Alternate care: what if the solution is the problem!

Complex care in hospitals and simple care in the first line, that is the ideal picture. GPs and medical specialists are trying to refine this ideal by offering simple specialist care in GP practices through numerous projects. In short, the cardiologist, dermatologist, geriatrician or other specialist who sees patients a few hours a week in the GP practice. Alternate care is the trendy term given to this phenomenon. At first glance, one-way care doesn’t seem so bad. It brings care closer to the patient and that’s what we want. But we also want better care for less money, and unfortunately, in most cases, single-level care does not lead to that. This is not so strange, because what can you achieve with half a shot when you need to de-fragment the healthcare system to bring about real improvements? In this blog, we’ll be filleting the term other-worldly care. We show the pitfalls and give tips on how to achieve better health outcomes, better patient experiences and lower healthcare costs – or triple aim outcomes.

What is other-worldly care?

Divergent care is the transfer of hospital care to general practices. This is care that does not require sophisticated, expensive equipment. The idea is that the specialist might as well come to the patient for this kind of care. One-stop-shop care can be seen as a first cautious step towards abandoning the traditional echolalia approach – first line versus second line. The proponents of other forms of care say that this way of working is not only cheaper but also more pleasant for patients. They can often get their care faster and do not have to pay a contribution based on the excess. But that is the theory and practice, unfortunately, shows otherwise. Why is that?

Alternative care: what goes wrong?

When shaping other forms of care, we make mistakes in our thinking and our form on a number of fronts:

1. Unclear terminology.

Divergent care is in line with population management, network care, Proper Care in the Proper Place, substitution of care and transmural care. It is not a synonym for these terms, but part of them. You could say that one-way care is a part of substitution of care which, in turn, is a part of a care network (also referred to as ‘the right care in the right place’ or transmural care). One-way care is a small piece of the large puzzle that network care could be. Because all these terms are used interchangeably, a lot of confusion arises.

2. One-stop-shop care is pigeonholing.

The reasoning behind the establishment of other forms of care is as follows: the care system around the primary and secondary care is too fragmented to provide good care for vulnerable patient groups, so we are creating other forms of care as a solution. Then we will discuss whether this one and a half line should be generalist or specialist. So basically, that’s just adding a layer without changing anything. In other words, one more box on top of all the boxes that are already there….

3. Law of inhibitory chain care.

Too much is still done on the basis of the chain-based care model, while a crucial mistake was made when it was introduced in the Netherlands. We have forgotten to include the second line in the financing of the chain, so that the desired results in the field of quality improvement and cost savings are not achieved. But it can also be done differently! In countries where integrated care is successful, health insurers enter into integrated care contracts with both primary and secondary care providers working together in one organisational network. As long as the Netherlands lacks such integral financing and management, we will continue to suffer from the law of inhibiting chain care. As a result, new hypes are constantly being introduced, such as other forms of care, in an attempt to find a model that does work.

4. Who is ‘in the lead’?

Is it the general practitioner or the medical specialist (the hospital) who pulls the strings? There is often a lack of clear agreements on this, which leads to a lack of cooperation. In addition, the various stakeholders often have different interests, which hinders fruitful cooperation. Moreover, the cooperation is often motivated by external parties and lacks a real transmural incentive.

5. Lack of data exchange.

Effective collaboration requires the exchange of data between healthcare providers. In the Netherlands, however, data collection is incomplete and fragmented. This makes it virtually impossible to gain an insight into the current and future demand for care, and new care initiatives regularly miss the mark.

6. Process rather than outcome control.

The design of care is too often based on illness rather than on the needs, wishes and outcomes for the patient. Scores are awarded on process indicators rather than outcome indicators, while the latter should form the basis for healthcare improvement and innovation.

What to do then: four tips for practice

Multiple care is a Dutch concept, partly in response to the failed introduction of integrated care. It was conceived from a policy paradigm and not from the patient’s perspective. This ultimately makes it doomed to failure. If we want to find a serious solution to the problems currently facing our healthcare system – an increasing and more complex demand for healthcare and soaring healthcare costs – we must opt for an integral approach: networked care. But how do you approach network care? We give four tips:

Tip 1: Are you willing to take risks?

In a care network, all those involved have their own role and share responsibility for outcomes and costs. But as a healthcare provider, are you willing to run this risk? Second-line care is more advanced than first-line care, but first-line care is also necessary for successful network care. Ultimately, it is a matter of all care and assistance providers involved in a care network making agreements about the coordination of care, the division of responsibilities and the measurement of results. A number of best practices abroad show that it works for complex patient groups if you organise care across the whole network of prevention, care and welfare and make people jointly responsible for the outcomes. Daring to take joint risks therefore pays for itself!

Tip 2: Focus on results: Triple Aim outcomes

Put your achieved and desired outcomes at the center of how you design your care. Let the ideas of Triple Aim serve as a guideline. The Triple Aim approach is all about improving your outcomes in terms of quality, health and cost. To achieve the desired outcomes for a specific (sub) population, you work with a group of care providers in a coordinated way and share the risks. Together you are responsible for whether or not the quality and costs of care are achieved.

Tip 3: Winning is starting with the soft side

Working together and sharing responsibility is not always easy. It requires trust, openness and transparency. To make care networks a success, it is important that the individual interests are clear and that clear agreements have been made between them. Define a shared ambition together, link your objectives to it and make sure there is support for it among all the partners in the collaboration. This support can be created by building on trust. Make clear how the shared ambition contributes to achieving the objectives within a network. Create a safe culture in which people are willing to meet mutual agreements and dare to call each other to account if things are not going well. In short: make sure the soft side within your care network is in order.

Tip 4: Agree on the top 3 pitfalls

Clear agreements are needed in the areas of financing, data exchange and interests in order to increase the chances of successful cooperation. In terms of data exchange, make mutual agreements about which data you register and how and for what purpose you analyse them. And be aware of the differences in interests between medical specialists and general practitioners. For medical specialists, turning over volume is of great importance, while general practitioners have a much greater interest in creating space in their practice. How can you come closer together in this respect; how can you help and strengthen each other? This is context dependent. Starting from the care needs in your region increases the chance of a successful collaboration in your care network.

Getting started with care networks

Want to know more? Download the ebook Care networks that work and read more about the theoretical and practical side.

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dr. Pim Valentijn

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