Piloting an Integrated Care Model in Kosovo Introduction of Physical Activity Sessions to Elderly patients with Type 2 Diabetes

Introduction AQH project in Kosovo is funded by the SDC and implemented by Swiss TPH with a focus on Primary Health Care (PHC) on managing NCD’s. The AQH is piloting an IC model in one municipality.The quality of PHC services in Kosovo is poor mainly due to lack of basic equipment and infrastructure, but also because of the lack of multi-sectoral cooperation.Description of practice change implemented A nurse together with a social worker visited patients in their homes for geriatric assessment. Nurses at PHC facility level were equipped and trained on how to use the handgrip dynamometers to assess level of frailty. Based on findings from GA the teams developed individual care plan.Aim The aim of IC Initiative is to improve the wellbeing and functional status of patients through better coordination of services provided by the health and social sectors. Whereas, the objective of the group exercise classes is for patients to have strategies to support themselves to stay motivated to complete these exercises as part of their own daily routine (social and family support, routines and use exercise record).Targeted population and stakeholders Patients over the age of 65yrs with Type 2 Diabetes. A Working Group which includes: Representatives from the Health Sector, Reprsetatives from Social Services and local NGO’s.Timeline Started in 2018 and will continue throughout the duration of the project untill the end of 2023.Highlights IC as a new concept in Kosovo promotes the person-centred care and boosts the motivation for patients to stay active physically.At this early stage, we only have output results while the outcome results can be expected at later stages. Sustainability The Physical Activity is designed in collaboration with social and health sectors and the same were introduced to the patients in order to ensure sustainability.Transferability As the project has involved health professionals from the MFMC at all stages, they also received support from the international experts and shared the knowledge with colleagues.Conclusions (key findings) 82 Geriatric assessments and 66 geriatric plans were conducted. The first cycle of three sessions of physical activities for the diabetic elderly patients were organized by nurses at MFMC where the first 30 patients were divided into groups i.e. 43.3% robust, 36.6% pre-frail and 20% frail conditions. Glucose level under 7.8mmol/L 2 hours after eating was measured only in 33.3% of patients. Regarding medical therapy 10% were on insulin therapy, 23.3% on insulin plus oral medication, 63.3% on oral medication and 1 was keeping glucose level under control only though diets.Discussions o Every six months a comparison of above-mentioned parameters should be conducted.o Stable patients should be encouraged to attend community exercise groups or walking groups.Lessons learned Multi-sectoral collaboration proved to be effective on motivating patients to socially interact and enhancement of confidence to safely stay physically active

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