Facilitators and Barriers to Scaling-Up Integrated Care for Arterial Hypertension and Type 2 Diabetes in Slovenia: Qualitative Study

In the theme of “Political interest, commitment, and power dynamics”, the barrier was the inactive and unresponsive political structure in Slovenia. Additional barriers emerged in the “Stakeholder collaboration” theme, with participants highlighting that innovations and adjustments are introduced without consulting relevant experts. Moreover, already published research findings are not acknowledged by policymakers and remain unimplemented.

“Innovations are implemented without prior piloting, but the pilot should be first and then implementation.” (Meso level, female, code ZDL-113)

Within the “Policy, regulation, strategy” theme, potential facilitators encompass reduced taxes on healthy food choices and health-promoting recreational and educational activities. Additionally, possible improvements in food labelling, including larger and more comprehensive nutrient information, were identified. Ensuring that accurate content related to HTN and T2D is included in the media (internet, radio, television, etc.) was also deemed beneficial. Moreover, creating a national-level unified website for T2D and HTN, offering verified medical information in one location, implementing prescription training, and introducing a nominal pharmacy fee for medication collection to reduce excess medications at home were other facilitators that were identified.

In the “Health insurance and social protection” theme, the outdated healthcare financing system, which prioritises service quantity over quality, was acknowledged as a barrier. A consensus emerged that reform is needed to support an integrated care model. In the “User financial payment” theme, the increasing demand for patient copayments for services and medications was recognised, with an agreement that patients should not bear the financial burden of healthcare financing. Within the “Budget/Sources of funding” theme, participants linked the aforementioned issue to budget constraints, inefficient spending, and inadequate resource allocation.

“Financing models should be modernised to better suit integrated care, e.g., by focusing on health outcomes.” (Macro level, female, code MB-36)

In the “Primary healthcare level” theme, the barriers related to healthcare facility accessibility based on location and the related financial burdens were identified. Urban areas struggle with a shortage of parking spaces near healthcare facilities, while rural regions face difficulties due to long distances to healthcare facilities. The introduction of advanced nurses in family practices was seen as a facilitator, enhancing monitoring and patient education. Patients less comfortable with technology faced a barrier when transitioning to new electronic communication methods, such as email or web portals.

In the “Secondary and tertiary healthcare level” theme, prolonged waiting times, which lead patients to opt for self-funded healthcare services, were acknowledged as a significant barrier.

Within the “Integration throughout the healthcare continuum” theme, participants noted the barrier of the duplication of services across various healthcare providers (e.g., patients with T2D often receive redundant treatments from family medicine doctors, advanced nurses, and diabetologists). They emphasised that expanding the range of services available at the PHC level and enhancing home care could be potential facilitators. Tailoring care to individual patient needs could also be encouraged by implementation of comprehensive and specific treatment plans, which include well-defined tasks for patients. Additionally, the adoption of telemedicine, especially for vulnerable populations such as geographically distant, elderly, or immobile patients, was highlighted as an effective strategy.

“Our experience with telemedicine pilot projects taught us that some patients with HTN have been over-treated, while for patients with T2D it was empowering to receive feedback on their measurements.” (Macro level, female, code ZDT-5)

In the “Teamwork” theme, the barrier that was identified was the lack of clearly defined responsibilities among healthcare providers. Conversely, the introduction of dietitians, mental health consultants, and social advisors into PHC teams, along with the well-defined delegation of tasks, were all identified as facilitators.

Within the “Quality of care” theme, the implementation of regular supervision meetings aimed at improving patient care, education, risk management, and overall well-being was a recognised facilitator.

Within the “Time burden” theme, the barrier of a shortage of medical personnel leading to excessive workloads and an elevated risk of burnout was identified. The burden of administrative tasks was also acknowledged as hindering curative and, particularly, preventive activities.

“Physicians are burdened by computer tasks, reducing their ability to fully engage during check-ups.” (Patient, male, code FSFB-304)

Within the “Education and training” theme, the barrier of insufficient knowledge and a lack of regular refreshment, including understanding patient motivation, were discerned. It was also acknowledged that healthcare workers at times fell short in offering adequate support, displayed impatience, were resistant to alternative treatment methods, and set a poor example by consuming unhealthy food and smoking in the presence of patients.

Barriers identified in the “Patient empowerment” theme were that some patients find it challenging to accept a new illness and may not fully accept responsibility for their health and self-care, often shifting it onto the healthcare system. Although they have access to reliable and verified information, they frequently struggle to follow medical instructions and recommendations, such as regular medication use or attendance at workshops.

In the “Lifestyle” theme, participants recognised the barriers associated with the motivation to make lifestyle changes. Incentivising patients who adopt a healthy lifestyle was thus identified as a facilitator.

“If you’ve lived unhealthily for 60 years, your body initially resists change. It is hard, but progress can be made with gradual steps.” (Patient, male, code FSBA-180)

Within the “Patients associations” theme, patient associations were identified as a facilitator by playing a crucial role in bridging the gap between healthcare professionals and the general public. They are seen as valuable sources of reliable information about diseases, empowerment, and emotional support. Patients put a high level of trust in these associations.

In the “Individuals” theme, participants recognised the positive impact of educating patients’ family members. This education can improve patient care and reduce the burden on the healthcare system.

Within the “Informal caregivers” theme, the introduction of peer supporters was highlighted as a facilitator to address the shortage of healthcare professionals and empower patients and their families. These would be individuals living with HTN and T2D who receive specialised training to offer reliable information to other patients.

“Patients are more inclined to trust peer supporters who can relate through shared experiences – these cannot be received from health professionals.” (Meso level, male, code DDO-162)

Within the “Local community” theme, multiple facilitators were recognised. Participants underscored the authority of municipalities (local authorities) and the need for them to play a more active role in promoting a healthy lifestyle. Additionally, there was a call for systematic education on maintaining a healthy lifestyle to be included in primary schools. Moreover, participants emphasised the importance of employers encouraging their employees to embrace healthy habits.

Within the “Horizontal and vertical collaboration” theme, participants noted barriers in both horizontal (within healthcare teams) and vertical collaboration (between different levels in the healthcare system). The latter is limited to formalised systems of referrals and reports, which are considered inadequate. Consequently, the exchange of information is challenging.

“Collaboration between healthcare professionals and social workers is severely lacking, despite the pivotal role of social issues in elder care.” (Meso level, female, code ZDL1-215)

Within the “Pharmaceutical” theme, the participants noted that one facilitator was the role of the pharmaceutical industry and pharmacies in educating and advising patients on the safe and effective use of medications. Nonetheless, the participants also pointed out the barrier of an excessive focus on product sales by these entities, which, in their opinion, hinders the provision of trustworthy information regarding the effectiveness of specific drugs and dietary supplements.

“I have reservations about pharmacies due to the overwhelming advertising in pharmacies, making me question the reliability of their information.” (Patient, female, code FSBA-315)

In the “Fragmentation” theme, a barrier to the flow of information was found in the excessive number of health information systems, which lacked interconnectedness.

Within the “Data Management System” theme, data protection regulations were identified as an additional complicating factor. Conversely, in the “E-health” theme, the introduction of improved and more user-friendly interfaces for information systems was recognised as a facilitator.