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Health and vulnerability: creating a care guideline for general practitioners


Liesbet Meyvis

Stad Antwerpen, BE
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The municipality of Antwerp supports general practices in connecting with welfare organizations.

Since March 1st 2018, the city of Antwerp supports vulnerable inhabitants in vulnerable neighbourhoods in the area of health and prevention through their project: ‘Health and vulnerability: creating a care guideline for general practitioners’. This project focuses on 3 aspects: the organization of the general practice, its collaboration with the neighbourhood and the monitoring of vulnerable patients associated with the practice.

Objective: The final objective of the project is to set up a formal cooperation between each individual general practice and the care/welfare actors in the neighbourhood. In a first phase, the project focuses on patients with diabetes. On the basis of concrete patient counseling the evidence-based medical guidelines evolve to a guideline that includes well-being.

Practice: Nurses carry out the project: they are linked to general practices in a vulnerable neighbourhood. Each nurse works temporarily in a general practice to identify the patients; to activate the network around the patient and to activate the network around the practice.

To identify this vulnerable group of patients we search for diabetic patients with a bad hba1c value, patients with poor adherence. Our nurses supervise these patients, identify the underlying problem and make connection with other organizations or medical services. From individual case level we take these problems to the GP’s practice level and start formalized collaborations with several partners for instance the social services of the public health insurance.

In the following phase of the project, the nurses will no longer be present in the GP’s practice, but GP’s themselves have to identify the underlying problem and refer the patient to the most suitable welfare organization with whom we previously agreed on how to work together.

To help the GPs identify those underlying problems we searched for a solution that fits their diagnosis – treatment thinking. We found it partly in the patient registration system were GPs use ICPC codes mainly for medical problems. Our nurses now teach the GPs gradually to use the ICPC Z-codes to identify social problems. We associate these Z codes with organizations to which the GP can refer.

First Conclusions: On the basis of the first experiences we found out that: general practitioners have very little knowledge about the functioning of social organizations, both the GP and the social services/welfare organizations label themselves as 'head coordinator', the presence of our nurses in the GP’s practice influences the concrete organization of the general practice in a positive way.

These initial conclusions confirm that investing in the support of each individual practice is needed to respond to the changing need for care. The project offers the support that practices need to guide vulnerable or under-informed patients in the follow-up of their chronic illness (additional consultations at a nurse,…) This project aims to ensure that the patients who need more follow-up because of financial problems, the lack of a network, frailty or limited health literacy are included in a well-structured system for the follow-up of their chronic illness.
How to Cite: Meyvis L. Health and vulnerability: creating a care guideline for general practitioners. International Journal of Integrated Care. 2019;19(4):414. DOI:
Published on 08 Aug 2019.


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