What you should know about care networks
The Dutch healthcare system is coming under increasing pressure. The ageing population and the increase in the number of people with a chronic condition and/or multimorbidity are changing and increasing the demand for care and the costs of care. At the same time, the shortage of professional caregivers is growing. In response, the government is encouraging people with complex, long-term care needs to continue living at home for longer. In addition, the government encourages citizens to provide care and support to others. As a result, care providers see their field of work shifting from intramural to extramural. In addition, they are increasingly dealing with volunteers and informal carers. The question is: how do you arrange this properly? A care network is seen as the solution. But what exactly is network care, how do you organise it and what can you achieve with it?
Social networks improve health
International studies show that 36% of health is created by individual behaviour and 24% can be explained by social circumstances (Figure 2). If you want a return on health, you have to focus on these factors. And it actually has an effect. International research shows that social networks have a demonstrable influence on, for example, smoking, diet, exercise, depression, therapy compliance and obesity. A good example are the results of a recent study among patients with a chronic heart condition or diabetes. This research shows that influencing healthy behaviour mainly happens through the social network of a patient. This leads to fewer hospital admissions and lower healthcare costs. A network approach therefore offers promising opportunities to really improve health.
Figure 2. What influences health?
What is a care network?
The next question is: how do you organize care according to the principles of a network? Let’s start by giving a definition of a healthcare network, because there is quite a bit of ambiguity about that. Not least because of the huge list of synonyms in circulation: integrated care, comprehensive care, network medicine, 1.5-line care, substitution of care, care in the right place, sensible care, you name it. All terms that amount to the same thing and for which the following definition applies: A healthcare network is a coordinated way in which a group of healthcare providers work together to improve the health outcomes of a (sub) population. The care providers are prepared to bear the joint risk of whether or not quality and costs of care are achieved. To make it more concrete: a chronic patient with comorbidity will soon have to deal with ten care and assistance providers: the general practitioner, medical specialists, a physiotherapist, the district nurse, domestic help, the pharmacist, the WMO day care centre, informal carers, volunteers, etc. All these people have their own role and responsibility in the care process. If they work together in a coordinated way and share responsibilities, this is called a care network. Network care aims to improve the accessibility, quality and efficiency of care and to increase patient satisfaction. It is not an end in itself, but a means to achieve value-driven care – also known as Value-based Healthcare or Triple Aim.
Why are care networks necessary?
Quite simply, to meet the changing demand for care. A normal occurrence. Throughout history, the healthcare system has continually adapted to changing circumstances. Whereas in the late 19th century the primary objective was to combat infectious diseases, today the challenge is to combat chronic diseases. This can only be achieved by operating in networks.
How do you organize network care? Four types of care networks
A care network is seen as the answer to the increasing demand for care and the rising costs of care. But how do you put it into practice? The Rainbow Model (Figure 2), can help with this. This model distinguishes four areas where action is needed. This involves legislation and regulations at macro level, cooperation between organisations and professionals at meso level and self-management support for patients at micro level. On the basis of the Rainbow Model, the following types of care networks can therefore be distinguished:
- 1. System Networks
- 2. Organizational Networks
- 3. Professional Networks
- 4. Patient Networks
Figure 1: The Rainbow Model
Patient networks
The patient is the main pillar of a healthcare network. The self-reliance of people is currently high on the political agenda. They are encouraged to better manage their own health, possibly with the help of informal caregivers and volunteers. But this only works if patients have insight into the quality and costs of the care offered and own their own health data. Unfortunately, in practice this leaves much to be desired. The patient’s input into his own care network can be optimized by deploying eHealth applications and home care devices and by training people in their use. In addition, it is important that there is clear communication on a regular basis with the care providers in the care network and with fellow sufferers. All of this is only possible with a legal framework for access to personal health data, transparency about treatment outcomes, and disclosure of information systems.
Professional networks
Interprofessional cooperation between care providers is the core of a care network. This is characterised by joint quality frameworks, guidelines and protocols and multidisciplinary consultation. In the Netherlands, we mainly see forms of horizontal cooperation within the first line (health centres, GP outposts and care groups) and second line (multidisciplinary consultations and care pathways in hospitals). Vertical forms of cooperation between primary and secondary care are rare, while they are essential for a successful care network. To achieve this, different legal and financial frameworks are needed. Only then can the profession of healthcare provider start to develop in the direction of ‘organised professionalism’. This means that professionals in the field of prevention, care and welfare are entering into partnerships within supportive (virtual) care networks. Through new contract forms (such as bundled payments and shared savings), they are increasingly held accountable for clinical and economic care outcomes. Payments are going to be an incentive to provide the best care at lower cost. This carries clinical and financial risks that are difficult to manage at an individual level. That is why new inter-professional standards, curricula, training courses and professional associations will make their appearance, as is common practice in the legal and accountancy professions, for example.
Organization network
Care professionals work for organisations and these organisations also need to enter into alliances to make a care network a success. Research shows that a regional approach is the most effective. For a fruitful cooperation between organizations, data exchange and integrated forms of financing are absolute requirements. To take the example of integrated care: health insurers can enter into integrated care contracts with general practitioners and medical specialists to stimulate cooperation between first and second line. In addition, they ensure proper alignment and coordination of care and are jointly responsible for medical, social and economic outcomes. In this respect we can learn a lot from foreign initiatives, such as Accountable Care Organisations and Patients Centred Medical Homes in the US.
System network
Unfortunately, both in terms of policy and financing, Dutch healthcare is very fragmented. The difference in scale, organisation and orientation between health insurers and municipalities means that network care is not perpetuated in practice. A care network requires an integrated policy and approach that goes beyond the walls of municipal, care group, home care and hospital organisations. It is important that we start to develop a long-term strategy for care networks between the prevention, care and welfare sectors. This, in turn, calls for integrated legislation and regulations and associated forms of financing. Without these preconditions, realising network care becomes a mission impossible.
The show must go on. But who will take the lead?
We are increasingly aware that care networks are the answer to increasing demand for care and rising healthcare costs and that it is time for action. Still, things don’t work out that way. Why is that? In any case not to the individual motivation of patients, professionals and volunteers. They want to, but they are up against walls. Looking at the Netherlands, the biggest showstoppers for care networks are:
- 1. The lack of an integrated policy between care and welfare;
- 2. Fragmented funding between primary and secondary care;
- 3. Lack of data linkage between first and second line.
All of these factors are – strikingly enough – located at the level of the system and organisation network. So therein lies the key. The million dollar question is: who is in charge here in the polder? Where do we plug in? At the Ministry of Health, Welfare and Sport with a four-year policy agenda? At the Health Inspection? At the Dutch Health Care Authority? Or with the health insurance company? It is a sad fact that the policy-oriented pigeonholing mentality in the Netherlands does not exactly help to realise care networks in practice. Integral compliance, control and financing prove very difficult in our compartmentalized healthcare system. While everyone knows that the sum is greater than the parts… In fact, many international best practices show that an integrated approach/networked care leads to better outcomes. There is therefore an urgent need for cross-thinkers and ‘fresh thinkers’ to put integrated policy and financing into practice. With an integral policy agenda and administrative decisiveness, we can lay the foundation for creating regional care networks at the level of the patient, care professionals and organizations. Care networks that provide high-quality, people-centered care, that use the latest technology, and that, through high patient involvement, quickly produce the desired results: higher patient satisfaction, better health outcomes, and lower costs. It really is possible, provided we are willing to step over our own shadows!
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