Nearly 30% of Belgians report having at least one chronic condition, such as diabetes or cardiovascular diseases. To maintain a good quality of life, these patients require medical follow-up by a healthcare provider in a general practice. However, this care is extensive and often complex to organize effectively. For a patient with type 2 diabetes, up to 62 care-related tasks need to be performed annually.
Organizing this level of care for each individual patient presents a significant challenge for a general practice. In multidisciplinary practices, the workload can be shared, but the question remains how to organize all this care efficiently and with high quality. Developing a care pathway offers a potential solution, allowing care to be organized and documented in a structured manner, and facilitating collaboration between multiple care disciplines. A care pathway is a complex intervention but can be summarized into three core tasks:
- Organizing care-related tasks on a timeline.
- Distributing tasks and responsibilities among different care disciplines.
- Creating an interdisciplinary communication plan.
Each general practice is unique, with its own patient population, team composition, vision, and way of working. Therefore, the goal of this pilot project is to support general practices in creating a care pathway tailored to their specific needs. We provide concrete tools and guidelines, enabling practices to develop and implement a care pathway efficiently and with high quality, while allowing them to work at their own pace.
