Introducing Integrated Care for older people in Kosovo using Diabetes Mellitus Type 2 as an entry point

Since July 2017, IFIC’s Dr Viktoria Stein has been working with Accessible Quality Healthcare (AQH) to introduce integrated care in Kosovo. The AQH project is funded by Swiss Agency for Development and Cooperation (SDC) and implemented by a team of experts from the Swiss Tropical and Public Health Institute (Swiss TPH) and Save the Children, in close collaboration with the Kosovo Government and the Ministry of Health in particular. It works in 12 Kosovar Municipalities to strengthen quality of primary care services, improve management at facility and municipality levels and increases health literacy for non-communicable diseases. As part of these efforts, the municipality of Fushe Kosova has been selected to pilot an integrated care model targeting older people with diabetes. The diabetes diagnosis will serve as an entry point to introduce a comprehensive geriatric assessment, and support patients, families and professionals to work towards a goals-based healthy ageing approach for the individuals. The first 12 months have been spent with building local support, introducing the key principles of integrated care to the local working group, and, based on a literature review about diabetes management for people 65+, adapting the international evidence to local needs. The second phase of the pilot, which runs until July 2019, will see intensive trainings for health and social care professionals, and the testing of the model.


A key success factor of the project so far has been the continuous and enthusiastic support of the local working group, with representatives of all the relevant stakeholders necessary to make this happen, i.e. primary care, social services, NGOs, the Pensioners Association, Nurses Association, among others. In regular workshops organised by AQH and supported by Dr Viktoria Stein, the model, implementation plan and evaluation framework have been co-designed, ensuring that international experience, evidence and local needs are all reflected in the final product. Thus, it was decided that the diabetes diagnosis would be used as an entry point, to start conversations with patients and their families about healthy ageing, self-management and lifestyle changes. This is key in a country, which does not have prick tests or relevant lab tests readily available, and where nutritionists do not exist. The tests will be provided by the project, alongside multi-disciplinary trainings for nurses, social workers and GPs on care planning, comprehensive geriatric assessments, and motivational interviewing, along with education on the various aspects of diabetes management.

This project demonstrates once more, how vitally important it is to translate international experience and evidence into local solutions. By co-producing the design, implementation and evaluation with local stakeholders, combining the building blocks for successful integrated diabetes management with evidence-based elements of geriatric management, and emphasising education and training for professionals, patients and families, this initiative utilises integrated care principles to improve the quality of primary care services, build a cross-organisational delivery network, as well as improve health literacy and professional education in the local community. First fruits of these efforts have also been presented at the ICIC18 in Utrecht here

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