert
prior permits or recognitions of residential units into residential care centres or short-stay
centres based on the required and desired care services in the primary care area or regional care
area.
Customised support for all the families by the family care services will be explicitly developed as
a framework. When developing the future vision, we will pay attention to a more communitydriven operation with specific attention to greater flexibility.
To address the increasing demand for supervision by social workers, we are reviewing the
possibility for reinforcement.
For efficiency reasons, we are investigating the possibility of having the assignments and
resources of Regional Service Centres absorbed by other provisions that are included in the
Flemish Parliament Act on Residential and Home Care.
Investments will be made into further expansion of residential care players. In the future, this
will also be supported through the study by the Support Centre WVG ‘Prognosis of care need and
model for budgetary control’:
In this coalition period we have already invested, within the budget of Welfare, Public health and
Family, in things such as
 expansion of the family and supplementary home care for which a growth path is provided;
 the growing intensity of care in the residential care centres;
 additional capacity for residential care centres and short-stay centres via the recognition
calendar;
 the growth of day care centres and local service centres;
 social work.
3.1.14 More mental health care in primary care
We want to bend the thinking in sectors and provisions in mental health care (GGZ) into thinking in
care circuits and networks for achieving (care) functions and (care) programmes linked to age
categories and specific target groups. This thinking makes it necessary for a regional embedding of
mental health care. Inter-sectoral thinking is essential within the GGZ networks. Within this we are
empowering the role that primary care, such as General Welfare Centres, youth help, etc. should
take. These networks also have second and third care partners, such as centres for mental health
care, psychiatric hospitals and centres for ambulatory revalidation.
Evaluation of the project ‘Psychological primary care function for adults’ and experiences from
similar, not funded by the Government of Flanders, innovative practices confirm the demand for an
accessible, quickly approachable generalist basic care for mental health in primary care. The
psychological primary care function for persons with a psycho-social care need who are treated for a
limited period of between one and five sessions, is positioned within this basic care. Evaluation of the
projects also teaches that referral to specialised care is often still necessary (up to 60%) because of
the severity of the problem.
26
The following groups have been or will be started: groups of assisted dwellings, convalescence centres, day care centres and collective day care for elderly
people, services for logistical help, local service centres / community care, mobile local service centres and community-driven operation, the social work services
of the health insurance funds, regional service centres, Under 1 roof, informal care, legal position of WZC client, future WZC profile.
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The psychological primary care function is involved after referral by e.g. the general practitioners, the
OCMWs, General Welfare Centres and social work centres of the health insurance funds, with
respect for the free choice of the person with a care need. Collaboration between the mental health
care and other primary care providers is crucial.
With the coaching and informative role of the primary care psychological function, these partners are
reinforced in the recognition of psychopathological problems and are stimulated to set to work or to
refer patients quicker and more focused. The primary care psychological function has the desired
competence profile and the necessary expertise. The link with the specialised mental health care is
vital, both for the quality of the care offered and for knowledge acquisition and dispersion. The input
of the psychological primary care function should consequently also be coordinated in and with the
networks of mental health care (including the network of adults ‘article 107’). The spread and
expansion of specialised mental health care should also be included within the mental health care
networks. For this, consultation with the federal government is necessary. The current boundaries of
the mental health care networks, and also the operating areas of the mental health care provisions,
will be homogenised on the basis of demarcation of the primary care areas and regional health area
(see later).
Collaboration with and participation of context and informal caregivers is a challenge, as too is the
deployment of new methodologies, such as the organisation of a group offer, combining with online
therapy.
The current pilot projects in the psychological primary care function have been extended until the
end of February 2019.
We will also start with psychological primary care function projects for children and young people.
The conclusions of the KCE study on the organisation and financing of psychological care (2016) will
be included in this. This psychological primary care function for children and young people will be
closely aligned with the ‘early detection and intervention’ programme for the implementation of the
new mental health care policy for children and young people.27 This programme will concentrate on
children, young people and young adults (0 to 23 years of age) from the first indications of a possible
mental or psychological or psychiatric problem. Within this programme, particular attention will be
paid to psychosis, suicide, eating disorders and addiction. Needless to say, strong links will be
extended from this programme to primary care and organisations active in primary care, such as
TEJO28.
A broad rollout across Flanders of this psychological primary care function also necessitates
consultation with the federal government concerning possible recognition and payment of clinical
psychologists and special education experts for performances that are undertaken in the context of a
psychological primary care function.
The core assignments of the consultative mental health care platforms will be assumed by the
support structure of the regional health zone (see later) and will help to support the primary care
areas in the approach to mental health problems. They will have a bridging function between
primary care and specialised mental health care and contribute to care-strategic planning.
Actions:
27
28
www.psy0-18.be
TEJO offers easily accessible, therapeutic support to young people between the ages of 10 and 20, short-term, immediate, anonymous and free. The service
provision is undertaken by professional therapists on a voluntary basis. www.tejo.be .
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We are looking for levers to increase the commitment of primary care partners in the GGZ
networks.
In the Flemish Mental Health Action Plan, which was submitted to the Government of Flanders
on 16 December 2016, the psychological primary care function pilot projects for adults were
extended until the end of February 2019 and reinforcement is provided for experimenting with a
psychological primary care function for children and young people. This latter function should be
closely aligned with the ‘early detection and intervention’ programme for the implementation of
the new mental health care policy for children and young people. Integration with primary care
remains necessary here.
We will enter into consultation with the federal government on the possible recognition and
payment of clinical psychologists and special education experts in the context of the
psychological primary care function.
The structure and core assignments of the consultative mental health care platforms will be
assumed by the support structure of the regional health zone.
The independent psychologists are invited to create an operational circle that corresponds with a
primary care area (see above ‘The primary care area’).
3.1.15 Complex care
There is no unequivocal definition of complex care. Often the link is made with a prolonged or
permanent need for care that can evolve over time. Generally we can state that the complexity of
care is determined by:
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The person with the care need: he has (a combination of) different needs in the corporal,
psychological and social areas. Determining the care aims is complicated by this.
The conditions of the person with a care need: social-economic problems, a variety of care
providers, no informal care, care services not attuned to the care aims of the person with a care
need, etc.
The nature of the disorder(s): multi-morbidity, fragile elderly people, frequent
(re)hospitalisation, polypharmacy etc.
3.1.15.1 Complex Care: good digital registration and collaboration
At the moment, 70.1% of the Flemish population has a General Medical File in a GP’s practice29. A
considerable share, but with the final aim being complete digital collaboration and data-sharing
between all relevant care providers, this means we still have quite a way to go. Notwithstanding all
the efforts undertaken by the care providers and the authorities in this country, we must conclude
that we are not there yet. The ambitions are also high. That is why a sensible, cautious approach is
necessary. We must have the courage to learn from our experiences, and state what the blocking
and delaying elements are.
All this should take place with a clear objective in mind. A radical digital collaboration and datasharing between care providers thus demands a clear perspective and specific ambitions that
indicate the added value for the care providers and for the person with a care need. But there is also
29
IMA-Atlas: http://atlas.ima-aim.be. Since 2002, the Intermutualistisch Agentschap (IMA) has gathered data from the seven mutual
insurance funds and has processed, analysed and interpreted them in the context of policy-relevant research projects. The IMA-Atlas, an
initiative of the IMA, is accessible to the general public. If
you have an email address, you can create a user profile
online. In this way, you can access statistics and indicators - derived from the IMA databases - for Belgium, regions, provinces, districts
and municipalities.
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a need for a justified, realistic approach that takes into account as far as possible the possible
dependencies for the stakeholders, the levers that are available, any technological barriers, financial
thresholds, etc.
The most important condition that must be fully satisfied is the need for an unequivocal commitment
from all the care providers and stakeholders involved. In other words: everybody must participate.
That is the task of all of us.
The Government of Flanders shares the ambitions concerning the aim of the federal government to
achieve complete digitisation of the GPs’ medical files by 2020. Flanders also wants the
multidisciplinary sharing of a care and support plan to be in place by 2020. This reflects the
philosophy of the eGezondheid [eHealth] action plan to evolve into a ‘multidisciplinary patient file’
whereby relevant data are made accessible. The Government of Flanders is investing in Vitalink,
since accessibility of the data and user-friendliness can increase for the care providers and citizen
through mobile applications (M-health).
Flanders also wants the multidisciplinary sharing of data by digital means to be a fact by 2020. It will
achieve this by drawing up the demands that the electronic patient files of each professional group
must meet and linking virtually the electronic patient files of the various professional groups into one
shared file. The first step here is the medication schedule, a subsequent one is the journal and
agenda function.
These ambitions take the designated pathway in the context of the e-health plan into account as far
as the approach is concerned. We will coordinate our ambitions around the digital journal, the
agenda and care aims in consultation with the federal government and the stakeholders from the
sector.
In the process that Flanders is undertaking as part of the e-health plan, we are opting for BelRAI
(screener) as a uniform grading instrument as part of the Flemish Social Protection. In this way, the
care need can be measured in a uniform way. The BELRAI will be introduced gradually in the various
sectors of the VSB. The needs assessments are not disconnected from the care process. This should
also lead to less strain for the person with a care need and to a reduced burden on the primary care
providers (residential care players, general practitioners, nurses, occupational therapists etc.).
Decreasing and simplification of the administrative burden is, incidentally, a general aim of
digitisation in care.
The professional care providers will therefore be able to use BelRAI for in support of clarification and
assessment of the care need, with a view to drawing up a care and support plan. The use of BelRAI
offers other advantages, such as optimisation of continuity and quality of care, a common language
for the care providers, optimisation of inter-disciplinary and inter-sectoral collaboration and a
systematic monitoring of the care need in a standardised way.
Actions:
 By 2020, Flanders will realise a digital care and support plan for the care providers. An initiative
will be started to develop and test a standardised care and support plan.
 Vitalink is the platform for digital data-sharing in primary care in Flanders. We will provide userfriendly access for care providers and citizens.
 Together with the federal government, Flanders will focus on further digital data-sharing
between care providers as formulated in the e-health plan.
 BelRAI will be gradually rolled out as the uniform grading instrument in care in the various care
sectors in the context of the Flemish Social Protection.
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
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Initiatives will be undertaken to lend transparency of online and m-health applications that can
give support in a validated way via new technology in care and welfare.
Continuation of the eWZC action plan.
3.1.15.2 Complex care: the multidisciplinary care team and care coordination
For a complex care problem in which multiple care providers from various disciplines are involved, a
care team is created. The person with a care need and his informal caregiver form an integral part of
this. The composition of the care team is made, initially, by the person with a care need and, if this is
not possible, by his informal caregiver based on complete freedom of choice. This care team is thus a
customised team that is composed by the person with a care need and has sufficient capacity,
expertise and mutual communication possibilities in order to make adequate care and treatment
possible.
Based on the analysis of the care needs and the desired quality of life, the care aims are determined
as suggested by and with the person with a care need. For the realisation of each care aim, care
providers from different disciplines can be involved. If informal care is present, the support
requirements of those persons (informal caregiver) will be clearly formulated and translated into
care aims and associated acts or actions.
Within the care team, the following tasks (not exhaustive) must certainly be included and
designated:
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together with the person with a care need, investigate and evaluate what his needs and care
aims are;
bring the person with a care need, if necessary and desirable, into contact with additional
services, or involve these directly, taking into account the freedom of choice of the person with a
care need;
together with the person with a care need, develop a care and support plan and assess which
components of integrated care are applicable (e.g. prevention, presence and support of informal
caregiver, etc.);
allocate the care aims with actions to members of the care team and reach agreements together
on how these will be achieved;
evaluate whether the care and support matches the needs and care aims and analyse where the
gaps and problems are;
adjust the care aims and/or the care and support plan on the basis of the evaluation;
etc.
Within care teams, familiarity with each other’s way of working via clear collaboration agreements
and digital data-sharing is important for the continuity, efficiency and quality of care, and this with a
minimum of administrative burden.
Assuming the freedom of choice to compose a care team according to the preferences of the person
with a care need, the individual members of a care team can thus be expected to do everything to
guarantee quality care, accessibility and efficiency of collaboration.
The complexity of the care process and the number of care providers present in the care team
sometimes demand a coordinating function.
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Coordination of the care is a role that is assumed - in order of preference - by the person with a care
need or his informal caregiver or a professional care provider from the care team, and means that
somebody in the care team is given the mandate by the other members of the care team to:
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monitor whether the agreements made are implemented and if necessary to take action;
stimulate consultation between the care providers and, if problems arise, to initiate multidisciplinary communication (organising virtual or physical consultation);
evaluate, together with the person with a care need, whether certain needs have be solved or
care aims achieved;
work closely with the informal caregiver and offer support to the informal caregiver;
involve as much as possible the person with a care need in the care and try to recognise as much
as possible his control at each step.
promote care continuity by ensuring a rapid transition between the various care situations. The
care coordinator is the link between the care at home and in the hospital, the mental health
care, the residential care centre (incl. day care and short stay). During an admission, the care
coordinator is the contact point for the in-patient care and home care. All this with respect for
the freedom of choice of the person with a care need.
The responsibility for the medical aspect of the care process is always with the GP. The care provider
who assumes the role of care coordinator never acts in the place of another care provider from the
multidisciplinary care team.
Depending on the primary focus in the care aims, the person with a care need, his informal caregiver
or a certain discipline can be more properly assigned this role: the GP (for primarily medical
problems), the social worker (for primarily social or welfare problems), etc. The care coordinator is
designated by the person with a care need or his informal caregiver.
Actions:
 The federal government will be asked whether the reform of RD No. 78 will allow the inclusion of
care coordinator in the description of the professional profiles.
 Suitable extra training should be provided for the care providers to allow them to perform this
role properly in a qualitative manner.
3.1.15.3 Complex care: case management in action
For the deployment of a case management function, we must assume an exceptional situation.
Realising the care process and care coordination within the care team will be the norm.
The figure below is an adaptation of the Kaiser Permanente Pyramid. In addition to the various
categories of persons with a care need, it also shows the distinction between care coordination and
case management:
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This figure shows that the case management function is reserved for persons with a major and
particularly complex help and care demand.
The number of situations that consequently arise for case management must be restricted. The
request for support through a case management function can only be made by the care coordinator
from the care team after consultation with the other members of the care team. After this
consultation, a decision can be reached together as to whether to invoke support through this case
management function. A constant in this is that the deployment of a case management function can
only be invoked for persons with a particularly complex care situation, whereby the care team is
made up of a variety of care providers from various disciplines who request and initiate the case
management.
Which exceptional situations can justify the deployment of a case management function?
 Very complex care situations or persons with multiple chronic situations, whereby one or more
of these conditions can lead to a severe loss of autonomy.
 The care team in crisis: the care team reaches the limits of its possibilities and capacities through
an increasing degree of complexity in the care situation. A conflict can also arise between the
person with a care need and the care providers.
 The refusal of care by a person with a care need. The surroundings (family or professional)
ascertain that the care and support is not functioning properly and the care needs are being
insufficiently addressed. For example, if the informal caregiver reaches his limits with regard to
providing care, but the person with a care need still refuses all professional care and support.
The case management function forms a temporary support for the care team. The care team remains
fully responsible for the care process.
To arrive at a reliable and permanent solution with the care team, the case management function
analyses the following steps that have been taken:
1. Has an analysis of the situation taken place?
2. Is there a general multi-disciplinary evaluation (BelRAI if the person is elderly)?
3. Has a care and support plan been drawn up based on interdisciplinary consultation?
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4. How is the implementation and coordination of this care and support plan operating? Is the plan
being kept up to date?
5. How is the monitoring of the care and support of the person with a care need progressing?
This analysis must show which steps should be taken by the case management function in order to
tackle the problems. This can result in:
1. taking steps that have not, or have not sufficiently been taken;
2. adjusting the care and support plan;
3. supporting the care coordination.
The case management function will carry out an evaluation to assess whether the intervention has
resulted in optimisation of the care provision.
The case management function will be undertaken by an expert, who is not a member of the care
team around the person with a care need. The expertise of the case manager should reflect the main
problem off the person with a care need. When developing the profile and role description of the
case manager, account will be taken of experiences from care research areas, care innovation
projects, chronic care pilot projects and the pilot projects from the coming appeal (see actions).
Anyone wishing to fulfil a case management function will have the necessary competencies for this
or will obtain training in them. The person who performs the function will have the following
competencies in various areas:
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Knowledge of the social map;
Knowledge of health and welfare care;
Knowledge of the target groups;
Communication skills;
Interview skills;
Administrative, technical and editorial skills;
Organisational skills;
Problem analysis and problem-solving skills.
The conditions under which this function can be adopted must be developed further.
Actions:
 The legislation concerning multi-disciplinary consultation will be thoroughly revised in close
consultation with relevant experts. The use of modern communications technology (instead of
physical consultations) for consultation will be enabled.
 In order to determine workable contours for a case management profile, an appeal will be
launched for pilot projects that prepare the path for a Flemish rollout.
 Criteria and conditions for the introduction of a case management function will subsequently be
included in legislation.
 Existing forms of care coordination and case management will be better attuned to each other,
so that the possibilities for this become more transparent.
 The care team will be supported by the primary care area (see later) in the implementation of
the methodology of integrated care planning (see later).
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3.1.15.4 Primary care opts for digital care coordination
In the previous sections, the need for and the tasks of a multidisciplinary team, care coordination
and, where necessary, case management, was explained for complex care situations. Good
communication, clear agreements on the care aims, monitoring of the care tasks included and
executed, etc. are essential for the success of the care coordination and the performance of the care
team.
The digital revolution in care offers the possibility of facilitating consultation about the person with a
care need and collaboration between the care providers. For this, a sound concept is needed, with a
clear spread of responsibilities, before investments can be made in applications that allow smooth
consultation via the digital highway. Below we formulate a conceptual start of a digital care and
support plan that facilitates consultation around the person with a complex care need, in light of the
previously formulated function of care coordination and the tasks of the care team.
Together with the medication schedule, the journal function (rapid and brief communications
between the members of the care team about the care given) and the agenda function (who does
what, when, for this person with a care need?) are two important additional building blocks in a
digital care and support plan.
The intention is that the care provider can, from his own package, consult all relevant and shared
data on the person with a care need via the Vitalink platform, including from the patient’s home.
Mobile applications (M-health) contribute to ease of use. Ease of use for the care provider and the
citizen is thereby a priority and the responsibility of all stakeholders.
Integrated care provision thus very clearly demands an integrated digital system. The care providers
share relevant information from their electronic (patient) file (EPD) via Vitalink with the aim of an
integrated Personal Health Record (PHR). Every person with a care need, and his informal caregiver
under certain conditions (e.g. permission from the person), is given access to his shared information
via a user-friendly application (viewer, web portal, app etc.) and can, in time, manage and share his
own personal data from his personal electronic file (PHR), communicate with his care providers,
make appointments, add data, virtual consultations etc.
Additionally, there is a need for decision support and integration of CEBAM modules in order to
promote evidence-based decisions and advice in a way that is feasible for the care providers, and the
GP in particular.
With a view to realising a digital and integrated care and support plan, the Government of Flanders
will, in consultation with the care players and coordinated with the e-health plan, focus even more
intensively on IT support of the care providers. However, simply focusing on support by developing
supportive applications and offering an intensive training to the care providers, will not be enough.
Among other things, Flanders will review the existing financing mechanism for multidisciplinary
consultation and possibly other subsidy flows, and use them to stimulate digital collaboration.
Actions:
 Within the data-sharing consultation committee of the Flemish Agency for Collaboration on
Data-sharing between Players in Care30 that is to be set up, in 2017 we will start developing a
30
Remit and composition of the Flemish Agency for Collaboration around Data-sharing between the Players in the Care
in short VASGAZ: see appendix
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
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draft digital and standardised care and support plan. This draft will consist of three main parts:
administering/coordinating care within teams, performing administrative task and reporting
information. With this we are aiming for the following functionalities:
 Care section
 picture of information about care user from various sources (incl. Vitalink, BelRAI);
 communications, possibility for making remarks or comments on the care given,
registering of certain important observations concerning the care user (= journal);
 who provides care around the care user, the care team;
 which care is needed, care aims;
 planning, who will provide which care and when (= agenda).
 Administration section
 Invoicing
 Administration
 Reporting section
 Policy reporting (big data).
One initial point of attention in the care block is a section for journal and agenda in order to
support communications between care providers. The digital and standardised care and support
plan will gradually replace the existing e-care plans.
We will take the legislative initiatives as quickly as possible to use the existing funding
mechanisms and subsidy flows to stimulate digital partnership. First, the legislation that applies
to this will be listed by the Care and Health Agency.
In the context of the Flanders’ Care 2.031 Action plan, we will focus on digitisation. We will
implement these actions fully.
3.1.15.5 Primary care is the requesting party for good coordination with the hospitals
Person-driven care transcends walls, departments and lines. Integrated care is increasingly the rule
for persons with a chronic care need (oncology, COPD, dialysis, etc.). Specialists and general
practitioners, social work in and outside the hospital, the hospital and the home nurse need each
other to ensure good continuity and other aspects of quality of care. Shorter stays in the hospital also
means concentrating more on communicating with each other and data sharing.
The interaction between hospital and primary care will become more intense and run at a faster pace.
The hinge moments between different care forms often act as the weak links in our care system.
Various initiatives have already been undertaken to improve integrated care agreements between
general practitioner groups and/or partnership initiatives between primary care and hospitals,
discharge managers in hospitals, the safe-deposits and the hub and meta-hub systems for integrated
data sharing, the care pathways for kidney deficiencies and diabetes and the local multidisciplinary
networks, etc.
With the needs of the local population as starting-point, we can state that there is sufficient regional
dispersion of basic specialist services. The task of a base hospital consists of offering specialist care
that can be provided in a safe and high-quality way in the vicinity of the place of residence of the
person with a care need. The services must always be based on the needs of the local population.
31
https://www.flanderscare.be/sites/default/files/media/VR%202016%200502%20MED%20%200056%202BIS%20Actieplan%20Flanders%20Care%20-%20Actieplan_def.pdf
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Because of the ageing population with multi-morbidity and often reduced mobility, it is, after all,
important that standard care is offered as close as possible to the home environment.
The base hospital should also support the primary care players in their role, in order to care for the
patient for as long and as comfortably as possible in their familiar surroundings and to avoid
unnecessary hospital admissions and readmissions.
We will define the activities of a basis hospital further, in consultation with the federal government.
Actions:
 Agreements between primary care and the hospital in the region should be taken at regionalurban level (i.e. the level of the regional care area, see later) on the basis of a Flemish framework
(cf. Flemish Institute for Primary Care). We will enter into consultation about this with the federal
government.
 We will monitor, within the instrument of care-strategic planning, sufficient availability and
accessibility of a qualitative range of basic specialist care in each regional care area. The
following issues will be mapped: the instruments necessary in the area of infrastructure,
equipment, logistics, medical competencies, current obstacles in the area of funding, norms and
other cross-compliance (such as non-emergency recumbent patient transport, the consequences
for management of future hospital networks, etc.).
 The regional care area will be given the task to make clear agreements with both primary care
and the hospital care from the region on the basis of the Flemish framework concerning the carestrategic planning, etc.
 The regional care area will be involved in the care-strategic planning of the hospitals.
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3.2
SUPPORT OF THE CARE PROVIDERS
Accessible care provision assumes clarity and recognition, for the citizen but also for the care
providers. That is why we are restructuring, simplifying and integrating various network and
consultation structures in primary care. This means more time can be given to care and support of
the players in the care and less to consultation.
For the reorganisation of the primary care landscape, the starting point is the principle that support
of the care players should be decentralised as much as possible and thus placed as close as possible
to the person with a care need and his care team.
The restructuring will be clarified in this section of the text. For continuity of the support, no abrupt
change will be implemented and we will provide a transition period, so that it is possible to achieve a
carefully chosen redesign of the tasks and a gradual repositioning of the staff. We will ensure a
seamless transition from the current situation with its consultation structures to the new landscape
with a simplification and reduction of the number of consultation structures.
3.2.1
Primary care area
In the primary care area, the primary focus is on support of the practice or the service provision and
on the inter-sectoral partnership of local authorities-welfare-health. The primary care area is the
geographic description of the area in which the local authorities and the service providers who
develop their care and service provision there (including the partners of the integrated wide
admission), try to shape their partnership and assume their responsibility for the population of that
primary care area. The current SELs, GDTs and LMNs will be integrated into the primary care areas.
This does not, of course, detract from the freedom of choice of the person with a care need to
consult and use the services of primary care players from an area other than in the area where he
lives. Choosing a permanent general practitioner and opening and updating a General Medical File
with this general practitioner is, of course, strongly recommended because this offers the best
guarantee for continuity of care and the creation of a relationship of trust. The primary care area
must, first and foremost, be seen as a level at which the care providers are organised and where the
needs of the population from that are identified.
The Academic Chamber of Reflection advises primary care areas to the size of a population of 75,000
to 125,000 residents, which appropriately matches the number of micropolitan care regions in the
current Care Region Decree.
The current Care Region Decree was developed on the basis of a social-geographic study by Prof. em.
Van Hecke from 2001. To increase the consensus for the primary care areas, it is appropriate that not
only the behaviour of the population is taken into account, but also the local operation of the care
and welfare organisations and the collective operations of independent care providers in primary
care.
An appeal to the primary care players and local authorities will be made to submit a proposal for a
primary care area that has gained consensus and meets a number of criteria.
When demarcating the primary care areas, the primary care players and local authorities must take
into account a number of admissibility criteria:
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A primary care area encompasses one (part of a large) city or two or more municipalities with a
total number of residents between 75,000 and 125,000. An exception can be made to this based
on historic (already existing consortia) or social-geographic arguments. If the primary care area is
too large, this reduces the chance of effective partnership between the primary care players. If
the primary care area is too small, it restricts the possibilities of support.
The primary care area fits into the boundaries of one regional-urban care region or regional care
area. Various primary care areas together form one regional care area.
To be eligible as primary care area, the scope must have consensus among the important
stakeholders, such as general practitioner group practices, consortia or representatives of
professions, local authorities, residential care players etc.
The primary care area does not make the coherent inclusion of the whole region in primary care
areas impossible or very incoherent.
Currently a merger movement is taking place at municipality level in several regions. Since a division
of one municipality into two different primary care areas is not appropriate (this is not realistic for
local authorities), a merger of municipalities will also have an impact on the final regional
demarcation. In large cities, the division of the city into different primary care areas is sometimes
necessary. Here it is appropriate to follow district or borough boundaries.
The Government of Flanders is authorised for the recognition of general practitioner group practices.
They are an important partner in a primary care area. Initiatives are also developed in a primary care
area to support collective practices from other primary care disciplines, with, among other things, a
view to proper representation in the Care Council (see further). The general practitioner group
practices will be encouraged to align their area of operations with the primary care areas, so that the
integrated care provision can be promoted. This can, in turn, have a positive influence on the
embedding by the general practitioner group practices of the (federal) out-of-hours surgeries (the
locations where the general practitioners organise their standby duty).
The following tasks will be implemented at the level of the primary care areas under direction of the
Care Council, when a qualitative integrated care provision has achieved its maximum development:
1. Stimulate the support of group practice operation by the various professional groups and
interdisciplinary cooperation between the care providers in care teams and at the level of the
primary care areas.
2. Promote substantive coordination between prevention, remedies, rehabilitation, supervision,
support, etc. in welfare and health, including coordination with the Child and Family Agency (via
Children's Centres) and with the Centres for Pupil Supervision, occupational healthcare,
environmental health care etc.
3. The signalling at regional care zone or Flemish level of problems, bottlenecks or obstacles for
which a solution cannot be found or cannot be sufficiently found within the working area.
4. Preparing consultation (based on data provided by the Government of Flanders or the Flemish
Institute for Primary Care) on the required and desired care services in the primary care area.
The result of this consultation in the Care Council will be submitted to the regional care area for
further elaboration. A methodology will be developed (by Leuven University and Deloitte) for
mapping the needs and requirements of the population and setting the objectives for the care
provision and an optimum development of the care services in the primary care area. For the
local application and analysis of the results, the primary care area will be supervised by the
Flemish Institute for Primary Care.
5. Making multi-disciplinary recommendations operational by reaching local agreements on the
application of the recommendations (e.g. via care pathways). This includes support for the care
pathway supervision for diabetes type 2 and chronic kidney failure patients.
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6. Helping organise educational programmes, geared to the educational needs in the primary care
area and particularly directed at professional development around all aspects of integrated care
provision (interdisciplinary partnership, target groups (e.g. informal caregiver, the disadvantaged,
vulnerable elderly people, persons with dementia etc.), and use of ICT applications for supporting
the practical operations.
7. Supporting initiatives and practices of care providers so that care providers involve informal
caregivers as fully-fledged care partners.
8. Offering support during the application of the methodology (under development) around
integrated care planning for the person with a care need. The methodology around care planning
encompasses the formulation of care aims, drawing up a care and support plan, care
coordination, where necessary involving case management and offering support in concluding
and negotiating care (pathway) contracts.
9. Helping the care providers with the solution of problems, bottlenecks or obstacles in the area of
practical operation.
10. Supporting participation in the development of an integrated broad and recognisable admission,
under the direction of the local authorities.
11. Stimulating local partners to take initiatives around community-driven care and offering support
when implementing these initiatives (without acting in the place of these local partners). Specific
attention is given here to the accessibility of care to vulnerable groups.
12. Participating in designing and implementing a Flemish quality policy for primary care, based on
the directives and methodologies devised for this by the Flemish Institute for the Quality of Care.
Both process and outcome indicators will be developed for this.
13. Assisting in making Flemish and local objectives for primary care operational, in partnership with
the local partners and care providers.
14. Handling complaints for which no solution can be found between the person with a care need
and the care provider concerned. (see further under ‘Quality policy)
15. Supporting local and supra-local care-strategic planning appropriate within the Flemish
framework. Under the new local social policy decree, local authorities can take a collective
initiative to develop a supra-local social policy.
16. Stimulating digital data-sharing between the care providers at the level of the primary care areas
and helping to put this into practice.
It is clear that there is still an important process to be undertaken to achieve the rollout of such
areas, provided with the necessary support. In some regions there is (still) insufficient consensus to
demarcate the area in a consistent way. The realisation of all the functions also presupposes a strong
area governance and, of course, the necessary resources. For this we first and foremost look at
efficiency gains through integration of existing structures, such as the SELs, GDTs and LMN. That is
why a clear transitional process is necessary.
After all, in the initial stage after the reform of primary care, not all tasks stated above can be
assumed. Not least because placing autonomy with the care providers and stakeholders has farreaching consequences and implies a change of mentality and a learning process. We are assuming a
growth scenario in which the development of primary care area operation will progress in phases.
The tasks that must be given priority are:
1. Encouraging interdisciplinary cooperation between the care providers in care teams and at the
level of the primary care areas and supporting (the development of) group practices in the
various professional groups.
2. Promoting substantive coordination between prevention, remedies, rehabilitation, supervision,
support, etc. in welfare and health, including coordination with Child and Family Agency (via the
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Children's Centres) and with the Centres for Pupil Supervision, occupational healthcare,
environmental health care, etc.
3. Offering support during the application of the methodology (under development) around
integrated care planning for the person with a care need. The methodology around care planning
encompasses the formulation of care aims, drawing up a care and support plan, care
coordination, where necessary involving case management and offering support in concluding
and negotiating care (pathway) contracts.
The primary care area will be directed by a Care Council. This council is composed in a pluralistic and
diverse manner and consists of care providers from various disciplines and of representatives of the
residential care centres, family care, social work services, CAW, and local authorities, supplemented
with a representation of the care users and informal caregivers and with, preferably, a local general
practitioner as chair. The regional care area will keep available experts on prevention, palliation,
dementia and mental health care for the Care Council.
The choice has been made for a bottom-up approach. If, in an area, there is sufficient consensus and
a Care Council can be installed and recognised, it will be eligible for support. This implies that the
Government of Flanders can approve the demarcation of the primary care area if it can be
demonstrated that the area satisfies the following criteria concerning start-up and operation:
 The Care Council consists of representatives of care users, informal caregivers and welfare and
health players and also representatives of local authorities. The Care Council has adopted
participation methods directed at the maximum involvement of the care users.
 The Care Council is the only legal entity recognised and subsidised by the Government of
Flanders that the representatives participate in. During the transition stage - an evaluation of
which will take place in 2021 - work will be undertaken with an effective partnership.
 The existing and new group practices will align themselves with the primary care area.
The intention is, first and foremost, to deploy gradually, in a careful way and with respect for social
consultation, employees working in the SELs, GDT and LMN (local multi-disciplinary networks) in the
support and expansion of recognised areas and councils. In the course of the transition stage, these
employees and operational resources will be transferred to the legal entity at the level of the primary
care area. The intention is to recognise and finance one legal entity per primary care area. Thus, it is
not the intention to set up new structures in a specific region alongside the existing structures. A
thorough evaluation of the transition process will take place in 2021. Subsequently, the Government
of Flanders can choose to impose the development of primary care areas in a more imperative
manner.
The achievement of these tasks will be a growth process. Initially, the emphasis will mainly be on the
coordination, growth towards spontaneous partnership and agreement frameworks, culture change
and identifying the needs for care. The partners of the Care Council will be stimulated to think about
an expansion in the number of support employees. In addition to the reorientation of resources from
the Flemish policy level, thought can be given to co-funding from the organisations in the Care
Council, so that support can be strengthened over time.
The expansion of a primary care area does not detract from the director role that local authorities
have in the area of:
 The best possible coordination of the services with the local needs;
 Direction over the expansion of integrated broad and recognisable admission;
 Initiatives of informal care and community care.
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On the contrary, the primary care areas are supportive of the local authorities to adopt this directing
role to the full and offer at the same time the possibility of tackling needs and problems that extend
beyond the local level.
In regions where no primary care area meets these criteria, a minimal support will be provided from
the regional care area (see later).
In dialogue with the local authorities concerning accommodation, the aim will be the maximum
possible use of existing infrastructure, but with the guarantee that the employees can carry out their
duties independent of the structure and its operation.
Action: appeal for submitting an application for recognition as primary care area in 2017.
3.2.2
The regional care area (at regional-urban care region level)
In the regional care area, area-encompassing expertise must be ensured that is on a higher level than
the primary care area: because the critical mass for intervention must be sufficiently large (e.g.
palliation) or because care and welfare and local authorities are only two of several operational fields
(e.g. prevention and ‘health in all policies’). Here again simplification and integration of the
structures and the increase of efficiency is necessary. As new functions and competencies are
developed at Flemish level by the Flemish Institute for Primary Care, primary care areas and councils
are recognised and their support becomes effective, the functions that must be adopted at the
regional urban level can be further slimmed down.
We will start initially with combining the current tasks around prevention, palliation, dementia and
consultation around mental health care, each time within one and the same geographically
demarcated regional area. For this, the existing LOGOs (prevention networks) palliative networks and
consultative platforms, multidisciplinary support teams for palliative care, regional expertise centres
for dementia and the consultative platforms for mental health care will create partnership
agreements so that a suitable range of services is available in each care region. A number of the
current tasks (such as drawing up education packages and certain takes involving raising the
awareness of the population and care providers) will shift to the Flemish Institute for Primary Care.
The multidisciplinary supervision teams for palliative care are not support structures like the other
structures mentioned, because they also provide care. These must be geographically aligned with the
operational area of the regional care area for the sake of clarity and transparency.
The collaborative form that must be given to the regional care area will, in the transition stage,
gradually be given shape and this will take place in consultation with the existing organisations
involved. The aim is that one support structure per regional care area is recognised and funded and
that the current support structures will consequently no longer be recognised and funded by the
Government of Flanders. The Government of Flanders will ensure continuity of employment of the
staff members that are involved in the transition.
The shared savings through partnership will, according to the needs, be used at this level or at the
level of the primary care areas.
The funding will take place according to the characteristics of the operating area (size, number of
residents, social-demographic characteristics etc.) and a portion of the resources will be allocated
and justified per task and sector operation (prevention, palliation, dementia etc.). Regional care
areas can, in all openness and transparency and on the basis of consensus, pool the funding of
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certain tasks for specific groups (cf. coordination of partnerships of specialised mental health care
sectors) and themes. The acquisition of funding via alternative sources will also be permitted.
Several primary care areas together will form a regional care area. With a view to good partnership
between the primary and secondary line, these regional care areas should ideally coincide with the
future 14 (federal) hospital networks in Flanders, which in size are at the same level as the regional
urban care regions of the Care Region Decree. Coordination and partnership with coordination
functions within the welfare and health areas from other authorities (cf. federal government network coordination mental health care) is necessary. Coordination with the federal government is
thus necessary.
These regional care areas have the following characteristics:
 Coordination with districts of the clinical hospital networks, a population with a size of around
400,000 residents;
 the regional care areas encompass the entire Flemish territory;
 the regional care areas consist of several primary care areas;
 each primary care area is part of only one regional care area.
The following tasks will be allocated to this level:
1. Adopting the tasks that until now have been performed by making available the LOGOs, palliative
networks and partnership platforms, multidisciplinary supervision teams for palliative care,
regional expertise centres for dementia and consultative platforms for mental health care,
expertise around prevention, palliation, dementia and mental health care, to the primary care
areas (education, support of care coordinators and case managers, good practices etc.) based on
directive and education packages developed by the Flemish Institute for Primary Care. To make
the agreements concerning support very clear, an agreement will be concluded with the primary
care areas that belong to the regional care area. For a description of the current tasks, please
refer to the appendix.
2. Coordination of the primary care services with the services of specialised base hospital care
through the development of a regional strategic care plan in which the needs for basic care at
the primary and secondary care level (primary care and residential care, social care provision and
support, mental health care in primary and secondary care, general base hospital care,
prevention and palliation) will be documented and submitted. When drawing up this strategic
care plan, the contribution and participation of both the hospitals of the regional care zone or of
the clinical network as primary care players is indispensable. The regional care area will act as
articulation level between primary care and the specialised care services.
The Flemish Institute for Primary Care will offer the necessary support for this. This collective
thinking on development of the services to the benefit of a population by both the actors of
primary care and the specialised care is more than ever relevant, considering the growing
importance of integrated interactions, for example the increase of ambulant specialised care and
daytime hospitalisation, preparing in the hospital for a return to the home situation, forms of
extended rehabilitation, respite care for the informal caregiver, etc.
Since the strategic care plan indicates needs at various levels, action will be required at local,
Flemish and also federal level. It has already been stated that dialogue and coordination between
the authorities are necessary. A strategic care plan that meets the quality criteria specified in
advance will form the framework for the Government of Flanders against which individual
applications from care providers (provisions) for permits, recognition or infrastructural fixed
sums are assessed and is, in that sense, an important policy instrument.
3. Support of organisations that set up pilot projects or research with regard to better organisation
of the care in the regional care area.
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4. Treating problems, bottlenecks or obstacles that are identified by the primary care area and for
which no solution can be found at that level.
In the bilingual area Brussels-Capital, the regional care area will be supported by the House of Health
in consultation with the Flemish Community Commission and the Brussels administration
coordination. A study will be made with these partners as to whether new legislation should include
a separate Brussels paragraph, in order to be able to take into account the specific situation of the
care players in the bilingual Brussels-Capital area.
3.2.3
The Flemish level: From Partnership Platform to a Flemish Institute for Primary
Care
After the primary care conference held in 2010, a Partnership Platform of Primary Care was set up by
a Government of Flanders Decree in which forty representatives of virtually all stakeholders in
primary care became acquainted with each other and met three times a year to discuss subjects of
collective interest. Working groups were set up (i.e. the ICT working group, which, among other
things, gives advice on projects to be developed under Vitalink).
The preparations of the primary care conference of 16 February 2017 also began in this partnership
platform.
The working groups that have helped prepare this conference and the academic chamber of
reflection put forward the proposal to set up a Flemish Institute for Primary Care.
The necessary knowledge and expertise can be brought together in such an institute, which can
support the broad primary care. In order to fulfil its role properly, the Flemish Institute for Primary
Care will have a strong link with the federal government and the Government of Flanders, with
research and knowledge centres and with universities. The operation of such an Institute will depend
on government funding and will be directed by the policy.
We are assessing how existing expertise can be bundled and how existing Flemish initiatives and
structures can be integrated into the institute. The project-driven funding of éénlijn.be and the
Expertise Point for Informal Care (which is to be created in partnership with the associations of users
and informal caregivers) will be included in this. The partnership platform for primary care will also
be integrated into the operation of the Flemish institute.
Coordination will be sought with the recently unified welfare support centre and the future support
centre function for mental health care.
Preparing and revising legislation is unquestionably a task of the government, as is assessing the
accountability of the public resources that are made available from the Flemish budget.
We will assign the following tasks to the Flemish institute:
1. Bundling of expertise, evidence, experiential expertise necessary for the underpinning of
integrated care models. For example:


developing a framework for determining care aims of the person with a care need
(methodology, digital support);
developing a template for local authorities and care players in primary care for the
organisation of community-driven care.
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2. Making available to the public a complete, up-to-date and customer-driven overview of the care
services in Flanders, based on validated databases.
3. Making available digital and easily accessed welfare and care information for the informal
caregiver, the person in need of care, professional care players and other interested parties.
Making available a website where knowledge, methodologies and information about informal
care is centralised and provided, accessible information about local support initiatives for
informal caregivers, bundling know-how, stimulating knowledge acquisition, etc.
4. Informing the citizen about and involving him in the integrated care approach (raising awareness,
strengthening position, general information).
5. Supporting an education policy and developing training courses. The task of implementing ICT
expertise and support also fits within this framework. The current project-based funded task of
éénlijn.be will be structurally embedded in the Institute.
6. Providing support to the primary care areas in the fields of organisation, funding, planning,
strategic care planning, administration, etc.
7. Setting up innovative projects, stimulating innovation and offering support in their
implementation.
8. Assisting in the formulation of proposals for a research agenda, e.g. for KCE, support centre,
Institute for the Future, Flanders’s Synergy, universities, around funding mechanisms (e.g.
pursuant to incentive funds, case management or care coordination and consultation), inflow
and outflow in care, working models etc.
9. Offering support in the definition of health and welfare objectives and indicators for primary care
which are suitable and can be monitored at the level of the primary care area and regional care
area.
10. Developing a transparent and uniform complaints policy in partnership with the primary care
areas. Complaints are an important issue for the measurement of quality. It is about the
subjective satisfaction of the persons with a care need.
11. Facilitating and supervising the strategic care planning at the level of the primary care areas and
regional care areas.
12. Collaborating with the Flemish Institute for the Quality of Care in the development of quality
indicators that are applicable in primary care.
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3.3
PRECONDITIONS
It is clear that the authorities will also have to undertake the necessary efforts to ensure that care
and social services develop further in the proper direction.
We assume that the care and support will perform efficiently and well if:
 Each care provider has thorough knowledge of the care services, so that a targeted referral and
the composition of a care team becomes clear-cut;
 Cooperation is undertaken in an interdisciplinary way and information is shared digitally, based
on the care aims of the person with a care need;
 Clear task agreements and a clear allocation of tasks exist;
 There is sufficient digital support to ensure that the care process runs as smoothly as possible;
 A professional mechanism exists for the professions (group practices);
 Adapted funding is provided, that promotes and supports the integrated and digital operation.
Reorientation of existing funding streams will be reassessed for this.
 There is sufficient participation by the users.
The care and support will be of high quality if:
 There is basic and ongoing training that teaches the care providers the necessary competencies
and skills concerning integrated care and support, and use of e-health services;
 Sufficient care capacity is available;
 A quality policy exists, with objectives for primary care and a complaints policy;
 Substantive expertise can be supplied, provided with the necessary methodologies to support
practical implementation;
 Coordination between generalist and specialist care operates smoothly;
 Care and support is coordinated to the requirements and needs of the population in the working
area of the care providers;
 Good support of the care providers is present.
 There is room for innovation and entrepreneurship.
Below we expand on several of these elements and indicate which policy actions must be taken to
achieve all this.
3.3.1
Initial training and on-going training
The correct basic attitude and competencies are taught in the initial training of the care players in
the most efficient way possible. This implies that the initial training assumes an integrated care
approach, in which the person with a care need takes the central position. During this training,
attention is needed for interviewing the person himself, the process of empowerment, framing the
care needs and linking the actions performed to these aims. The training should view the
multidisciplinary approach to complex care needs as self-evident. Work placements and training on
interdisciplinary partnership are needed. Care providers should learn these skills in order to include
care coordination as a fundamental part of the care. With regard to accessibility of the care,
attention must be given to the physical, psycho-social, cultural and financial obstacles that persons
with a care need can face. Care players should also be able to find their way easily to up-to-date data
on the care and welfare services and the availability of those services.
They are trained from a broad definition of care, going from health promotion, disease prevention
(including population studies), treatment of disease, monitoring after treatment to palliation and the
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end of life. There is sufficient training about care and welfare among diverse age categories and
target groups, so that the care provider can take a whole approach to the person with a care need. It
is extremely important that the training provides a broad perspective of the profiles and expertise of
other care providers. In this way, the care providers learn to recognise each other’s tasks and
competencies and can correctly assess the added value of each care provider.
The care providers of today, who have not yet undergone the training outlined above, require on-going
training coordinated to federal initiatives.
Action:
 Consultation with the Minister for Education concerning:
 initial training (and permanent training) of care providers;
 adding health literacy as a learning aim in the education policy;
 The successfully acquired know-how concerning support of the care providers, the development
of a training policy and elaboration of training programmes with a view to implementing ICT
expertise and support of the care providers, will be embedded in a sustainable way. The current
project-based funded task of éénlijn.be will become a structurally embedded task of the Flemish
Institute for Primary Care.
 Assessing what éénlijn.be can mean in on-going training.
 As agreed in the action plan eGezondheid32 between the federal government and the federated
states, the following actions will be undertaken in advance:
 An ‘e-health’ subject in each training course in healthcare (doctors, pharmacists,
physiotherapists, nurses etc.) with the number of hours or study points to be determined
later.
 Inclusion of e-health in the competence profiles of the various care professions.
 Specific training on the actual use of e-health services (EMD etc.) is a mandatory element in
all accreditation and further training systems.
3.3.2
Care capacity in primary care
In addition to supporting the care players within primary care, and building further on the ‘Action
Plan 3.0 - Making work of work in the care and welfare sector’, the policy concerning care
professions and ensuring the necessary influx of manpower are essential. If the quality of primary
care is to be guaranteed, it is essential to have sufficient, well-trained care providers.
Analyses of the available figures show that important professional groups, active in primary care,
may be on the increase in total, but that the need for new care providers is still very great,
considering the increasing number of care providers who will retire in the coming years. The
necessary attention for on-going promotion and attention for the various professional groups may
therefore certainly not weaken.
The Sixth State Reform has transferred important powers concerning this to the municipal level: the
recognition of healthcare professions and setting sub quotas.
As far as general practitioners are concerned, the Government of Flanders will, in consultation with
the deans of the medical faculties, the federal government and representatives of the doctors,
ensure that the number of potential general practitioners increases in terms of the total Flemish
contingency of doctors.
32
Ehealth in the training via http://www.plan-egezondheid.be/actiepunten/12-opleiding-en-ict-ondersteuning-van-zorgverstrekkers/
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Action: consultation with the deans of the Flemish universities, representatives of the doctors and
the federal government.
A well-considered organisation for training of new healthcare professions, which makes it possible to
reallocate tasks via the principle of subsidiarity, is advocated. This is also important for keeping care
cost-efficient and affordable, but also for coping with shortages. For example, surgery assistants
could be deployed for dentists and general practitioners, or nursing care workers to relieve nurses.
To cope with the shortage of dentists, it could also be considered whether the admission test for
dentists could be separated from that for doctors (without in doing so paving the way for
circumvention of the admission test for doctors).
Action: The Royal Academy of Medicine and the Dentists’ Associations will be asked for advice on
this matter. Coordination with the federal government is also essential here.
The federal government is competent for the regulations of the health-care professions. The federal
government has announced a thorough reform of this via the reform of RD78.
The Flemish Community has framed the following positions concerning this:
 Develop a better, clearer and specific differentiation between nurses holding HBO5 (higher
professional education level 5) and those with a Bachelor degree.
 Retain the profession of nursing care worker.
 Upgrade care workers to nursing care workers.
Action:
 A plea for greater clarity for differentiation in the care professions will also be developed.
 We give further implementation to the plan ‘Making work of work in the care and welfare sector
3.0’.
3.3.3
Support of primary care practice forms
It is necessary to create organisational conditions so that care and welfare providers - with the
professional expertise that is theirs - can collaborate on targeted care, across the boundaries of
organisations. How can teams be facilitated which have as large a responsibility as possible to
achieve this targeted care? What leadership does this imply? Who assumes which role within the
group? These are open, learning networks that, according to the mission and the needs, for example
concerning innovation, have a changing and open composition. Multidisciplinary partnership is thus
taken as starting-point in all future developments of training, funding models, digital
communications etc. The administrative burden with which care providers are confronted must be
given special attention by authorities that must be open to suggestions from the care providers on
ways to reduce this burden.
Fewer and fewer young people find a solo practice inviting and are opting to enter into group
practice (whether or not in the form of a firm). The profession of independent care provider is
accompanied by greater complexity in the area of taxes, social status, staff policy, etc. The starting
and organisation of a group practice increases this complexity. Because of this, independent care
providers require support in the area of running a practice and particularly when starting up a
practice. A better legal and fiscal framework will promote the social entrepreneurship of
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independent care providers. The Federation of Liberal Professions and the professional associations
play a crucial role in this.
The Federation of Liberal Professions was given the task of developing models for integrated
practices for independent care providers. In an initial stage, an inventory of existing initiatives (with
special attention for forms whereby integration exists between health and welfare) was drawn up.
The ‘best practices’ of integrated primary care by independent care providers were analysed. Legal
and deontological obstacles (also those concerning nomenclature) were mapped and also the
relevant needs and requirements of the care providers.
In a subsequent stage, they will develop models for integrated primary care in which the following
aspects of partnership in an integrated care organisation will be handled: the legal translation,
deontological, pluralistic, financial, organisational and personal aspects, quality and participation and
freedom of choice by the person with a care need.
Several models of partnership are possible. The Government of Flanders is not opting for one
approach in which all practices in primary care must be encapsulated in strict recognition criteria.
The principles that we give primary emphasis to in our policy are interdisciplinary operation and
integrated care and support, whereby the person with a care need is always given the central
position and has complete freedom of choice. Important aspects that the government must enable
for this include: the use of a uniform indication instrument, data-sharing via use of electronic patient
files, facilitating consultation, clarity of the function of care management and care coordination, use
of quality indicators, administration simplicity, etc.33 We also rely here on the dynamic of the care
teams and care councils.
The basic conditions for socially responsible care34 must be guaranteed: quality, performance,
fairness and accessibility. The aspect of ‘accessibility’ is also an important basic condition for
vulnerable groups, such as people in poverty. All care providers must also bear in mind this group of
people, who often postpone care because of other problems (work, housing, financial problems,
growing isolation).
In order to provide clarity to the person with a care need about the care providers in his region, the
social services directory will be adapted and supplemented so that he obtains insight into the care
providers to which he can appeal.
As far as general practice is concerned, the incentive fund provides a business establishment grant, a
loan or support from a (tele) secretariat. The study into how the incentive fund35 works indicated
that:


the Incentive Fund is used a lot by general practitioners: more than half the Flemish general
practitioners makes use of the secretariat support.
every general practitioner is very positive about the support he receives (whether this is a bonus,
a loan or secretariat support).
33
Draft memorandum on change agenda for elderly care via:
http://www.jovandeurzen.be/sites/jvandeurzen/files/160205_Conceptnota_Vlaams%20welzijns%20en%20zorgbeleid%20voor%20ouderen_0.pdf
34 Vision memorandum : Socially responsible care. Strategic Advisory Council Welfare, Health and Family. Available via:
http://www.sarwgg.be/sarwgg/document/visienota-maatschappelijk-verantwoorde-zorg
35
Van Roy, K., Peersman, W., De Lepeleire, J., Mamouris, P., De Sutter, A. ,De Maeseneer, J.& Goderis, G. (2017). Evaluation Incentive Fund report UGent and KULeuven.
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



the Incentive fund has made a real contribution to professionalising the performance of the
general practitioners, regardless of the form of the practice.
the Incentive Fund was a push to think differently about the way of running the practice.
the business establishment grant is not in itself a deciding factor in determining where to locate
the practice. Impulseo has no effect on the density of general practitioners.
The support centres were seen as an important added value.
Following recommendations were made:
1. Continued focus on the appreciation of general practitioners and the recognition of their needs.
2. The primary objective of the support must remain directed at guaranteeing accessibility of the
primary health care through good dispersal of the services and attention for socially vulnerable
groups.
3. The criteria for determining areas with few general practitioners or priority areas should be more
refined and diversified.
4. Support in running the practice in primary care can best be extended from (tele) secretariat
support to other disciplines within the practice (surgery assistant, social work, nurse etc.).
5. Greater focus on stimulating and supporting partnership (multidisciplinary working).
6. The possibility for evaluation must be included from the start.
These recommendations can be transformed by a differential allocation of (a limited part of the
resources of) the Incentive Fund. In 2017, this amounts to 14,786,000 euros in total. While awaiting
the development of the actions below in consultation with the general practitioners, the current
operation of the Incentive Fund will be continued.
Actions:
 In consultation with the umbrella organisations of doctors and general practitioners and the
Flemish Institute for Primary Care:
 review the conditions for determining priority areas in the context of the Incentive Fund,
based on social-demographic and social-economic factors;
 we will explore, for the setting up of surgeries in priority areas, whether and how the existing
instruments and incentives (CIPA support and incentive bonus) can be harmonised,
optimised and further allocated within primary care.
 we will assess the possibilities and conditions for extending the current concessions for
administrative support to other disciplines in the surgery and to do this with a view to
facilitating more integrated care and interdisciplinary partnership. This will take place within
the budgetary possibilities.
 we will explore how electronic data-sharing and work placement support can be stimulated
via criteria for the allocation of the aforementioned concessions.
 The social services directory will be adapted so that the necessary clarity exists about the
services of care providers and organisations.
 We will also focus on ICT development and support as part of Vitalink.
 Via the service providers of the SME portfolio.
 Can the supervision of startup care providers be supported in development of their own
practice
 training will be offered as part of the needs of the target group, such as care management,
and in due time, if desirable, training on multidisciplinary partnership can also be created.
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3.3.4
Funding of primary care
3.3.4.1
Funding from the federal government
A glance at the federal expenditure for primary health care shows a general budget of 4.3 billion
euros for Flanders in 2017. This budget is divided as follows over the various budget items:
honoraria
logopedisten
1%
Federaal budget 2017 - Vlaanderen
honoraria
kinesitherapeuten
10%
subsidies diensten
voor thuisverpleging
1%
honoraria
tandartsen
13%
honoraria
thuisverpleegkundig
en
21%
honoraria
vroedvrouwen
0%
honoraria huisartsen
(incl. wachtposten)
22%
terugbetaling
geneesmiddelen in
officina**
32%
Over a period of five calendar years, this budget rose in total from 3.9 billion euros to 4.3 billion
euros.
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Federale uitgave 2012 - Vlaanderen
honoraria
kinesitherapeuten
9%
honoraria
logopedisten
1%
honoraria
tandartsen
12%
subsidies diensten
voor thuisverpleging
0%
honoraria
vroedvrouwen
0%
honoraria huisartsen
(incl. wachtposten)
20%
terugbetaling
geneesmiddelen in
officina
39%
honoraria
thuisverpleegkundigen
19%
The Government of Flanders had, in contrast to this, a budget of 2.77 billion euros for the same
primary health care.
Vlaams Budget 2017
ondersteuning
€ 034
thuiszorg
€ 685
MBE
€ 008
ouderenzorg
€ 2,052
€ 000
€ 500
€ 1,000
€ 1,500
€ 2,000
Millions
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care
Multidisciplinary support teams for palliative care
€8,328,659
support sector
Palliative Networks
support sector
€1,516,341
support sector
Associations concerning palliative care between care institutions and
services
Collaboration initiatives in Primary Healthcare
support sector
Integrated Services for Home Care
€1,399,617
support sector
Local Multidisciplinary Networks
€4,950,000
support sector
support sector
Impulseo business establishment grants, telesecretariat and surgery
support
Impulseo loans
Flemish expertise centre and regional centre of expertise for dementia
support sector
General practitioner group practices
home care sector
home care sector
Services for family care, supplementary home care, minders and foster
care
Social work services
home care sector
Local service centres
home care sector
Regional service centres
home care sector
Associations of users and informal caregivers
home care sector
Personal alarm appliances, Projects
care
Residential care centres
care/welfare
alternative employment measures WZC ex-DAC and GESCOs
€44,846,000
care
Day care centres, short-stay centres
€45,709,000
prevention
Local Health Consultation
€960,697
€2,512,704
€14,786,000
€3,565,000
€1,656,000
€2,351,000
€657,174,729.33
€17,186,743.92
€7,755,719.59
€1,587,273
€620,306.34
€625,000
€1,953,000,000
€6,819,000
The funding from the NISDI includes the fees for the varied professional groups of RD No. 78. A large
part of the budget includes the refund of medications. The latter also includes the fees of the
pharmacists.
The fact that the federal government is competent for the settlement of performances of the
healthcare professions influences to a large degree the way in which the reform of primary care can
be achieved.
An integrated care organisation demands an integrated funding of that care. Such funding focuses on
the accessibility of the care, quality of care, interdisciplinary partnership, coordinating the care for
the promotion or retention of autonomy and the directorship role of the person with a care need.
Person-linked funding is, according to the Government of Flanders, an important lever in this.
The competences in the field of primary care will remain, despite the Sixth Reform, dispersed over
the communities and the federal government. Collaboration and coordination is needed to arrive at
a coordinated policy.
A first step is the common action plan for integrated care for the person with a prolonged and
complex care need. This plan is intended to promote a more integrated policy in the area of primary
care. The most important line of action is the operation of pilot projects. Throughout Belgium, a
maximum of twenty pilot projects will be started in June 2017; of these, 10 will be held in Flanders.
The integrated care pilot projects are currently working on bottom-up proposals for an adapted
funding system. Flanders is also asking them to experiment with person-linked funding. Lessons can
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be drawn from their experiences concerning the feasibility and desirability of specific funding
mechanisms.
How the care providers, primarily those stated in RD no. 78, are funded and what their job
description looks like is of considerable influence on the way in which these care providers organise
and provide care. The RD no. 78 is currently under review by the federal government.
The RD has two sections - one section with the profiles of the care providers and another on quality.
The substance of both sections will influence the Flemish reform of primary care. Here again,
coordination is required. The Flemish Community submitted an opinion to the federal government
on the reform, in which it clearly expressed that a unilateral reform would have negative effects on
the performance of the competences of the Flemish Community.
For the reform of RD No.78, coordination will also be required around the care and service providers
recognised by the Government of Flanders, in the care and assistance decree. Coordination is
indispensable for arriving at an integrated care model. During the reform, the federal government
should ideally also take into account developments within the integrated care pilot projects. Within
these projects, thought is being given within a loose framework to appropriate elaboration of the
allocation of tasks to allow care to be offered as efficiently as possible.
3.3.4.2
Funding from the Government of Flanders
The Government of Flanders spends an annual budget of 2.77 billion euros on primary health care
(see later). It is clear that, for example, via development of the Flemish Social Protection and the
benefits and person-linked funding of help and service provision connected to it, a general
framework must be developed for the coming years. This must be empirically validated (support
centre WVG is currently working hard on this). Because this implies fundamental budgetary choices,
everything must be done so that, when the next coalition agreement is concluded, long-term
agreements can be made. In the meantime, further work will be undertaken along the growth paths
set out (e.g. family care, residential care for the elderly, etc.) and possibilities within the available
budgetary scope of the policy area of welfare, public health and family.
The financial resources allocated by the Government of Flanders to the current support structures
will be redirected to the new structures.
Generally speaking this is a sum of 11,598,704 euros in 2017 (SEL/GDT, LMN, resources of GDT for
multidisciplinary consultation: physical, coma and psychopathological and éénlijn.be).
Currently there are at least 90.20 FTEs employed in the SEL/GDT and LMNs. In the transition stage,
this funding will be gradually redirected to the ‘autonomous’ primary care areas, whereby there will
be proportionately less resources allocated to the current structures, which will then die out over
time.
As appendix you will find an overview of the number of FTEs (2015) and also the available financial
resources (2017).
3.3.4.3
Communicating budgets in closed barrels
The sixth state reform undoubtedly gives the Flemish Community the opportunity of adding its own
dynamic to the development of care as provided in primary care. But - and this was actually no
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different before the last state reform - intensive consultation and partnership are absolutely
necessary.
The special legislative body clearly states that the performances undertaken by care providers (fees
and the nomenclature (the list of provisions that are fully or partly compensation by the health
insurance)) is a federal operation.
The admission of, for example, primary care psychologists to the care profession for which
performances are eligible for repayment fall under federal competence. The subsidising of the
operating costs of hospitals is also a federal competence. Subsidising infrastructure costs of hospitals
in Flanders and of single-community, Flemish hospitals in Brussels is, on the other hand, a
competence of the Government of Flanders.
When the Government of Flanders earmarks budget to update a traditional rest home bed (ROB) to a
rest and care bed (RTV-bed) for residents with demanding care needs (an increase of the subsidy per
residential unit that is occupied), this means, in the current situation, that the costs of the
performance of physiotherapists are borne by the Government of Flanders and no longer the federal
health insurance.
When the federal minister shortens the length of stay in hospital for young mothers and their newborn baby, this increases the demand for maternity care at home that is provided by family care
services which are financed by the Government of Flanders.
A policy measure with budgetary impact which is taken by the federal government can thus also have
an impact on the expenditure of a Community (Government of Flanders). And vice versa.
But the budget forecasts and the budget expenditures do not coincide. The sixth state reform does
provide binding legal agreements (in the special funding act) whereby an earmarked amount for the
competences that are transferred is followed from the federal to the Flemish budget. But
reorganisations that take place after the transfer of the competences under the sixth state reform
must be funded (or lead to savings) within the own federal or Flemish budget.
Action: A clear, transparent, proactive coordination between the federal government and the
federated states in the inter-ministerial conference and in the Institute of the Future (which is still to
be set up) is therefore necessary in the interests of the persons with a care need and care providers.
3.3.5
A digital primary care
The Government of Flanders shares the ambition of the federal government and the other regions to
achieve complete digitisation of the medical files of the general practitioner by 2020, in the action
plan e-Gezondheid.36 For Flanders, this means that by 2020 the multidisciplinary sharing of a care
and support plan will be a fact.
The Government of Flanders therefore focuses further and more specifically on the expansion of
Vitalink, as essential and crucial network of data-sharing in care, which is important for an integrated
care provision, such as the journal and the agenda, as soon as the concept and the context of the use
is sufficiently sharply defined and other preconditions are met. It is also important to continue
coordination with the other authorities, as we do today in the context of the e-health plan. The datasharing agency will be the forum where the stakeholders of the Flemish welfare and health care
sector find each other and where new concepts concerning data-sharing can be developed. The
36
Action plan eGezondheid 2015-2019 via http://www.plan-egezondheid.be/
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monitoring of existing projects and actions, such as those included in the e-Gezondheid plan, can also
take place within this agency and collective opinions can be taken and agreements reached.
Vitalink will, together with the associated applications, become the forum in which the care
providers can work in an interdisciplinary manner on realising the care together with the person with
a care need. The crucial condition that must be met in order to achieve our ambitions for a digital
and integrated primary care is the unequivocal commitment of all care providers and stakeholders
involved. As stated already: everybody must participate.
But the ambition goes farther: not only the care providers in healthcare but also the care providers in
the welfare sector should take the path towards a digital working environment. In other words, we
do not just evolve to an e-health situation, but to an e-care situation, and only then can we really talk
of integrated care.
During various information technology projects that Care and Health have initiated in the recent past
(2013-2016), considerable practical experience was acquired concerning data-sharing in primary care
and also, for example, in elderly care. Through integrated care provision, a person with a care need
comes into contact with various care providers within primary care, elderly care and specialised care.
An optimum exchange of the relevant care and medical data between various care players is thus
elementary for care continuity.
Further attention will be given to various projects that facilitate integrated communications between
the various care players in the day-to-day care practice. Within the eWZC project (digitisation of files
in residential care centres), for example, various technical functionalities are being developed that
make the exchange of data possible between hospitals, general practitioners, pharmacists and
residential care centres, and with the BelRAI platform.
This answers one of the objectives from the eGezondheid action plan to promote the exchange of
data with all care institutions and players from primary care and the specialised care.
Eénlijn.be is a broad change project to promote the use of ICT applications in primary care through
training, e-learning and a helpdesk and to promote the partnership between the primary care
players. It aims, through ICT, to promote the sharing of data between primary care players by using
the e-Gezondheid services, such as Vitalink medication schedule, Vitalink SUMEHR (summary of
essential medical data), Recip-e (electronic prescription) and the e-HealthBox (secured
communication of personal data between healthcare practitioners).
Between 2013 and 2016, in total 1,509 sessions were given to 17,250 care providers. The majority of
these sessions were for general practitioners (around 90%). There were 6,251 visitors to the
éénlijn.be website.
A second project period started at the end of 2016 and is running until the end of 2019, whereby the
range of training will be expanded and will evolve from supply-driven to demand-driven training.
3.3.6
Innovation and entrepreneurship
In the context of offering and providing care, also in primary care, reference is often made to the
term ‘social enterprise, or socially responsible entrepreneurship’. Social entrepreneurs aim, by
means of their activities, to create social added value. In other words, irrespective of the legal status
of the health and social care organisation, they do not aim solely for profit. The enterprise can
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develop both within profit and non-profit organisations and attaches importance to both social and
economic value creation to ensure the financial sustainability and the economic vitality of the
initiatives.
Social enterprise means being primarily focused on innovative, creative and flexible ways of offering
demand-driven care and support. Within a rule-free context, with sufficient room for management,
social entrepreneurs can respond to changing care and support requirements. It goes without saying
that agreements with regard to information and transparency concerning the quality, performance
and the price are part and parcel of this, together with a good staff policy.
We also conclude that in primary care there are care providers active as self-employed
entrepreneurs or as part of a firm. In that sense, there is also an element of market forces present,
whereby the mechanism of supply and demand plays a roles. A health market mechanism with
increased objectivity and transparency offers, in combination with social enterprise, added value to
primary care in the area of quality competitiveness, cost efficiency, demand-driven provision and
innovation.
The most important innovation for the future of primary care is in the reform of care into a more
integrated care system. This involves a change in thinking and attitude and a change in care
processes.
Innovation projects that have been initiated in this area in recent years include the Care Testing
Grounds, projects of the Government of Flanders Architect (see appendix), the care innovation
projects and the starting of integrated care pilot projects. The integrated care pilot projects are being
implemented in partnership with the Federal Government and the federated states and were set up
for the implementation of the collective plan for integrated care for persons with a prolonged care
need.37 These projects contain all the elements that should lead to more integrated care:
empowerment of the person with a care need, interdisciplinary partnership, quality policy, adapted
funding, care coordination and case management, training etc. The aim of the projects is to give the
care providers themselves the responsibility of organising care differently.
The success of Vitalink, as network for data-sharing between the players in care, depends to a large
degree on the effective use by the players in care. It is equally important that these players in care
can avail themselves of the necessary adapted (user-friendly) software. Currently there is no formal
consultation with producers of software for players in care. The new Agency of Data Sharing is asked
how consultation and partnership with a representation of software producers can be organised.
This would be a strong signal towards valuing their expertise in the further evolution of, among other
things, Vitalink. This should improve the dialogue between, on the one hand, the players in care
about their expectations and priorities concerning software/ICT solutions, and on the other software
producers about the technological possibilities and priorities. Both target groups need each other,
are dependent on each other and therefore a dialogue and cooperation are essential.
The Government of Flanders will continue to stimulate and support innovative initiatives. Based on
Flanders' Care 2.0, where we want to ‘improve in a demonstrable way and through an innovative
range of qualitative care and stimulate responsible entrepreneurship in the care economy’, we want
to make use of the results of the testing grounds and other initiatives. These can make an important
37
Collective Plan for chronic diseases. Integrated care for better health. Available via:
http://www.integreo.be/sites/default/files/public/content/plan_nl.pdf
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contribution to achieving innovation and entrepreneurship within the eco-sysstem of the Flemish
Institute for Primary Care and, through extension, the entire primary care.
Actions:
 In all our actions, we will ensure that this takes place with a minimum of administrative red tape,
where possible with a reduction in costs and minimisation of rules.
 The Flemish Institute for Primary Care and Flanders’ Care will coordinate how, in synergy, the
following actions can be included for primary care:
 Via the participation platform Flanders’ Care, we will announce the existing care and welfare
initiatives in care and welfare in general and in primary care in particular.
 Monitoring, announcing and adding further to the existing innovation instruments and the
possible support that can be offered.
 Identifying and dispersing “best practices” concerning innovation and entrepreneurship in
care and welfare in general and in primary care in particular.
 Listing success factors, insights and experiences concerning care innovations both at home
and abroad.
 Ensuring interaction with care providers and welfare workers from the very start (already at
the concept stage) and in all other stages of the innovation process.
 Giving preference and focus to demand-driven innovations based on the person with a care
requirement/citizen, the healthcare practitioners and the welfare workers.
3.3.7
Quality policy
Implementing a quality policy is an indispensable element of integrated care.
To tackle this specifically, we are working on determining the objectives for primary care. For this we
can will gain inspiration from the health objectives that have been formulated and achieved in the
preventive healthcare policy.
This will require an analysis at Flemish level and at the supportive level of the care providers and
resources available and also of the needs and risks of the population: number of elderly people,
persons with a chronic disease, functional condition, addiction, etc. The primary care areas will
contribute to the performance of this analysis. In addition, data from studies, complaints, quality
measurements, BelRAI, information from patient and user associations will be included. Based on
this, and in consultation with a broad platform of experts, players involved at various support levels
and the population, the objectives will be drawn up. Indicators will be attached to these objectives.
These indications will form the basis for the expansion of a quality policy that is supported through
the participation of the stakeholders concerned.
Indicators for measuring quality will preferably first be developed for each discipline. Measuring
quality also demands a major culture shift for diverse disciplines. Only when the indicator sets prove
stable enough and are sufficiently underwritten by the people in the field, can thought be given to
measuring interdisciplinary partnership. The reform of RD No. 78 includes expansion of the area of
quality on the agenda. The Government of Flanders will enter into consultation on this with the federal
government.
The Flemish Institute for the Quality of Care will develop the quality policy, together with the Flemish
Institute for Primary Care.
Both institutes will study together how to shape a transparent and independent complaints policy.
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Complaints policy is, after all, an important component of the quality policy. The complaints
settlement will be, preferably, easily accessible and organised in a simple way, for example at the
level of the regional care area. Since the authorities in a complex country such as Belgium cannot
expect the citizen to distinguish between Flemish and federal competence in the area of healthcare,
and thus also not know to which authority he should turn with a specific complaint (see appendix),
coordination with the federal government is appropriate, with a view to achieving one point of
contact or desk. This entire process must be carefully prepared and discussed with all the
stakeholders before a start can be made on a new regulatory framework.
For the implementation, the regulations on the Consultative Platforms for Mental Health Care can
prove inspirational. The Consultative Platforms have an ombudsman function at their disposal, as
stipulated in the law concerning the rights of the patient. The external ombudsmen of the
Consultative Platforms are autonomous and independent and focus on all patients with complaints
about their treatment or supervision, cf. the law on patient rights, within the specialised mental
health care, running from Centres for Mental Health Care (CGG) to Psychiatric Hospitals (PZ). The
Consultative Platforms are funded by the Government of Flanders. For the ombudsman function,
psychiatric hospitals can choose to involved the consultative platform as external ombudsman
function. This function is then partly funded by the psychiatric hospitals.
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4
CHAPTER 3. Transition
Achieving the ambitions in this plan will take several years. It requires considerable consultation with
all the parties involved. The regulatory process to achieve these ambitions will be started on the day
following the primary care conference.
Periodic monitoring, evaluation and, where necessary, adjustment are envisaged. During this
transition period, the following activities are important:
4.1
PREPARING REGULATIONS
The following regulations, with specific relevance to primary care, are eligible for amendment:
 Decree of 3 March 2004 concerning primary health care and the partnership between the
healthcare providers
 Care region decree of 23 May 2003 concerning categorisation in care regions and concerning the
partnership and programming of healthcare provisions and welfare provisions.
 Decree of 18 May 1999 concerning mental health care
 Residential and Home Care Decree of 13 March 2009,
 Government of Flanders Decree of 19 December 2008 concerning the partnership initiatives for
primary care
 Government of Flanders Decree of 26 December 2015 concerning the general practitioner group
practices
 Government of Flanders Decree of 9 September 2011 on the establishment of the Collaborative
Platform for Primary Health Care
 Government of Flanders Decree of 7 October 2011 containing the designation of the members of
the Collaborative Platform for Primary Health Care
 RD of 23 March 2012 on the establishment of an incentive fund for general practice and for
framing it operational rules
 Royal Decree of 8 July 2002 on determining the standards for the special recognition of
integrated services for home care
 Royal Decree of 14 May 2003 on determining the provisions stated in article 34, first paragraph,
sub-section 13 of the law on the mandatory insurance for medical care and benefits, coordinated
on 14 July 1994
 Royal Decree of 15 December 2009 on the establishment of conditions under which the
mandatory insurance for medical care and benefits allocates funding to the integrated services
for home care
 Ministerial Order of 18 November 2005 on determining the amount of and the conditions under
which a concession can be allocated for the provisions stated in article 34, first paragraph, subsection 13 of the law on the mandatory insurance for medical care and benefits, coordinated on
14 July 1994
 Royal Decree of 22 October 2006 on establishing the conditions under which the Insurance
Committee, pursuant to article 56, par. 2, first section, 3, of the law concerning the mandatory
insurance for medical care and benefits, coordinated on 14 July 1994, can conclude agreements
for the funding of therapeutic projects concerning mental health care
 Royal Decree of 27 March 2012 on establishing the conditions under which the Insurance
Committee, pursuant to article 56, par. 2, first section, 3, of the law concerning the mandatory
insurance for medical care and benefits, coordinated on 14 July 1994, can conclude agreements
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











for the funding of the participation in consultation around a psychiatric patient, the organisation
and coordination of this consultation and the function of a reference person
Government of Flanders Decree of 3 May 1995 on the recognition and subsidising of palliative
networks
Coordinated law of 10 July 2008 on the hospitals and other care institutions, article 10
Royal Decree of 19 June 1997 concerning the establishment of the standards that a partnership
concerning palliative care must meet in order to obtain recognition
Royal Decree of 19 June 1997 whereby some provisions of the law on hospitals, coordinated on 7
August 1987, were declared applicable to the partnerships for palliative care between care
institutions and services
Royal Decree of 19 June 1997 concerning the establishment of the subsidy allocated to the
partnerships for palliative care between care institutions and services and concerning regulation
of the allocation procedure
Government of Flanders Decree of 6 February 2015 on the amendment of article 1 and repealing
article 2 of the Royal Decree of 19 June 1997 concerning the establishment of the subsidy
allocated to the partnerships for palliative care between care institutions and services and
concerning regulation of the allocation procedure
Royal Decree of 19 June 1997 concerning the establishment of the standards that a partnership
concerning palliative care must meet in order to obtain recognition
Royal Decree of 13 October 1998 on determining the minimum criteria that agreements between
the multidisciplinary support teams for palliative care and the Insurance Committee established
at the Service for medical care of the NISDI must meet.
Royal Decree of 15 September 2001 on the implementation of article 59 of the programme act of
2 January 2001
International treaties legislation: Regulations EC 883/2004 and 987/2009 on the coordination of
social security systems, and the bilateral agreements concerning social services
Ministerial Order on the allocation of a project subsidy to the initiators who organise a local
multidisciplinary network
Ministerial Order of 20 July 2015 concerning the general practitioner areas
In the new legislation, each primary care area, each regional care area and the Flemish Institute for
Primary Care (to be founded) must adopt transparent operation, with public accountability of the
resources that have been made available by the community.
4.2
REALLOCATION OF STAFF AND RESOURCES
First of all, the sectors will be listed which will be absorbed into the new structures of the future. This
exercise will result in an overview of available resources and staff. The transition assumes a gradual
reorientation of the funding of operation and staff to the simplified structures in the new landscape.
The transition assumes a gradual transition to the new structures, without double funding. We will
adopt these with care for the employees.
From the moment that the autonomous primary care areas are recognised, they will be allocated the
resources and personnel. Staff and resources will also be allocated to the Flemish Institute for
Primary Care, whereby first of all a review will be held of the reorientation of existing resources.
The reorganisation of primary care is not hidden austerity. The focus is a strengthening of primary
care whereby the ambition of the Government of Flanders is to continue to invest in primary care.
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The Government of Flanders will, in this connection, encourage co-funding for the primary care
areas.
Finally, it must be absolutely clear to the employees involved that their employment is not under
threat. Naturally, every care will be taken and the necessary social consultation held. The transition
process will be carefully supervised.
4.3
SHARING OWNERSHIP OF THE REORGANISATION
It will, no matter what, be necessary to spread the new vision on integrated care and the
reorganisation of primary care this entails to everybody who works in primary care or in the
supporting structures. The conference on 16/2 is a first step in an entire transition process.
Commitments from the professional group practices, from the LMN and the SEL/GDT, the services for
social work, the local authorities and their welfare council and social centre, the CAW, the palliative
networks/partnerships, the consultative platforms for mental health care, the expertise centres for
dementia and the LOGO prevention networks are essential for this reform to succeed.
Particular attention will be given to the education and supervision of employees who will be asked to
help sustain and flesh out these reform. Ultimately, they will implement and embody the reform in
the field.
A participatory process will be set out for the preparation process and also in the post process,
sufficient consultation will be held with those sectors involved in primary care.
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5
Summary
Various independent care providers, organisations and structures have been providing accessible,
high-quality and affordable care for many years. Because of the way in which these organisations and
structures have arisen, care unfortunately also takes place in a fragmented way and from too many
structures. The citizen can no longer see the wood for the trees and has insufficient grasp of the
organisation of his care and support. The care providers see too much of their time consumed by
administration and meetings. It must become simpler, more effective and more transparent,
whereby the person with a care need has the highest possible control over the organisation of his
care.
The Flemish Coalition Agreement 2014-2019 includes simplification of the primary care structures
and the strengthening of primary care. The Sixth State Reform provides the momentum for focusing
entirely on this. A participatory process with six working groups gives us sufficient information and
insight for seeing the necessary evolutions clearly.
This text therefore outlines the policy direction for primary care in Flanders between now and 2025.
The World Health Organisation has given us an inspirational model. The WHO model positions the
informal caregiver, the volunteers and the neighbourhood as the first protective and supporting skin
around the person with a care need, who takes central place. When care needs become more
complex, primary care must be activated. Considering the increasing care needs of an ageing
population, it is of vital important to be able to rely on strong, well developed primary care. Let us try
to bend the lines into circles in a concentric model.
From the circles of the concentric model we review the desired changes.
Person with a care need at the centre
Each person is entitled to care and support that allows the best possible quality of life. Helping
people achieve the best possible quality of life and which they personally desire is the ultimate aim
of our care and support. And so we come automatically to an integrated approach. Care and support
in which lines, levels and sectors are subordinate to this aim and whereby care is offered in an
integrated way. Care in which the person takes the central position and where the care providers,
together with the person, map out the path to the best possible and attainable quality of life and
help him achieve it. The term ‘help him achieve it’ is very important here. It suggests that the
autonomy of the person is the starting point and the role of director is assumed by the person
concerned, or his informal caregiver.
To improve that autonomy, lifelong efforts are needed to gain empowerment and acquire healthcare
skills. When the person is confronted with a complex or prolonged care need, we assume the ideal of
self-management. If a person is confronted with a reduction in autonomy, the management role of
the informal caregiver as trusted person must be fully respected. Informal care providers (family,
friend, neighbour, volunteer and informal caregiver) must be placed on an equal footing with
professional care providers. The Flemish informal care plan aims to strengthen that position of the
informal caregiver.
Persons with a care need or care demand or their informal caregivers often look for information and
a suitable answer. There is also a need for reachable, easy to access, local admission functions, both
physical and digital, where help-seekers and their informal caregivers can obtain all useful, objective
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information about their support demands. We will bundle the expertise of the the General Welfare
Centres (CAW), the Public Centres for Social Welfare (OCMW) and the social services of the mutual
insurance funds in a partnership of integrated admission that is broad and recognisable.
Community-driven care
Persons with a chronic care need or reduced self-care ability generally want to stay at home longer.
Being able to achieve this wish is often made possible by a range of support from professional, but
also from informal, care providers. Neighbours who help and volunteers form a valuable link
between the person with a chronic care and support need and the society in which he must be able
to participate for as long as possible. Volunteers and informal caregivers must be able to rely on care
and support in their vicinity that makes their intervention more bearable. Local service centres,
fewer mobile exchanges for transport, centres for day care and day activities, services for family care
but also volunteer minders can provide the informal caregiver some respite and allow them some
time for themselves.
The organisation of primary care cannot be viewed in isolation from the local social policy. Via a new
decree, local administrations will receive the assignment to include inclusive and integrated local
social policy aims in their long-term plans.
Professional care
General practitioners, dentists, nurses, midwives, pharmacists, physiotherapists, social workers,
occupational therapists, primary care psychologists, dieticians, podologists, nursing care workers,
nurses, etc. form the basis of primary care in Flanders. All play an essential role in the care for the
person with a care need. Each from their own expertise, competences and capacities. They provide
supervision and advice from birth to the final days of life. With their generalist view on the care
needs, they deliver the most suitable care themselves or they provide a targeted referral within
primary care or to the more specialised care.
When developing a future vision, we want to pay attention to a more community-driven operation of
family care. Making family care flexible is part of this.
Residential elderly care is currently in flux. The residential care centre has literally become the
physical intersection within primary care from where support and care in the community can be
offered.
The increasing demand for supervision and support by social workers in complex home care
situations implies additional investment in social work from various authorities.
The current pilot projects in the primary care psychological function have been extended until the
end of February 2019. We will also start with primary care psychological function projects for
children and young people.
The care providers also have a part to play in preventive health policy. Methodologies are available
for this and the care providers are supported in applying this in practice.
Composition of care team and care coordination
If the care situation is complex and demands the deployment of care providers from different
disciplines, a care team is formed. The person with a care need and his informal caregiver form an
integral part of this. The composition of the care team is made, initially, by the person with a care
need and, if this is not possible, by his informal caregiver based on complete freedom of choice. This
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care team is thus a customised team that is composed by the person with a care need and has
sufficient capacity, expertise and mutual communication possibilities in order to make adequate care
and treatment possible.
Based on analysis of the care needs and the desired quality of life, the care aims are determined as
suggested by and with the person with a care need. For the realisation of each care aim, care
providers from different disciplines can be involved. If informal care is present, the support
requirements of those persons (informal caregiver) will be clearly formulated and translated into
care aims and associated acts or actions. The complexity of the care process and the number of care
providers that are present in the care team sometimes demand a coordinating function.
Coordination of the care is a role and this can be assumed by the person with a care need or his
informal caregiver or a member of the care team. Depending on where the focus lies in the care
aims, a certain member of the care team or discipline can more or less be designated to adopt the
role of coordinator (e.g. more social problem, more medical problem etc.).
The care aims, associated operations or actions, planning and task agreements, care coordination,
evaluation and adjustment. All these elements find a place in the care and support plan. This forms
the instrument for shaping, implementing, monitoring and adjusting the care process. We further
focus on a complete digitisation of the care process.
Case management function
Only an exceptional situation can justify the deployment of a case management function. Achieving
the care process and the care coordination within the care team are the norm. The number of
situations that arise for case management must thus be restricted. The request for support through a
case management function can only be made through the care coordination of the care team after
prior consultation and in consensus with the other members of the care team. The case management
functions forms a temporary support for the care team. The care team remains fully responsible for
the care process. Anyone wishing to fulfil a case management function will have the necessary
competencies or obtains a training for this.
Digitisation of the care process
When we talk of digitisation of the care process, we must of course think of the care and support
plan. Together with the medication schedule, the journal function (rapid and brief communication
between the members of the care team) and the agenda function (who does what when) are two
important additional building blocks in a digital care and support plan. The Government of Flanders
shares the ambitions concerning the aim of the federal government to achieve complete digitisation
of the medical files of the general practitioner by 2020. Flanders also wants the multidisciplinary
sharing of a care and support plan to be realised by 2020. This reflects the philosophy of the
eGezondheid [eHealth] action plan to evolve into a “multidisciplinary patient file” whereby relevant
data are made accessible.
Support of the care providers
For the reorganisation of the primary care landscape, the starting point is the principle that the
support of the care players should be decentralised as much as possible and thus placed as close as
possible to the person with a care need and his care team.
In the primary care area, the primary focus is on the support of the practice or the service provision
and on the inter-sectoral partnership local authorities-welfare-health. The primary care area is the
geographic description of an area than houses about 75,000 to 125,000 residents. Local authorities
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and the service providers who develop their care and service provision there work together (in,
among other things, integrated broad and recognisable admission) and assume responsibility for the
population of that primary care area.
In the initial stage of the reform of primary care, not all tasks stated above can be assumed. We are
assuming a growth scenario. Development of how the primary care areas operation will be phased
in. An appeal to the primary care players and local authorities will be made to submit a proposal for a
primary care area that has gained consensus and meets a number of criteria.
The primary care area will be directed by a Care Council. This council is composed in a pluralistic and
diverse manner and consists of care providers from various disciplines and of representatives of the
residential care centres, family care, social work services, CAW, and local authorities, supplemented
with a representation of the care users and informal caregivers.
The people employed in the SELs, GDT and LMN will gradually be deployed in the support and
expansion of the primary care areas and Care Councils. The intention is eventually for one legal
person per primary care area to be recognised and funded.
Support for palliation, prevention, dementia and mental health care will be placed at the level of a
regional care area that encompasses an area with something like 400,000 residents. The idea is that
several primary care areas fit into one regional care area. First and foremost, a partnership
agreement will be concluded between the Logos, palliative networks and partnerships and the
multidisciplinary support teams, the expertise centres for dementia and the consultative platforms
for mental health care in order to gradually arrive at integration.
Ideally, the regional care areas will coincide with the clinical networks of hospitals in one region, as
these are viewed by the federal government. In this way, the regional care area can become the
platform where primary care and specialist care meet and work together.
A Flemish Institute for Primary Care will be founded. The necessary knowledge and expertise can be
brought together in such an institute, which can support the broad primary care. We are assessing
how existing expertise can be bundled and how existing Flemish initiatives and structures, possibly
after a certain time, can be integrated into the institute. The partnership platform for primary care
will be integrated into the operation of the Flemish institute.
Initial training and continuous training
The correct basic attitude and competencies for integrated care are taught in the initial training of
the care players in the most efficient way possible. This implies that the initial training assumes an
integrated care organisation. Work placements and training about interdisciplinary partnership are
needed. Care providers should learn these skills in order to include care coordination as a
fundamental part of the care. Care players should also be able to find their way easily to up-to-date
data on the care and welfare services and availability of those services. It is important that the
training gives a broad perspective on the profiles and expertise of other care providers. In this way,
the care providers learn to recognise each other’s tasks and competencies and can correctly assess
the added value of each care provider. The care providers of today, who have not yet undergone the
training sketched above, require on-going training coordinated with federal initiatives.
Sufficient capacity
We are working on the implementation of action 3.0 ‘Making work of work in the care’. A wide
inflow into the study courses for care professions must remain open in the future. It is also important
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that the share of the general practitioners in the total number of graduated doctors increases. With
my colleague from Education, we can assess whether the admission test for dentists can be split from
that for doctors. Task delegation by, for example, “surgery assistants” for dentists and general
practitioners, nursing care workers to relieve nurses etc. must be made more possible.
Support of practice forms
Several models of partnership between care providers are possible. Innovative partnership forms
must be supported.
Funding
The competences in the field of primary care remain, despite the Sixth Reform, dispersed over the
communities and the federal government. This includes the funding of primary care. An integrated
care organisation demands, however, an integrated funding of that care. Collaboration and
coordination is needed to arrive at an aligned policy.
Digitisation in primary care
Vitalink will, together with the associated applications, become the digital platform where the care
providers can work in an interdisciplinary manner and share data with the person with a care need
and his informal caregiver. The concept and the context of the use of functions to be newly
developed, such as the journal and the agenda (who does what when with this person?) must be
clarified. The commitment of all care providers and stakeholders concerned is necessary to book
progress in the digital area. Subsidies and support mechanism will increasingly be based on digitised
files with the care providers.
Innovation and entrepreneurship
The action lines of Flanders’ Care concerning data sharing, mobile health, assistant technology and
aids, the chronic care model, new partnership and organisational models and care for talent have a
strong relationship to innovation in primary care.
Quality of care
Primary care may not lag behind in measuring the quality of the care provided using quality
indicators. The foundation of the Flemish Institute for the Quality of Care will become the think tank
and database in connection with quality indicators, also for primary care. Complaints management
forms a complementary component of the quality policy. Complaints about professional conduct of
care providers will, however, fall under federal competence. Complaints about care and relief
workers do fall under the Flemish competence. That is also true for complaints about the
organisation and operation of primary care.
Start of the reform
This conference is a first step in a whole process. Achieving the ambitious aims sketched here will
take several years. We all realise that a radical change process costs time and energy and cannot be
achieved overnight. The time frame for this reorganisation of primary care extends until 2025 and
will be regularly evaluated and where necessary adjusted. A participatory process will be set out for
the preparation process and, also in the post process, sufficient consultation will be held with those
sectors involved in primary care. It certainly will not succeed unless everybody becomes a part-owner
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of this reorganisation. If we want strong primary care - and the WHO strongly recommends that to us
- then everybody must join us in the change process.
This year, an appeal will be sent to the stakeholders to submit a collective and agreed proposal for
the demarcation of the primary care area to the agency. This spring, a start will be made with a
revision of the legislation in decrees and orders. This will be a participatory project. The foundation
of a Flemish Institute for Primary Care must be included in this.
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6


Appendices
Lexicon
Division of power Flemish - federal government
The appendices below can be found on https://www.zorg-en-gezondheid.be/conferentiereorganisatie-van-de-eerstelijnszorg-in-vlaanderen
 Description of current tasks of Logos, palliative networks and partnerships, regional expertise
centres for dementia and consultative platforms for mental health care
 Task and composition of the Flemish Agency for Collaboration around Data sharing between the
Players in the Care (abbreviated in Dutch to VASGAZ)
 Composition of steering group primary care conference
 Composition of academic chamber of reflection primary care conference
 Overview of number of FTEs and available resources
 Innovating building projects
 Legal context complaints policy
 Geographic maps of current structures
6.1
LEXICON
Case management
function
A targeted care intervention whereby a care provider, who is not a member of
the care team for the person with a care need and who is specifically trained to
assume the case management function, is engaged because the content and the
organisational complexity of the care process rises above the normal care and
support and the ability of the person with a care need to assume control of the
care and support process has been greatly diminished. Case management is an
intervention with a systematic, cyclical and finite character. In partnership with
the person with a care need (and his care team), all the steps of assessment,
care planning and care coordination are analysed, so that the problems become
visible. The care provider who assumes the function of case management then
intervenes in those steps that demand a solution. Certain steps are possibly
carried out (if they have not been) or repeated. The improved care and support
is carried out by the care team. The case management function does not
perform in the place of the care team. Evaluation of the intervention from the
perspective of case management must assess whether the intervention has
achieved the desired solution.
Social work service
General term that is used for services that offer social work, mainly as part of a
larger organisation, for example a mutual insurance fund, hospital, OCMW, a
residential care centre. In healthcare, social nurses often work in these services.
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Primary care
The provision of universally accessible, integrated and person-driven care for
welfare and health in the community by professional care providers, who are
responsible for tackling the vast majority of health and welfare problems. This
care provision is achieved in a sustainable partnership between these
professional care providers and the persons with a care need and their informal
care providers, in the context of the family and the local community, and plays a
central part in the general coordination and continuity of this care provision to
the population.
Own control/self
direction
Sel- Management
Integrated care
Having the ability as person to have the care (both process and content) reflect
the quality of life that one desires.
Community care
Community-driven
care
A future model that care and support of persons with a care need aims to
organise by focusing on an active partnership at the local level. Starting point is
to allow the person with a care need to live at home for as long as possible and
by doing so create a community with a lot of informal care and a cohesion
between care, living and welfare. It is directed at everybody in the community.
Health literacy
The degree to which people have the knowledge and skills to obtain, process
and understand fundamental services and information in the area of health and
welfare, so that they can take decisions to the benefit of their quality of life.
Informal care
The care that is given by persons with a social or family link with the person with
a care need on a voluntary basis. This care is not performed as a professional
service.
Integrated care and
support
A care approach that starts from the person as a whole, with all his possibilities,
capacities and skills. The care is shaped by taking the required quality of life,
care needs and care aims of the person as starting point.
Interdisciplinary
The partnership of care providers from various disciplines, based on the care
aims of the person with a care need. By working from these care needs, the care
providers go beyond the scope of their own discipline and grow closer in the
area of practice.
Journal/agenda
Journals contain shared information that is important for every care provider
involved in the care around a person with a care need. In Vitalink, a
journal/agenda will prove a means of passing on observations and signals in a
multidisciplinary context of care providers and persons with a care need who
enter into an interaction with each other around a specific care need. The
content is free text that is structured to a limited extent, and where relevant
linked to one or more data types that are shared in Vitalink (medication
schedule, Sumehr etc.).
Care (going from health promotion, disease prevention, intake, grading of care,
diagnosis of the disease, care supervision, medical treatment, support,
recuperation and care at the end of life) in which the provision, management
and organisation of it are brought together into a seamless whole.
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Life aim
That which a person wishes to achieve in his life and thus gives significance to
life. Examples of life aims are: being happy, having a family, building up a
successful career, being famous, being rich etc.
Socially responsible
care
Socially responsible care and social services must withstand an evaluation
against the principles: quality, performance, relevance, equability and
accessibility. If care is to be socially responsible, it must satisfy these conditions.
Each of the five conditions is equally important: there is no hierarchical link
between them. The conditions are, in other words, interdependent, an
indivisible whole.
Social work
Is one of the specialisations in the bachelor’s course in social work. Social work
responds to requests for help by people who experience difficulties in the
psychosocial functioning and/or in their attitude to social institutions and
provisions. Interventions by social workers always have an experience-driven
and social component and are directed at psychosocial relief, working on access
to provisions and signalling of structural deficiencies and gaps at community
level.
Macro level
The entirety of organisations and services that are responsible for expertise
development in the integrated care and support and the development of
methodologies and instruments to offer this expertise to the public, persons
with a care need and care providers.
Voluntary care
A form of informal care that is provided to a person with a care need living at
home.
Informal caregiver
A person who provides informal care.
Meso level
The entirety of organisations and services that are responsible for the support of
the practical implementation by the care providers.
Micro level
The entirety of organisations, services and independent care providers which
shape the practical implementation and are in direct contact with the person
with a care need and the informal care.
Multidisciplinary
Bringing together care providers from various disciplines and professional
groups around the person with a care need. In a multidisciplinary partnership,
each care provider offers care from his own discipline and organisations,
according to the professional profiles that are applicable for this.
Base line
This is the informal care.
Performance
Performing care is care that leads to increased care and quality of life and social
well-being. This can be achieved by providing care in a targeted, effectual,
preventive, sustainable and optional way.
Person with a care
need
Must be read as the person with a care and support need and concerns persons
with problems in the area of welfare and healthcare for whom care is
appropriate. This care can be informal care or professional care.
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Welfare and Health
Platform
The database of the Government of Flanders in which all data about care and
welfare services in Flanders are available. These data are made accessible to the
general public via a website. The professional care providers can enter and
update directly their data in this database.
Prevention
A methodology to inform, increase awareness and provide skills to the general
public for following a healthy lifestyle. Prevention covers both health promotion
and disease prevention.
Switching moment
A moment in the care process in which the person with a care need moves from
one care situation to another care situation. I.e. the transition from the home
situation to a residential care centre or from a home situation to admission in a
hospital. At such moments, the care services change and the person runs the
risk of an interruption of care continuity.
Social worker
Professionals who base their professional behaviour on the international
definition of social work. This means that the professional behaviour promotes
social change, improves problem-solving in human relationships and encourage
the welfare of people by focusing on empowerment and change in structures
that prevent the promotion of welfare. The bachelor course in social work,
within the social welfare studies area, trains people to become professional
social workers.
Accessibility
Care is accessible when the person with a care need can obtain this care
through correct information about the care services, which is sufficient and
understandable, through affordability, through ease of access, through it being
adapted to his culture, language and care need.
Second line
These are the specialised care services. Care that is directed at a well-defined
pathology.
Socialisation of care
A care concept whereby the aim is to allow people with an impairment (of a
physical, mental or psychopathological nature), the chronic sick, vulnerable
elderly people, young people with behavioural and emotional problems, people
who live in poverty etc. to assume, with all their possibilities and despite the
vulnerabilities, their own meaningful place in society, helping them with this and
having the care undertaken as far as possible in an integrated way within the
community.
Empowerment
Helping a person with the acquisition and improvement of the necessary
knowledge, skills and attitude for taking control of and autonomy over his life
and to undertake the necessary actions concerning this.
Self-management
The assumption of control in the care process by the person with a care need.
Care provider
A person who professionally provides care or services in primary care to a
person with a care need. This person can provide the care independently or as
an employee.
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Care need
The lack of support perceived by a person to achieve the desired quality of life.
This can result in a care demand. Within the Government of Flanders, we do not
speak of a care requirement but of a care need. The term ‘care need’ implies a
serious and difficult situation that demands a solution.
Care intermediary
A person, designated by the person with a care need or his informal care, who
stands up for the needs and interests of the person with a care need with the
care providers.
Care continuity
The degree to which the care process, characterised by various care providers
and care provision, takes place without interruption.
Care coordination
This is about the coordination and continuous monitoring and evaluation of all
the medical, paramedical and welfare needs that are identified on the basis of
the care needs of the person. If the person with a care need assumes this
coordination himself, we then talk of self-management. This self-management
always forms the starting point and can possibly be supported by informal care.
In cases in which the person with a care need or his informal care cannot or will
not assume the coordination, the care need is complex and where the care team
has care providers from various disciplines, a care provider from the care team
assumes the care coordination. This person (the person with a care need,
informal care or care provider) is designated as ‘care coordinator’ of the care
team.
Care and support
aim
An aim that is formulated between the person with a care need and the care
providers around the desirable care that offers the best possible answer to the
life aims and the quality of life which the person with a care need wishes to
achieve. The care aims have an impact on the care and support plan through
their translation into specific actions and operations. These are formulated as
far as possible as SMART aims.
Care innovation
The development and putting into practice of new or innovative elements and
instruments in the care processes, so that these can be adapted to the future
care needs and care aims of the population.
Care and support
plan
An instrument for expressing the agreements around the planned care for a
person with a care need in writing, so that this information is accessible for the
person with a care need, the informal care and the care providers, and can be
monitored and adapted. The care aims of the person with a care need form the
basis for determining the care and to translate this into agreements.
Care agency
Care team
Term adopted in the RD78. Within the Government of Flanders we speak of a
‘care provider’.
A group of persons, composed of the person with a care need, his informal care
and the care providers, who fulfil the care needs of a person based on the
formulated care aims.
Healthcare
practitioner
Term from the Primary Care Decree. Within the Government of Flanders we
speak of a ‘care provider’.
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Healthcare insurer
This term also includes ‘health insurance fund’, sometimes indicated by the
term ‘mutual insurance fund’. An organisation whose members are insured
against the costs of illness.
Care demand
See care requirement
Care need
Abbreviation of ‘care and support need’. A situation that has an urgent
character and must be answered in the short tterm. This answer can be offered
in the form of care and support based on community-driven care, informal care,
primary care or specialised care. The person is viewed as a whole. Care and
support also covers healthcare, welfare, living, work, mobility.
Care region
A geographically prescribed area, as determined in the appendix to the Care
Region Decree.
6.2
DIVISION OF POWER FLEMISH - FEDERAL GOVERNMENT
This is a rough sketch that does not by any means reflect all the nuances, nor is it comprehensive, but
aims to sketch a general picture and takes the current exercise of powers as starting point.
Flemish powers
Federal powers
Primary care
Integrated Service Residential Care (GDT)
Collaboration initiatives Primary Healthcare
Local Multidisciplinary Networks
General practitioner group practices
Health and disability insurance
Fees for healthcare practitioners
Reimbursement of medication
Chronic patient status
Increased insurance compenstion
Palliative cooperation partnerships
Palliative fixed sum/statute, incontinence fixed sum
(excl. residential elderly care)
Care pathways
Palliative networks
Multidisciplinary support teams for palliative care
Incentive fund for general practice
Prevention including
Quit smoking and exercise coaches
Local Health Consultation
Population studies (intestinal, breast and cervical)
Vaccinations at population level
Flemish Social Protection*
Allowance for the Elderly*
Mobility aids8
Basic support budget*
Allowance Flemish Care Insurance*
Medical aids/medical materials (not mobility aids)
General Medical File (fees general practitioners and
increase compensation)
Incontinence fixed sum
Maximum invoice
Accreditation doctors (also accreditation feeds)
Fees for medical-pharmaceutical consultation
Availability fees for participation in standby duty
Uniform emergency call centres (urgent medical
assistance)
Medical permanence (e.g. out-of-hours surgery and
stanby-duty)
Social statute doctors
Integrated surgery premium general practice
Medical houses (fixed fee repayment of medical
supplies)
Residential care provision
Services for family care and supplementary home
care*
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Services for logistic help*
Minder services
Home nursing services
Social work services of the mutual insurance funds
Local and regional service centes
Foster care services
Provisions for care of the elderly
Day care centre*
Law on patient rights (22/8/2002)
Law on palliative care (14/06/2002)
Recuperation centre
Short-stay centre*
Groups of assisted dwellings
Residential care centre*
Association of users and informal caregivers
Mental healthcare
Consultation platforms mental health care
Initiatives in sheltered Living*
Centres for Mental Healthcare*
Psychiatric care homes*
Rehabilitation conventions for mental health care
Decree on the provision of care and assistance
(18/07/2008) minimum qualification demands for
person who practise professionally activities for
care and assistance, whether or not in recognised
welfare provisions inl. nurses employed for family
care
Healthcare professions
Recognition of the healthcare professions
Setting (sub)quota, taking into account the federal
general contingency
Social agreements
eGezondheid
General, Academic and Psychiatric Hospitals
Planning and recognition
Recognition standards
Funding infrastructure works
Rehabilitation hospitals/non-affiliated hospitals*
Rehabilitation conventions (“long term care”
rehabilitation)
Law on euthanasis (28/5/2002)
Healthcare professions (law on performing
healthcare professions)
Setting standards for healthcare professions on which
collectives are recognised
Issuing visa (i.e. admission to practice a healthcare
profession)
Setting standards for recognising traineeships
supervisor/traineeship services
Recognition traineeships supervisor/traineeship
services
Approving permanent training (hospital pharmacists,
midwives)
Setting general quota for certain healthcare
professions
Social agreements
eGezondheid
General, Academic and Psychiatric Hospitals
Organic legislation (basic characteristics)
Programming
Funding (excluding infrastructure works)
Rehabilitation conventions (not “long term care”
rehabilitation)
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