Primary care collaboration within chronic care pathways

To fine-tune support, a multidisciplinary consultation is often organised. The aim of these consultations is to get a full picture of the situation and the concerns together. You then determine together what support is desired and make a concrete plan of action.


Multidisciplinary collaboration in primary care

Multidisciplinary consultation is defined as a means of discussing a patient's care plan. It refers to a consultation moment between different healthcare providers, involved with a patient, with a view to improving health status and care¹. This form of collaboration has several advantages. It not only contributes to a better outcome of the patient's treatment and health status. It also leads to an increase in job satisfaction among involved healthcare providers, a reduction in burnout, a decrease in health costs and, finally, a promotion of health promotion and prevention².

Research shows that multidisciplinary collaboration within primary care is essential for developing an integrated approach so that citizens' health is maintained or improved. One discipline is not able to fully provide care for a patient with a chronic condition because of the complex and high needs patients face today3|4. This requires the help and participation of other disciplines involved to create the fullest possible personalised care approach. Several initiatives have already been taken in Flanders to promote multidisciplinary cooperation in the first-line.


The initiatives in Flanders

In 2009, care pathways were introduced for patients with type 2 diabetes and patients suffering from chronic renal insufficiency. As part of the care pathways, the Local Multidisciplinary Networks (LMN) were also established in 2009. Their central task was to support primary care providers and doctors-specialists from hospitals in entering into and following up care pathways. In addition to the LMN, the Primary Care Cooperation Initiatives (SEL) were also responsible for fostering cooperation between different healthcare providers from the first-, second- and third-line.

Following the sixth state reform in 2011, the Flemish government wanted to thoroughly reorganise care in the first line. This eventually led, among other things, to the establishment of 60 first-line zones in Flanders5. Within these first-line zones, the LMNs and SELs of the regions concerned were integrated, as well as the Integrated Home Care Services (GDTs). Again, within these zones, integrated patient care is paramount with attention to the various forms of multidisciplinary consultation and intersectoral cooperation between the healthcare providers involved.

Anno 2020

Today in Flanders, however, there is still little to no multidisciplinary cooperation in primary care, but rather interdisciplinary referral to and between different healthcare providers and institutions. National and international research shows that several factors such as team structure, organisational context and social context underlie this6. To partly address these problems, several initiatives have already been taken. Thus, in addition to the establishment of the Care Councils, there was also the establishment of the Flemish Institute First Line (VIVEL) with the aim of developing best practices and implementation tools as well as offering tailor-made support.


Towards more efficient multidisciplinary cooperation

In striving towards efficient multidisciplinary cooperation in primary care, it is important to start bottom-up and take into account the local context. Before methodologies can be developed to promote cooperation, a thorough knowledge of practice and current obstacles within multidisciplinary cooperation throws up. Through field research, current ways of working together can be examined. Possible methods for this include carrying out process walks or observations where the entire process of multidisciplinary collaboration (planning to implementation) around the patient is closely examined. All stakeholders are closely involved. Additional data can be collected through a questionnaire and/or interviews. Special attention is needed for the existing barriers and facilitating factors and their impact on current cooperation.

Based on the collected data, strategies and methodologies can be provided to promote multidisciplinary cooperation. Taking into account the specific characteristics of the primary care area involved, with the participation of all stakeholders and, above all, focused on quality service towards the patient.

At Möbius, we like to be inspired by innovative reference frameworks that define key ingredients of a successful collaboration. This leads to an agility and dynamism that allows us to respond to changing needs within the volatile world. A great example are the seven principles of Sociocracy 3.0:

  • Transparency: all information is available and transparent to each partner (unless there are specific reasons for confidentiality)
  • Equivalence: every partner within the collaboration is equal
  • Empiricism: all assumptions are tested by continuous experimentation
  • Continuous improvement: to achieve the desired result, evaluation and step-by-step improvement based on empirical results take place
  • Effectiveness: time is spent only on actions that get closer to the goal or desired result
  • Consent: to achieve a better result, possible objections to decisions and actions are always sought
  • Accountability: everyone sticks to the agreements and takes ownership of the direction of the process

Would you like to know more about how we can support you in shaping multidisciplinary cooperation? Then be sure to contact our experts!



1Ursum, Rijken, Heijmans & Cardol, 2011; Raine, Xanthopoulou, Wallace et al, 2014
2Leach, Morgan, Strand de Oliveira et al., 2017
3Doekhie, Buljac-Samardzic, Strating & Pauwe, 2017
4Xyrchis & Lowton, 2008
5Decree 26 April 2019 on the organisation of primary care, regional care platforms and support for primary care providers
6Leys & De Roeck, 2013