Scaling up integrated care for chronic diseases in belgium: A process evaluation

Introduction
Few integrated care studies elaborate how interventions are brought to wider scale. The SCUBY project developed interventions for scale-up of an Integrated Care Package (ICP) for two common diseases - type 2 diabetes and hypertension-, comprising evidence-based roadmaps and policy dialogues. This paper's aim is to report on the process evaluation of the ICP scale-up in Belgium. Specific objectives are: to describe the development of scale-up interventions; to assess the actual process outcomes; and to assess progress on three scale-up dimensions coverage, expansion and institutionalisation.

Methods
A case study design, with data collection including project diaries, stakeholder surveys and interviews. 11 Key informant interviews were held with five research team members and six external people. Tools were developed to visualise progress for coverage, institutionalisation and expansion.

Results
The roadmap included three themes: primary care practice organization, data and monitoring, and healthcare financing. 99 policy dialogues of varying size and type were held. Stakeholders rated all themes relevant. For scale-up outcomes, progress was most on the institutionalization axis.

Discussion
Scale-up of ICP demands a collaborative, networking approach to build trust and buy-in. Protagonists need to strike a balance between relevance and feasibility of scale-up strategies, being aware of context elasticity. A roadmap can be a living document serving change teams in communication, planning and monitoring, while allowing intervention plasticity.