Table 1 Description of the program to enhance general practice care on a framework for high-performing primary care [2]

1 Engaged leadership

GPCC is arranged in special contracts, which have been developed by organisations of GPs in collaboration with health insurers.

AOK, the largest health insurer in the region, initiated the program together with the regional association of GPs, and supported it over many years.

2 Data-driven improvement

The physician participates in quality circles: small groups of physicians who receive feedback on their prescribing, evidence based information and plan improvements. The practice has a data-orientated quality system and decision support for prescribing medication.

The AQUA-institute, Goettingen, is responsible for the data-based feedback reports for physicians. GPs take part in 4 quality circle meetings per year in which benchmark reports with own prescribing data is discussed under supervision of a trained peer moderator.

3 Empanelment

The physician participates in disease management programs (DMP) which concern panels of patients with diabetes, asthma/COPD, and coronary heart disease.

Partipation by patients is voluntary and based on written informed consent. After consent, patients are added to the panel of patients in GP-centred care.

4 Team-based care

Disease management programs imply enhanced participation of practice assistants in clinical work.

Practice assistants are encouraged to take part in an additional training program (VERAH) for better management of patients with chronic diseases. Practices who have their assistants qualified are entitled to receive a financial bonus.

5 Patient-team partnership

Self-management support is an important component of disease management programs.

Patients who participate in a DMP are offered a validated educational program. This comprises of informative group meetings.

6 Population management

The decisions of the physician on pharmaceutical treatment follow prevailing recommendations, for instance regarding the prescription of discount drugs and such with therapeutic benefit (using a software tool).

Feedback and benchmarking on prescribing is supported by short written evidence reports. Recommendations are strictly evidence-based and not influenced by industry. Prompts in the software of a practice support use of generic and discounted drugs where eligible.

7 Continuity of care

Referrals to medical specialists are preceded by relevant diagnostic procedures and treatments and, in case of referral, the findings are clearly communicated to medical specialists and backwards.

The contract with GPs is supported by contracts with specialists such as cardiologists and orthopeadic surgeons in which care pathways are stipulated.

8 Prompt access to care

The practice organization of the physician has a number of clinical facilities (e.g., spirometer), daily consultation hours, up-to-date information technology. Patients benefit from shorter waiting times and absence of out-of-pocket payments for medication.

According to the contract practices have to have a comprehensive set of up to date primary care equipment available.

9 Comprehensiveness and care coordination

The physician is trained in primary care-relevant domains (e.g., pain treatment, communication skills) and participates in continuing education.

A committee of the association of GPs and academic departments of general practice in the area coordinates continuing medical education and sets topics for quality circle sessions for the participating GPs together with the AQUA institute.

10 Template of future

Participation in GPCC is a voluntary choice of physicians and patients. For the FP, is associated with about 40% increased reimbursement of the FP for enrolled patients as lump sum payment without pre-specified maximum.

The GP-centred care program is planned to remain in Baden-Wuerttemberg. Collaboration of primary care and medical specialists will be strengthened by programs targeted at ambulatory medical specialists.