Table 1.

Core elements of integrated care for type 2 diabetes in the Netherlands

Element	Description
Care groups and bundled payment system	Dutch integrated care for type 2 diabetes is organised via so-called care groups, legal entities that “establish contracts with health insurers in order to coordinate and execute chronic care in a specified region, with the aim of improving the quality of care” [11]. The legal form of these organisations varies but, in most cases, general practitioners (GPs) are (co-) owners [24]. In 2010, there were approximately 100 care groups offering integrated care for diabetes, many of which were also offering programmes for other chronic conditions such as COPD and vascular risk management [24]. In the funding framework introduced in 2007, the so-called bundled payment system, care groups act as intermediaries between health insurers and health care professionals by negotiating the content and price of a comprehensive package of diabetes care, the resulting agreements of which are captured in bundled payment contracts [24]. These contracts make it possible to buy care as if it were one single product, even though it consists of many components delivered by a diverse group of health care professionals often in more than one setting [24]. For those health care services not provided by GPs and practice nurses (PNs), care groups enter contracts with care chain partners such as dieticians, podiatrists or pedicurists, depending on the chronic condition.
Evidence-based care protocols	In the Netherlands, care provision for type 2 diabetes is based on national evidence-based care standards describing norms of high quality chronic care for specific chronic diseases, such as the diabetes care standard [23]. Based on the negotiations between care groups, health care professionals and health insurers, these standards are translated into specific care protocols, based on which, care is delivered and reimbursed. Negotiations do not only take place between one care group and one health insurer or one care group and one health care professional, but each care group enters into contracts with potentially all health insurers and all relevant health care professionals in a given region and vice versa [29, 30].
Health professional cooperation and task substitution	The delivery of diabetes care is performed by a group of health care professionals involved in the care for a specific chronic disease. The core of diabetes care includes GPs, PNs, diabetes nurse specialists (DNSs) and internists. The former two are located in general practice, whereas internists are located at the hospital, and DNSs are dispatched from hospital to general practice and are therefore present at both locations [31, 32]. It should be noted that, while internists are involved in the provision of integrated diabetes care, whether they are reimbursed via the bundled payment contract differs per region and care group. At the periphery, dieticians, podiatrists, pedicurists, optometrists and other medical specialists are also involved [23, 24]. Dutch integrated care is based on the assumption that substitution of professional roles and tasks will lead to more cost-efficient care. Horizontal substitution means the transition of patients from secondary to primary care, where stable diabetes patients as a default should be treated by the GP instead of the internist. Vertical substitution means that certain tasks traditionally performed by the GPs or internists are now performed by PNs and DNSs, respectively [11, 32].
Patient involvement	Involvement of patients both during consultations and in the organisation of health care is an important strategy in the Dutch approach to integrated care for type 2 diabetes [23]. One example of the former is shared patient-doctor goal-setting, mostly realised via individual care plans which, as opposed to general treatment plans, consist of precise and feasible goals that are set in a shared-decision making process between patient and health care professional. An approach to involving patients in the organisation of diabetes care is the consultation with patient advisory boards. With Dutch integrated care still being in development, both aspects of patient involvement are not yet fully implemented in practice [24].
Shared clinical information system	The electronic administration and exchange of data for patients with type 2 diabetes treated within the bundled payment framework is an important requirement for integrated care [23]. However, the number and type of electronic databases used in practice differs per region and care group. Often, GPs use their own GP information system (HIS) and practice nurses and care chain partners use a care chain information system (KIS). Care chain partners also use their own profession-specific electronic medical record systems. The HISs are commercial systems that can be chosen freely according to the GP’s own preferences. A KIS, on the other hand, is generally chosen by the care group, and every GP practice and care chain partner working with a certain care group must work with this specific KIS [24].