The 9 lessons from South Korea, Taiwan and Singapore for combating the corona crisis (COVID-19)

Based on recent figures, the coronavirus appears to be present mainly in South Korea and to a lesser extent in

Taiwan and Singapore. None of these countries have instituted a total lock-down, but they have been very successful in controlling the number of infections and deaths due to the coronavirus. Given this remarkable success, it is important to understand what these Asian countries are doing differently from the rest of the world. In this blog, we describe the essence of Asian corona measures. These insights are essential to contain the current COVID-19 outbreak or a possible second outbreak in the Netherlands.

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The right care in the right place: To measure is to know!

Correct care in the right place (JZOJP) is the latest buzzword of administrators and policy makers. NNot surprisingly, because it sounds like a logical and therefore attractive solution to all complex problems in healthcare. The growing group of frail elderly people with dementia, who are living at home for ever longer? No problem, JZOJP will solve this. But those who look beyond the horizon know that it is not that simple. In fact, what if JZOJP is part of the problem? In this blog, we explain the problem with the current JZOJP approach and what it will take to break it.

it sounds like a logical and therefore attractive solution to all the complex problems in health care. The growing group of frail elderly people with dementia, who are living at home for ever longer? No problem, JZOJP will solve this. But those who look beyond the horizon know that it is not that simple. In fact, what if JZOJP is part of the problem? In this blog, we explain the problem with the current JZOJP approach and what it will take to break it.

Bullshit bingo

The Right Care in the Right Place (JZOJP) sounds promising, but turns out not to be easy to apply in practice. The first results of research by the NZA show that approximately 70% of the initiatives fail. The underlying cause of this problem is the so-called Bullshit Bingo that has the Dutch healthcare system in its grip. Just cross it off on the map: Right Care in the Right Place, Care Network, sensible care, care paths, 1.5-line care, substitution, positive health, network medicine, lifestyle medicine, etc. These are all wonderful, simple terms that obscure or ignore the complex connections in the care of the growing group of people with complex problems such as dementia. As a result, none of them provide a concrete solution. The fact that everyone has different definitions of and images of the JZOP concept does not help. At its core, of course, it’s about collaboration and people being able to do that in their own teams and outside their organization, in a context of innovation and trust. It is unclear how well we are really doing.

Knowing is measuring

Therefore, DementieNet and the Essenburgh have started a scientific study into the JZOJP for frail elderly and people with dementia. This cooperation is often far from optimal in the Netherlands. Nevertheless, there are good international examples that show that improving cooperation has many positive effects: vulnerable older people and their informal carers experience better quality of care, it is more pleasant to work for the care providers and ultimately it is cost-efficient. The research of DementieNet aims to identify the building blocks for successful collaboration in the complex care of people with dementia based on the Rainbow Model. To prove this, 50 local networks are examined and compared with international best practices. The results of the research help to determine concrete input for improvement targets for a successful JZOJP approach in the Netherlands.

Are you with me?

Would you like to know how your care network is doing? Then take part in the DementieNet survey. When you participate in the survey, you get direct insight into the performance of your network and tips on how to optimize collaboration. We ask of your network:

• Participation in an online audit care network, possibly supplemented by qualitative interviews.

Your network gets from us:

• Report with the results and comparison with benchmark data.
• Action plan and tips to improve cooperation step by step.

Want to know more about the research? Click here.

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.

The Right Care in the Right Place: Roadmap for a successful implementation

The Right Care in the Right Place is the new hype in healthcare. We see the term popping up everywhere and the memorandum ‘Proper Care in the Right Place’ forms the basis of all the mainline administrative agreements that have been concluded.

This is understandable, because in essence the Right Care in the Right Place is a fantastic way to realise the principles of Value-based Healthcare or Triple Aim in a region. However, a recent report by the NZA shows that the implementation has not got off the ground. We also know that implementation of such complex grant programs fails 70% of the time. As a result, stated goals are not achieved, time and money are wasted, and frustrated professionals and disappointed patients are left behind. The bottom line is that the Right Care in the Right Place – as it is currently designed – is doomed to failure. A different approach is needed. The key to success is a good implementation model and the great thing is: it exists! In this blog we will show you how to successfully implement the Right Care in the Right Place.

Why the right care in the right place?

The composition of our population is changing and with it the demand for and intensity of care. Compared to the year 2000, the number of people in the Netherlands aged 65 and over will double to approximately 4.25 million by 2030. As a result, not only is more care required, but other care as well. A large proportion of these elderly people have to contend with multi-morbidity and therefore a complex demand for care. But also in the population as a whole, multimorbidity will increase as a result of an unhealthier lifestyle. On top of that, there are more and more treatment options. All this will lead to an enormous increase in costs. It is expected that the average healthcare costs per person per year will rise from over 5,000 euros now to 9,600 euros in 2040, unless we intervene in time. This can be done by implementing the right care in the right place in the right way.

What is Proper Care in the Right Place?

Before we explain how to successfully implement Just Right Care in the Just Right Place, it’s a good idea to give it a definition, as this is often lacking. The national government formulates it as follows: ‘De Juiste Zorg op de Juiste Plek is an initiative of care providers. In this philosophy, the daily functioning of people is central. From there, they look for ways to relocate care (closer to people’s homes), prevent more expensive care and replace it with eHealth, for example. This helps people to live better with their illness or disability. The Ministry of Health, Welfare and Sport supports this movement where possible and facilitates parties to learn from each other and to get in touch with each other. Juist Zorg op de Juist plek is therefore care close to the patient, with various care and assistance providers working together and with increasing use of digital channels. Now you may be thinking, “Isn’t that network care? That’s right, Proper Care in the Right Place is a synonym for network care. And also for care network, sensible care, care pathway, 1.5-line care and substitution of care. We do not say this to make things even more complicated, but because these terms are also used all the time without us being able to see the whole picture – the entire elephant (figure 1).

Figure 1: The land of the blind

Right Care in the Right Place: a recipe for failure!

Why is the Right Care in the Right Place, as we are now approaching it in the Netherlands, doomed to fail? Apart from the fact that everyone has different definitions and images of the concept Proper Care in the Right Place, we do not meet the necessary preconditions. There is a lack of structural, integral funding and a coherent, evidence-based policy agenda. We do not regulate the care in an integrated way, but choose to start up separate projects and subsidy programs (like Juiste Zorg op de Juist Plek) as a countermeasure for our fragmented financing. They are all just a bunch of excuses with no coherence. As a result, the desired effects of quality improvement and cost reduction will not be achieved. The care providers do want to, but are not really stimulated by the current financial incentives to work integrally. As a result, the Right Care in the Right Place initiatives are struggling to get off the ground, let alone becoming embedded in practice. The problem is higher up in the tree. At the government level, policy is fragmented and not based on an evidence-based policy agenda. This makes the Dutch healthcare system inefficient. And who will suffer as a result?

The Subsidy Frustration Carousel (SFC)

1. Patient:

The patient who keeps getting stuck in the system because the Proper Care in the Right Place project he is using is due to expire after three years.

2. Healthcare professional:

The healthcare professional who becomes frustrated because his efforts are not continued in practice after those three years by means of a contract with the healthcare insurer.

3. Driver:

The director who cannot bring about structural changes due to a lack of a structural, integrated purchasing policy and a long-term contract with the health insurer.

4. Policy maker:

The policy maker who, time after time, has the difficult/impossible task of successfully implementing a new ‘hype’ because the field suffers from SFC syndrome.

In fact, the only ‘winner’ is the consultant who has his hands full trying to find the possibilities within the depths of the system. Incidentally, in most cases without long-term success. By now, it’s probably obvious why….

How can the Right Care in the Right Place be successful?

For about 15 years we have been muddling along in the Netherlands, while in other countries, such as America, England and Germany, successful initiatives have been launched. The reason is that they have arranged their financing properly (see figure 2).

Figure 2: International examples

However, there is also a solution within reach for the Dutch situation in the form of a scientifically substantiated implementation model: the Rainbow Model.

Figure 3: The Rainbow Model

In the Rainbow Model, the needs of the patient are the starting point for various forms of clinical, professional and organizational collaboration. Such cooperation can take place at: 1) micro level: between client/patient and care provider, 2) meso level: between professionals and organisations, and 3) macro level: laws and regulations affecting all forms of cooperation.

Collaboration, that’s what it’s all about. The right care in the right place depends on people – patients, healthcare professionals and administrators – who are willing and able to work together, even beyond the walls of their organisations. And you can achieve this in four ‘simple’ steps:

Step 1: Map out your patients’ needs.

Do this at a regional level, so share practice data. Also, try to predict the future needs of your patient population. You can do this using clinical and cost data. This way you know what interventions are needed for your patient population now and in the future.

Step 2: Determine what outcomes you want to achieve.

Both clinically and in terms of patient experience and cost. Use the principles of Triple Aim for this. PROMs (patient reported outcome measures) and PREMs (patient reported experience measures) can be useful here.

Step 3: Determine what forms of collaboration you need to achieve those outcomes.

The Rainbow Model serves as a guideline for this. Look at the micro-, meso- and macro-level to see which forms of cooperation you could use.

Step 4: Identify and organise structural and cultural preconditions.

List what you need to make the Right Care in the Right Place a success in the long term. For example, look at funding and whether there is a culture within your organisation where people are prepared to make changes.

Towards evidence-based policy

The fact that most Proper Care in the Right Place projects fail has nothing to do with the potential of the concept, but with the way it is put into practice in the Netherlands. Instead of an integrated policy approach, we choose to finance separate projects. Subsidy money as a stopgap measure, that’s what it comes down to. We really need to stop doing that and make sure that we create the right preconditions to make the Right Care in the Right Place the success it deserves. This means that we make agreements at macro level about integrated financing, that we shape our policy on the basis of evidence and that we create conditions for information exchange. Use the needs of your patient population and the desired outcomes of your care as the starting point for care improvement. And very important: work together! With patients, with other care providers and with other care organisations. If so, the success rate of ‘Juiste Zorg op de Juiste Plek’ will increase by leaps and bounds.

Would you like to know more about successfully implementing Just Right Care in the Just Right Place? Read more in our eBook Care networks that work: The key to better outcomes.

Patient experience or patient satisfaction: what does it get your organisation?

Measuring patient experiences and patient satisfaction is becoming increasingly important in healthcare in order to assess the quality of care. But the concept of patient experience is surprisingly complex and is often equated with patient satisfaction.

These terms are also regularly used interchangeably in the literature. Confusing and unjustified, because patient experience and patient satisfaction are two different things. In this blog we will discuss these differences. We show you what to measure to gather useful data to improve the quality and efficiency of your organization. And how to make sure you have happy patients.

Patient experience and patient satisfaction: the differences

Although the terms patient experience and patient satisfaction are often used interchangeably, there is a subtle distinction between the two (see also Table 1).

1. Patient experience

Patient experience includes all interactions a patient has with care and how they experience it. You can think of the reception by the receptionist and the care by doctors, nurses and other care providers. When measuring patient experience, we look at whether something that should have happened actually did happen.

2. Patient satisfaction

Patient satisfaction is based on the patient’s expectations of care and whether those expectations were met. As a result, two people receiving identical care may score totally different on patient satisfaction.

Table 1. Patient experience versus patient satisfaction

In short: patient satisfaction is often very personal, while patient experience is about testing a defined standard of care. Subjectivity versus objectivity, in other words. The subjectivity of patient satisfaction surveys is also endorsed in several studies(Evans et al 2018; Dunsh et al 2018). These show that:

• Patients tend to make positive judgments immediately after treatment.
• The chance of a positive judgement is higher if the questions are formulated in a positive way.
• Satisfaction is not a reliable measure of quality.

So, all indications are that measuring the patient experience is more meaningful. Hence, in this blog we will focus further on this.

Why is a positive patient experience so important?

Of course we want to provide care that our patients experience as ‘good’. Satisfied customers are nice to have, but positive patient experiences can also bring important clinical and financial benefits, research shows. We will mention a few examples:

1. 1. Mortality

    

   Research among patients with heart disease shows that a positive patient experience has an effect on mortality (Meterko et al., 2010).

2. Costs

There is evidence that positive patient experience leads to lower average costs for healthcare organizations(DiGioa et al., 2007; Charmel et al., 2008).

3. 3. Quality of life

Research shows that positive patient experiences have a positive impact on self-management skills and quality of life in diabetic patients (Greenfield et al., 1988).

4. 4. Adherence to therapy

A correlation has been demonstrated between positive patient experience and adherence in patients with chronic conditions(Doyle et al., 2013; Beach et al., 2006).

5. 5. Satisfied caregivers

Positive patient experiences lead to reduced staff turnover and increased job satisfaction among healthcare professionals(NHS, 2010; Agency of healthcare Research & Quality, 2016).

6. 6. Patients

Moreover, research shows that patients want to be more involved in decisions about their treatment(Picker Institute, 2006).

So, good patient experiences have an impact on various Triple Aim outcomes. By focusing on this as a healthcare institution and improving patient experience, you create a win-win situation.

Improving the patient experience: how to do it

But how do you improve the patient experience as a healthcare organisation or healthcare provider? This can be done in many different ways that may vary for each organization, because no organization and no patient population are the same. But while there is no one-size-fits-all approach, there are several proven methods to improve the patient experience. We mention a few of them:

1. 1. Waiting times and queues

Communicate waiting times and ensure that queues do not become too long, for example, by online and offline solutions that allow patients to make their own appointments.

2. 2. Signage

Make sure patients can easily find their way around your organization. In that respect, digital navigation is the future.

3. 3. Information in your own language

Use communication tools with translation functions. A patient who does not speak the language is more likely to be dissatisfied with the care provided.

4. Waiting room
Create a calm, relaxed, comfortable atmosphere in the waiting room. The logic is simple: if patients feel positive about the environment in which they wait for treatment, they are more likely to be positive about the experience as a whole.

5. 5. Staff

Make sure your employees are positive about their jobs. One way of achieving this is by designing work processes as efficiently as possible to prevent unnecessary work stress. But also by providing insight into which behaviour produces positive patient experiences. Staff treatment has perhaps the greatest impact on patient experience.

6. 6. Involve patients in the delivery of care:

Try to choose appropriate care together with the patient and divide the tasks. Display messages in the waiting room about developments in healthcare and offer patients the opportunity to provide feedback through a survey.

Measuring patient experience: PROMs and PREMs

Patient experience is one of the most important parameters to determine the quality of care. You could even say that the survival of healthcare organisations increasingly depends on their ability to provide good patient experience, and therefore quality. Like no other, the patient makes bottlenecks in your care clear. But patient experiences are only useful if they are measured with valid and reliable measuring instruments. For this we have PROMs (Patient Related Outcome Measures) and PREMs (Patient Related Experience Measures). With a PROM the patient gives an opinion about the perceived health in the areas of, for example, pain, fatigue and depression. A PREM measures how the patient experiences the entire care process, such as the collaboration between care providers, treatment and efficiency of care. PREMs are particularly interesting for value-driven care,which can be seen as the way to restore health to our fragmented, costly healthcare system. The problem is that few PREMs have been validated. Based on scientific research Essenburgh has developed a PREM for integrated care and validated it internationally. This makes it a reliable tool to gain insight into how care is experienced in your organization. The short questionnaire is based on the patient’s perception of the situation and indicates whether and where they experience fragmentation in the care process. Strengths and weaknesses of the care process become visible at a glance. And because it is possible to compare scores at the level of practice, district and/or (sub) population, you will discover best practices and therefore concrete points of departure for improvement.

Figure 2: PROMs versus PREMS

Want to know more?

Download the free E-Book Care networks that work: the key to better outcomes. And learn what your organization needs to do to improve patient experience and satisfaction. Would you like to use our scientifically validated measuring instruments to map out the patient experience? We are happy to help you. Please contact us for more information.

Risk stratification: Drive value-based healthcare and the Triple Aim with smart algorithms

Consultation hours are overly busy, and a lot of time goes into checking off the required boxes. It drives healthcare providers crazy! Understandable, but unnecessary. With a different focus and approach, there is a lot to be gained in terms of the Triple Aim. The secret is to look at risks instead of diseases and making smart use of your own data through algorithms, also known as risk stratification. In this blog we will explain how you can organize your care based on patient groups with high, increased or low risk profiles. We will show you that it leads to: 1) better outcomes for patients, 2) lower workload and more job satisfaction for healthcare providers, and 3) more efficient business operations and lowering of costs for managers in the healthcare sector. And the best thing is: it’s all within reach.

Focus on risks instead of diseases

The biggest pitfall of our current healthcare system is the disease instead of person-focus view. Nowadays we are dealing with an increasing group of people who have two or more diseases simultaneously, who risk falling between the cracks because of this focus when it comes to healthcare. It is much smarter to adapt healthcare and organize it on the basis of risks and the patient’s corresponding health needs. By identifying unique subgroups of patients, healthcare organizations can offer person-centered care instead of a single disease one-size-fits-all approach. That way, they have more influence on a better outcome for these patient groups. They can also organize their care more (cost) efficiently. This means that the traditional chronic disease divide of groups (e.g. diabetes type 2, COPD, heart failure, oncology etc.) will become less important in the near future. This is a new way of thinking, at least for the Netherlands. In other countries, like the US, Australia, New Zealand and Colombia, it’s already proven effective. Their best practices show us that realizing the right kind of care in the right place starts with dividing patients based on risk stratification models.

How does risk stratification work?

All healthcare providers need to register data in a database. Releasing risk stratification algorithms on the data in such a database is a relatively simple way to categorize patients on the basis of risk profiles. Some people struggle with the idea of using algorithms because of negative associations. This is a shame and unjustified, because algorithms are much better at tracking down patterns than the average healthcare providerwhichis incredibly beneficial to your organization. We will try to explain what it benefits exactly based on three risk profiles that can be detected by means of risk stratification. We start with a short description of the profiles and explain step by step how, as a healthcare provider/organization, you can use it to adapt your healthcare services to these profiles.

Image 1: How risk stratification works

High risk patients

This group, which accounts for approximately 5% of the population, consists of people that visit their GP or another healthcare provider more than twenty times a year for different reasons. The so-called superusers.Not unsurprisingly, we find a lot of vulnerable elderly people in this group. But also people who have mental health issues. The group is more heterogeneous than you would think. For example, risk analyses can show us that a lot of superusers are middle-aged women with families. A group you wouldn’t necessarily think of right away, but that can clog up your consultation hour in your daily practices just as much as other high-risk patients.

Step by step plan:

1. Link every high-risk patient to a case manager. This can be a nurse practitioner, a district nurse, a GP or a specialist in geriatrics. The case manager coordinates the care of a patient along the entire spectrum of prevention, care and wellbeing.

1. 2. It’s important for the case manager to get off on the right foot with a patient. For example by making an appointment to get to know each other and explaining his/her role.
3. 3. The case manager and the patient then create a custom healthcare plan. The standardized approach with set templates and documentation options within the electronic health record (EHR) can be used for this. The healthcare plan can include clinical and non-clinical problems. Self-care and shared decision making are always part of a healthcare plan.
5. 4. Since a high-risk patient almost always deals with health and social related issues, it’s important that this case manager has a wide range of social tools at his or her disposal and is good at cooperating.

Increased risk patients

This group consists of people with one or more chronic diseases who switch between stable and unstable periods. It’s good to take into account factors such as obesity, depression, high blood pressure, high cholesterol, high blood sugar (pre-diabetic) and tobacco consumption in risk stratification algorithms. The goal here should be that these people don’t move into the high-risk category.

Step by step plan:

1. 1. Have a care group or health center coordinate the healthcare and make sure all relevant disciplines are represented. Models like Accountable Care Organization, and Patient Centered Medical Home (PCMH) are examples that already use this method.
3. 2. Try to involve the patients in their care as much as possible. This can be done through self-help support, shared decision-making, written healthcare plans and patient surveys. Family and friends can also be involved as ‘influencers’. They can encourage the patient in their self-care and act as an extension of the healthcare team, for example by informing the healthcare team of any significant changes.
5. 3. Plan yearly preventative screenings for chronic conditions. This will make it easy to detect gaps in care and risks. These can be done by a health coach.
7. 4. Invite increased risk patients to try new types of care. Like eHealth applications, online forums, group sessions and health coaches. Research has shown it’s also smart to involve family and friends at this stage.

Low risk patients

This is the remaining group: people that are healthy or whose health is stable. The goal of this type of care is to keep these people healthy. This can be done cheaper, more efficiently and more goal-oriented than it is now.

Step by step plan:

1. 1. Develop an online patient portal for the initial communications and encourage low risk patients to use it (image 1). You can put information about for example the most common conditions and what to do if you have those. This stimulates self-management. Research has shown that this approach increases the patient’s engagement with the organization. This is interesting because it can encourage efficiency in use of care. The number of unnecessary consultation visits can be brought down this way.
3. 2. Focus on low risk interventions. As described above, it is important to manage the low risk patient population in an efficient way. Explore other strategies to engage with these groups even better and prevent them from becoming increased risk patients.
5. 3. Reserve time and capacity for (online) prevention and preventing unexpected healthcare needs. This doesn’t necessarily need to be done by a doctor, often times a nurse practitioner or doctor’s assistant can suffice.

Image 2: Online e-Health interventions

How is this beneficial?

Research has shown that risk stratification is the way to put value-based healthcare (VBHC and/or Triple Aim)into practice and actually generate better outcomes. It forms the basis of offering custom proactive care. Coordinated, patient-centered care saves the patient unnecessary treatments and time. The focus on prevention can also avoid a lot of unwanted outcomes. This all leads to higher patient satisfaction and better healthcare outcomes. This is also beneficial for healthcare providers. By organizing care based on risk groups, valuable time can be used in a more efficient way. Instead of scheduling ten minutes for every consultation, you distinguish between these risk groups. You give low risk groups less time and high-risk patients more, which means you have more time to properly help the latter and they will visit less during consultation hours. It also means a better division of labor. Not every patient needs to see a doctor for every problem. Some cases can actually be easily solved online. This decreases the workload and costs and increases job satisfaction. Risk stratification also means managers can make more specific contractual agreements with health insurers or governments. Right now, those agreements are based on volume and price, mostly based on nation-wide statistics. But it’s hard to determine a nationwide average. The need for care in a metropolitan area is completely different from the one in rural areas. If you can map how they differ, you can make agreements based on the regional situation. This increases the quality of care and saves costs.

So what’s stopping us?

That’s the main question, because it doesn’t seem to be taking off. There is still too much talking and too little action. Risk stratification is only possible if healthcare providers manage their data right and report the relevant data. That means no process indicators, but outcome indicators, like quality, health and cost (Triple Aim). It’s also important to link data systems. And don’t say it can’t be done because of privacy. That’s a fallacy. It’s undoubtedly possible to link data sets and adhere to privacy regulations. It’s not technique and regulations that are stopping us, but the prevailing culture. It’s almost like we’re afraid of the unknown. We need to be brave enough to move past that. Because we can influence that full waiting room as healthcare providers. We can negotiate better contracts. Let’s try to do that proactively. Instead of waiting until the government or health insurers take action when the situation becomes unsustainable, let’s take matters into our own hands and work on risk stratification. That way we stand up for ourselves and for our patients.

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How to reduce workload in healthcare with smart algorithms

Consultation hours are overflowing and much of the time is spent ticking off mandatory lists. It’s driving caregivers crazy! Understandable, but not necessary. With a different focus and approach, there is a lot to gain in terms of time, money and satisfaction. The secret lies in looking at risks rather than diseases and using their own data intelligently with the help of algorithms. In this blog we describe how you can organize your care based on patient groups with a low, increased, and high risk profile. We show that this leads to: 1) better outcomes for patients, 2) lower work pressure and greater job satisfaction for caregivers and 3) more efficient operations and cost reduction for healthcare administrators. And the best part is: it’s within easy reach.

Focus on risk, not disease

The major pitfall of our current healthcare system is the focus on disease. These days, we are dealing with a growing group of people with two or more illnesses at the same time, who are at risk of falling between two stools because of this focus in terms of care. It is much smarter to coordinate and organise the provision of care on the basis of risks and the associated health needs of patients. By identifying unique subgroups of patients, healthcare organizations can provide the right care tailored to them rather than ‘one size fits all’. Thus, they have more influence on better outcomes for these patient groups. In addition, they can organize care more efficiently and cost-effectively. This means that the traditional classification (diabetes, COPD, heart failure, oncology, frail elderly) of groups will become obsolete. This is a new way of thinking, at least for the Netherlands. In other countries, such as America, Australia, New Zealand and Colombia it has already proven its effect. Best practices there show that realizing the right care in the right place starts with segmenting patients based on risk stratification models.

How does risk stratification work?

All healthcare providers must record data. GPs do this in the GP information system (HIS) and hospitals use a hospital information system (HIS). By applying algorithms to the data in such a system, patients can be categorised fairly easily on the basis of risk profiles (see Figure 1). Some people have trouble using algorithms because of negative associations. This is unfortunate and unjustified, because algorithms can detect patterns much better than an average healthcare provider, andthis will benefit your organisation enormously. What exactly, we will try to explain by means of three risk profiles that can be detected by means of risk stratification. We will briefly outline the profiles and then indicate step-by-step how you, as a care provider/institution, can go about tailoring your care provision to these profiles.

Figure 1: How risk stratification works

High risk patients

This group, which represents approximately 5% of the population, includes people who, for various reasons, visit the family doctor and/or another healthcare provider more than twenty times a year. The superusers , so to speak. As expected, the frail elderly are well represented in this group. We also find the Wajongers with mental health problems there. But the group is more heterogeneous than we think. Risk analyses show that middle-aged women with families are also superusers. A group that does not easily attract attention, but – just like the other high-risk patients – can cause clogging up of the consultation hour in daily practice.

• Step 1:

  Pair each high-risk patient with a case manager. This may be a nurse practitioner, a practice support worker, a district nurse, a GP or a geriatric specialist. The Case Manager coordinates a patient’s care across the continuum of prevention, care and well-being.

• Step 2:
  

  It is important that the case manager gets off to a good start with the patient. For example by making an appointment to get acquainted and to tell about his/her role.

• Step 3:
  

  The case manager then draws up an individual care plan together with the patient. For this purpose, a standardized approach is available with fixed templates and documentation possibilities within the electronic health record (EPD). Such a care plan addresses clinical and non-clinical problems. Self-care and patient involvement are always part of a care plan.

• Step 4:
  

  Since a high-risk patient almost always has to deal with both care-related and non-care-related problems, it is important that the Case Manager has a broad social map at his/her disposal and is able to cooperate well.

Increased risk patients

This group includes people with one or more chronic diseases that alternate between stable and unstable periods. It is a good idea to include in the risk stratification factors such as obesity, depression, high blood pressure, high cholesterol, elevated blood sugar levels (pre-diabetic) and tobacco use.

The aim of care provision must be to ensure that these people do not move on to the group of high-risk patients.

• Step 1:
  

  Coordinate care from a care group or health center in which all relevant disciplines are represented. Foreign models such as Accountable Care Organization, and Patient Centered Medical Home (PCMH) are examples that use this methodology.

• Step 2:

  Try to involve patients in the care as much as possible. This can be done through self-help support, shared decision-making, written care plans and patient surveys. Family and friends can also be involved asinfluencers. They can stimulate the patient in self-care and also act as an extension of the care team, for example by informing the care team when important changes occur.

• Step 3:

  Schedule annual preventive screening moments for chronic conditions. This allows gaps in care to be quickly identified. A health coach can also be used for this.

• Step 4:

  Invite high-risk patients to try new forms of care. Examples include eHealth applications, online forums, group meetings and health coaches. Research shows that it is also good to involve friends and family in this.

Low risk patients

This is the group that remains: the people who are healthy or stable in health. The goal of care is to keep these people healthy. This can be done in a cheaper, more efficient and more effective way than is often the case nowadays.

• Step 1:

  Develop an online patient portal for initial communication and encourage low-risk patients to use it (Figure 2). On such a portal, information can be put about the most common disorders and what to do in that case. This stimulates self-care. Research shows that this way of working increases patient involvement with the organisation. This is interesting because it can stimulate efficiency in the use of care. For example, the number of consultation visits can be reduced.

• Step 2:

  Focus on low-risk interventions. As described above, it is important to efficiently manage the population of low-risk patients. Look for other strategies to better reach this target group and prevent them from having an increased health risk.

• Step 3:

  Reserve time and capacity for (online) prevention and avoidance of unexpected care needs. This does not always have to be done by a doctor; often care provided by a practice support worker or doctor’s assistants is also sufficient.

Figure 2: Online | eHealth Interventions

So what does that get you?

Research shows that risk stratification is the way to put value-based healthcare (VBHC and/or Triple Aim) into practice and actually realize better outcomes. It forms the basis for proactively providing tailored care. Coordinated, person-centred care saves the patient unnecessary treatments and therefore time. In addition, with a focus on prevention, a lot of misery can be prevented. All this leads to higher patient satisfaction and better health outcomes. Care providers will also reap the benefits. By organising care around high-risk groups, valuable time can be used much more efficiently. Instead of scheduling ten minutes for each consultation, make a distinction between the risk groups. You give low-risk patients less time and high-risk patients more, which means you can help the latter group better and will probably see them less often at your surgery. In addition, tasks can be better distributed. Not every patient needs to see a doctor for every problem. In fact, some matters can also be handled perfectly well online. All this results in a lower workload, lower costs and more job satisfaction. Finally, risk stratification enables managers to make more targeted contractual agreements with health insurers. These agreements are currently based on volume and price, with national figures serving as the starting point. But there is no national average. The need for care in Amsterdam is completely different from that in East Groningen or South Limburg. If you map this out, you can conclude contracts that are tailored to the regional situation. This improves the quality of care and saves costs.

But what’s stopping us?

That is indeed the big question, because it does not really want to get off the ground. There is still too much talk and too little action. Risk stratification is only possible if healthcare providers have their data in order and report the correct data. That is, not process indicators, but outcome indicators, such as quality, health and cost. It is also important that data systems are linked. And don’t say you can’t because of privacy reasons. That’s a fallacy. It is perfectly possible to link datasets and comply with privacy legislation. Technology and legislation are therefore not the stumbling block, it is the prevailing culture. It seems like we have some sort of fear of the unknown. We should really dare to step over the line. As healthcare providers, we do have some influence on the overcrowded waiting room. We can negotiate better contracts. Let’s try and be proactive about that. Instead of waiting for the government or health insurers to take action when the situation becomes untenable, take matters into your own hands and start working with risk stratification. In doing so, we stand up for ourselves and for the patient.

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Want to know more about how to use smart algorithms in practice? And what else is needed to make data management & risk stratification a success? Download our e-Book Care networks that work.

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. 1. System Networks
2. 2. Organizational Networks
3. 3. Professional Networks
4. 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. 1. The lack of an integrated policy between care and welfare;
2. 2. Fragmented funding between primary and secondary care;
3. 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!

Download the ebook care networks and read what other steps are needed to successfully implement a care network.