A national research programme (2014-2015), committed by the Italian Ministry of Health and the National Agency for healthcare services, aimed to study the development and impacts of new primary care models focused on prompting chronic care management through proactive disease management programmes (DMPs). To investigate impacts from different perspectives, the research was broken down into five work packages (WPs), focusing on the health policy and management drivers, the clinical results, the workforce workload, the regulation and the social and economic determinants of patients and local areas. Indeed, the research provided a comparative case study analysis, exploiting mix methods. Seven case study sites were selected, according to three major criteria: the national coverage, the maturity level of the chronic care model (with at least two years since the implementation) and the DMPs included, being the programme focused on diabetes, heart failure and ischemic heart disease. The unit of analysis finally relied on seven models implemented at the level of Local Health Authorities, in seven Regions, namely, Emilia Romagna, Lombardy, Marche, Puglia, Sicily, Tuscany, and Veneto.
The paper shows the results from the analysis of the WP over the managerial and policy features, which provides an in-depth organisational comparative analysis of the seven case study sites aimed to identify the core processes, the functional and normative instruments and organisational patterns that determine the set up, development and effectiveness of those models. The comparative case study analysis hinges on a theoretical framework able to take into account the multi-level governance through which these reforming models took place (regulation, professional and managerial roles, incentives and resources, monitoring and evaluation methods) and the pillars of the models, by applying the framework of the Chronic Care Model (target recipients, information technology, patients engagement and evaluation). The multi-level governance approach allows distinguishing different roles, resources and institutional spillover effects among different stakeholders (i.e. the contract bargaining with General Practitioners, GPs). Three levels were included in the model: the Regional government, the LHA programmes dealing with chronic care management and the GPs, the professionals’ behaviours in participating. To the latter extent, a questionnaire and semi-structured interviews were administered through a control-study approach, which compared GPs joining the new models with those not involved.
Results can be clustered in two key messages for the policy makers, healthcare managers and stakeholders. Firstly, a road map of implementation drivers is delivered, detecting the key determinants that should be in place before introducing any new model of chronic care management in primary care and the resources and incentives that should be coupled with the reforms’ injection, if they have to be successful. Secondly, at the micro level, it actually emerged the buzz situation over today primary care and GP engagement. Results show that with GPs the actual effectiveness of these models relies yet on the previous experiences, which paved the way for new organisational patterns in clinical governance and behaviours, fuelled by higher economic incentives; yet on the provision of new professional roles, as the nurse case manager, directly from the LHAs.
