Tips for better cooperation in network care
The emergence of care networks is a fact. Regional initiatives with and for the patient are developing rapidly. Understandable, because the demand for care is changing. Multimorbidity and complexity of care are increasing. At the same time, people are living at home longer and after being admitted to hospital they return home as quickly as possible. Care, treatment and support are increasingly provided at or near home. This leads to a shift of tasks from the hospital to the district; the general practitioner and the district nurse play an increasingly important role. There is also a greater demand on informal carers. A different focus and a new way of working, therefore, which is desperately needed but quite a task. This is evident from the many network care initiatives that fail. What exactly is the reason for that? And how do we make sure it does?
What is network care?
Before answering these questions, it is worth briefly considering what network care actually is. People with complex problems who receive care and support have to deal with various care and assistance providers, such as: 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 in the care process and together form the care network. The size and composition of such a network differs per person.
In a care network, power is divided between the various organisations involved and control takes place according to the principles of the organisation network. We also call this the ‘pancake’ (see figure 1). An organizational network easily adapts to change. Control usually takes place on the basis of a mutually accepted form of direction. The leadership and power are often divided between different people; not ‘everyone a boss’, but ‘everyone the boss’ is the adage. Because of the relationship between the parties, knowledge, products and services can easily be exchanged. Of course there must be something to exchange. Therefore, heterogeneity within a network is a prerequisite. In other words, different organizations and professionals with different expertise.
Figure 1: The organisational network
Why does it often go wrong?
There are several reasons why network care does not always go as we would like. First of all, cooperation in a network regularly causes ‘hassle’. This is because as a healthcare provider you are giving up some of your autonomy and the duration of the collaboration is often unclear. This creates uncertainty. As a result, you see parties not clearly articulating their interests and expectations to each other. Afraid of having to make concessions, they don’t show the back of their tongues. What they don’t realise is that openness and transparency increase the chances of a fruitful, successful collaboration many times over, research has shown. And the fact that conflicts sometimes arise does not have to be a problem, as long as the frameworks are clearly set out beforehand. But aren’t you open with each other from the first moment? Are the individual interests not clear, have no clear agreements been made and is there insufficient trust? If so, network care is doomed to failure.
In addition, the design of care is too often based on the disease rather than on the needs and wishes of the patient. As a result, the supply of care does not match demand. Third, there is a lack of transparency in the area of care outcomes. This is often also a result of insufficient mutual openness. And finally, the financing of healthcare in the Netherlands is fragmented, making joint initiatives sometimes very difficult to finance and therefore to organise.
Lessons for successful network care
Practical examples in Germany, England and the United States, for example, show that network care can be very successful. We can learn important lessons from this at the level of administrators, healthcare providers and patients:
For drivers it is important to promote effective partnerships between prevention, care and welfare. Create support for this in the region. Be aware that significant investment is required. Implement contract innovation and outcome costing, and invest primarily in prevention. To bring the various stakeholders together and keep them together, it is wise to have an external person as an independent party supervise the jointly drawn up outcome indicators and rules of conduct. Have a general practitioner or district nurse act as a case manager to coordinate a patient’s care. Make sure that they are supported by a regional back-office, with people who have an overview of the data and can identify trends and problems. And finally, make sure you evaluate the process from the very beginning.
Vote as caregivers tailor the care you want to provide to local needs. Take into account diversity in language and culture. And don’t just look at it through clinical glasses. In other words, focus not only on the disease, but also on what the patient finds important. These can also be ‘small’ things, such as being able to continue living at home or pursuing a hobby. Research shows that people score higher on quality of life if you design the care according to their needs. And that in turn has a positive effect on their health. Moreover, it is more cost-effective. A win-win-win situation. Just make sure the care you provide is empirically based. And keep up with the times; be open to new role allocations (task delegation and differentiation) and technologies (eHealth). And if you want to implement new projects, form a special project management team to get this going.
The care must be organised in such a way that the patient stimulate healthy living and prevent disease. Self-management is the key here. Give patients ownership of their medical records and ultimately financial responsibility. This way they can make their own choices. Transparency in outcome indicators facilitates this choice process. And eHealth applications can play an important role in this, provided they are proven effective. It is important that the provision of information is in line with what the patient wants and is able to do.
Administrative decisiveness required
But first we need a coherent policy agenda and administrative decisiveness. Scope must be created in the current legislation and the financing system must be overhauled. Due to the fragmentation in these areas, there is no room for innovative projects. The pioneers, who are so important for bringing about innovation, are constantly coming up against walls and eventually, tired of fighting, burn down. As a result, the implementation of integrated network care at all levels is stagnating. This is a pity, because there is sufficient scientific evidence that an integrated approach to care actually leads to better health and lower costs.
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