Abstract
Strong collaboration among primary care physician, pharmacist, and a community nurse can provide close monitoring of the conditions of frail older adults in their home environment. Reforms in long-term care in the Netherlands provide incentives to improve this collaboration. The reforms are in line with the innovation in the home-care market. Buurtzorg uses small, self-managed, highly qualified teams for home care since 2006. With neighborhood-focused teams and a limited number of nurses who care for a patient, communication with other caregivers is easier. Moreover, the way to transform an organization to work with self-managed teams is discussed.
Introduction
The fast-growing number of independently living frail older adults 1 and the complexity of their problems raise the question of whether the way care is organized should be changed. Many studies show that miscommunication among providers and between providers and patients and their families is common. 2 What chronically ill people need, especially frail older adults, is a program where they receive close monitoring for changes in their condition and close attention to their ability to comply with their health plan of care. 3
In many Western countries, new ways of delivering care are introduced. In the Netherlands, the home-care organization Buurtzorg aims to improve communication in the health-care system and increase the satisfaction of clients and professionals with self-managed teams and a limited number of nurses who care for a patient. With neighborhood focused teams, they strive to build good relationships with other caregivers in the community. Reforms in long-term care in the Netherlands provide further incentives to improve collaboration between primary care physicians (PCP), nurse, and pharmacist. This article addresses the innovation in home care by Buurtzorg, the reforms concerning community nursing in the Netherlands and their possible impact on caring for frail older adults. Moreover, the way to transform an organization to work with self-managed teams is discussed.
Nursing and primary care in the Netherlands
The Netherlands has a public insurance system for acute care (Health Insurance Act). The care provided by PCPs is part of the health insurance act. PCPs contribute to various aims regarding the health of the population: helping people to remain healthy and assisting people with a chronic disease or impairment. 4 PCPs are gatekeepers, as hospital and specialist care is only accessible after referral by the PCP.
Until 2015, nursing was part of the Exceptional Medical Expenses Act (EMEA), a tax-based and nonmeans tested social insurance for long-term care. A representative agent of the insurance companies in a region, the “Zorgkantoor (ZK),” carried out the procurement of nursing. The ZK is a not-for-profit separate entity of the dominant insurance company in a region. It negotiates with each provider the number of hours that can be delivered and the price per hour. If more hours of nursing are supplied than contracted, the provider does not get funding for the overproduction. The price cannot be higher than a maximum, which is determined by the Dutch Healthcare Authority (NZa), the supervisory body for health-care markets in the Netherlands. In the negotiations about volume and price, the ZK can take into account scores on quality of care. Quality is measured by a consumer quality index (CQ-index), which is a systemized method to ask consumers what is important to them concerning care and what their experiences are with the care they received. Indicators of quality are experienced treatment, physical care, staff quality, information, and participation. 5 Accredited agencies carry out the measurement of the CQ-index. To get a broader perspective on quality, information on “the ultimate question” of the Net Promotor Score (NPS), whether the client would recommend the organization to others, was added by the association of home-care organizations (Actiz) since 2012. 6 In 2013, there were 606 home-care providers with more than 20 clients; 130 of these 606 providers had more than 500 clients. 7
For decades, home-care organizations aimed to work more efficiently by merging and differentiating task levels and employing lower skilled caregivers for the more basic care tasks. The care for a person was often divided over more caregivers. As a result, care became more fragmented and it became increasingly difficult for PCPs to find and communicate with the nurse responsible for a specific patient. 8 The relationship between PCP and nurse began to break down; direct contact of the PCP with the district nurses disappeared because patients were frequently cared for by multiple nurses. The nurse assigned to a patient may not have an adequate medical history or understanding of the patient’s condition, which meant that she might have difficulty answering the questions of the PCP. PCPs lost trust in the employees of home-care organizations over the years because of the effects of reorganizations on quality and communication. 9 Patients complained about the high number of caregivers being assigned to them. Many nurses felt that their jobs had been eroded and left nursing for other careers. 10
Self-managed teams in home care and nursing: Buurtzorg
Buurtzorg (Dutch for neighborhood care) is a very fast-growing nonprofit company, created in 2006. By 2013, Buurtzorg had 7000 employees, and the company is growing by more than 1000 employees a year. Buurtzorg’s financial turnover in 2013 was €217 m, 4–5% of the Dutch home-care market (nursing, personal care, and assistance). Buurtzorg is organized in small autonomous teams of up to 12 nurses within a neighborhood-sized care area, with about 700 teams throughout the Netherlands. Teams manage themselves and perform all of the tasks necessary to provide care for 50–60 patients, including assessment of patients’ needs, planning, continuing education, financing, and all coordination activities. 11 Teams recruit and select new team members themselves as well.
The nurses serve a wide variety of clients, including chronically ill and functionally disabled clients, elderly clients with multiple pathologies, clients in a terminal phase, clients with symptoms of dementia, and clients who are discharged from the hospital and are not yet fully recovered. 12 Approximately 70% of Buurtzorg nurses have level 5 education (the equivalent of a bachelor’s degree), and 30% have level 3 (two to three years of nurse training). 13 They all function as generalists and aim to work closely with the PCPs and other primary health-care workers. Buurtzorg limits the number of nurses who care for a patient to enhance the relationship between nurse and patient and to avoid fragmented care. 13 Team members meet weekly to discuss issues such as patients’ cases, the use of community resources, and the skills and knowledge needed to fulfill each of their roles. The overhead of Buurtzorg is small; the administrative back office team consists of 35 people. Except for this core administrative team, Buurtzorg does not have managers. The teams use portable information technology to keep their clients’ statuses immediately at hand.
Note that the growth of Buurtzorg should not affect communication with other caregivers. Whereas in the past mergers and growth of organizations coincided with differentiation of tasks and worsening of communication between caregivers, the teams of Buurtzorg are focused on a neighborhood, work autonomously and are responsible for their own communication with other caregivers.
Buurtzorg had the highest client satisfaction rates of 308 home-care organizations that supplied information on the CQ-index in 2008. 9 Clients were especially satisfied with the availability by phone, the skill level and safety of the care, and the availability of personnel. Six interviewed PCPs notice that questions are handled quickly and accurately. Because one of the nurses is their contact, they build a good working relation and lines of communication are short. 9 In 2013, Buurtzorg scored significantly higher (p < .05) than the average value of 370 organizations on three of five indicators of the CQ-index, experienced information, participation, and staff quality, ranking third to sixth on these indicators. They were ranked 10th on the indicator treatment and 35th on physical care. On the NPS, they were ranked seventh of 360 organizations of which patients said they would recommend the organization to others. 7 Note that the satisfaction rates of many organizations are based on a limited number of clients. The satisfaction among employees is high. In 2013, Buurtzorg was chosen as best employer in the category “care organizations” for the third year in a row. However, a disadvantage of a small team is, for instance, the planning during holidays and the availability during afterhours. 9
Regarding efficiency, Buurtzorg claims to be more efficient than the average health-care organization. 14 Buurtzorg can fulfill the care needs of clients in fewer hours than other organizations. Compared to the average of other companies in the Netherlands, Buurtzorg has lower overhead (12% vs. 26%), sickness absence (2.5% vs. 6.3%), and personnel turnover (10% vs. 15%); and productivity (percentage of hours dedicated to care of clients) is higher (between 58% and 51%).
A recent study indicates that—weighted for age, gender, social status, and several chronic illnesses and diseases—Buurtzorg had slightly lower total costs per client in terms of home care, nursing home care, hospital care, and primary care than other home-care organizations (€15,357 a year vs. average of other organizations €15,856). 7 The costs of home care of Buurtzorg were lower than 62% of 606 other home-care organizations in 2013 (€6428 a year vs. €7.995). This was based on a relatively high hourly rate (€54.47 vs. €48.74) and a much lower volume of care hours per client (108 a year vs. 168). Compared to clients of other home-care organizations, on average, the clients of Buurtzorg received care for a shorter period of time (5.5 vs. 7.5 months). However, the total “follow-up” costs—the costs of hospitalizations, PCPs, and nursing home care in the four quarters after the first quarter of home care—were relatively higher than those of other home-care organizations (72% of home-care organizations had lower follow-up costs €9,334 a year vs. €7,959). Although the follow-up costs of nursing home care were below the average (38% of the other organizations lower than Buurtzorg), the clients of Buurtzorg went at a lower age to a nursing home. The research had limitations. Factors like regional differences and problems with activities of daily living (ADL) were not taken into account for adjustment of the case-mix. Moreover, as mentioned by the authors, the follow-up costs include all hospital costs, which included some costs that are unrelated to the quality of the nursing by care organizations.
What caused these higher follow-up costs and what the relationship is with the care provided is left for future research. Because better communication between PCP and district nurses should lead to fewer (re)hospitalizations and hence lower follow-up costs, this is an important question to address. Questions that could be addressed are: what is the effect of a shorter care period on follow-up costs? Do differences in communication and collaboration have an effect on the moment of detection of a disease or admission to hospital care?
To address these questions, the use of a mix of qualitative and quantitative methods seems appropriate. With qualitative research, we get a better understanding of the mechanisms at work and the context how home care is delivered. There might be variation in the way the Buurtzorg teams are implemented and perform. Moreover, there might be other organizations that work (with elements of) the way Buurtzorg is working with self-managed teams. Ideally, for the quantitative research, a randomized study design should be used. If that is not feasible, it might be interesting to see what the results are with a setup of propensity matching to address the issue of selection.
Reforms in long-term care related to nursing
The Dutch government reformed the system of long-term care in 2015. Care should become more patient oriented. Specialization has led to fragmentation of care, and too often care is provided from a medical perspective, without treating the psychosocial problems that caused the medical problem (e.g., debt or loneliness). People depend too much on care provided by (professional) caregivers. 15 With an expenditure of 3.8% of gross domestic product (2011), the highest expenditure level on long-term care of Organization for Economic Co-operation and Development (OECD) countries and a yearly increase of the expenditure level of 4.3% since 2000, reforms in long-term care were inevitable. 15
Since 2015, nursing is part of the health insurance act. In 2016, the procurement of nursing will not be carried out anymore by the ZK, but by each insurance company for their own insurees separately. Whereas the financial health of insurance companies was mostly affected by costs of acute care (like hospital care), drugs, and care by PCPs, now with the shift of nursing to the health insurance act, insurance companies will have to consider nursing costs as well. This increases incentives to invest in the quality and effectiveness of nursing on follow-up costs. For example, preventing (re)hospitalizations by improving communication concerning patients between nurse, pharmacist, PCP, and hospital.
As part of the reforms, the payment system will be adjusted, which should lead to more freedom to act and fewer administrative tasks for nurses. 16 In the EMEA, the payment system for nursing was based on fee-for-service, with different hourly rates depending on the type of supplied care. Payments will be based on a fixed amount per episode of care, depending on the characteristics of the client.
Whereas in the EMEA an independent assessment center performs the assessment, in the new system, the nurse assesses whether a client is eligible for nursing. The nurse decides what is necessary; apart from regular ADL assistance, she or he might also deploy coordination of care or case management, coaching for self-management, and prevention. Carrying out a care plan and not a particular number of care visits is the basis of the new system. Future research should show what the effects are of the reforms by the government on the cost and quality of care.
Discussion
Developments in home care, facilitated by the reforms in long-term care, might enable better monitoring of older adults with chronic illnesses and functional impairments. The experiences with Buurtzorg point to better communication between caregivers. With the self-managed teams, Buurtzorg combats the bureaucracy and fragmentation in the supply of health care. However, why Buurtzorg had high (perceived) quality care on the one hand and high follow-up costs on the other hand should be investigated further.
Efforts to improve quality in a nation’s health-care system will fail to realize their potential unless both policymakers and practitioners consider and implement a more comprehensive, multilevel approach to change. 17 The ease of using Buurtzorg’s system of self-managed teams depends on payment systems and accounting rules. When billing is dependent on the number of hours of care and not on the episode of care, and when tasks of care have different rates dependent on the skill level of the nurse, it is more difficult for Buurtzorg to use their approach with the higher qualified and more expensive nurses. Moreover, with multiple payers and different accounting standards, the administration becomes more specialized work.
Can the innovation of Buurtzorg be implemented in other countries and existing organizations? The example of Buurtzorg has been imitated by many organizations within and outside the Netherlands. According to De Blok, the CEO of Buurtzorg, it should be possible to introduce the Buurtzorg way of working in a fairly similar way across different contexts. 18 Although in Sweden, Belgium, and the United States, self-managed teams are already operational, it is too early to discuss their results.
Buurtzorg started from scratch, while other self-managed teams occurred as changes in an existing organization, which brings transition issues. In Belgium, it turned out that one of the things that is difficult for the teams is to have an open discussion during meetings and to reach decisions jointly.
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Moreover, nurses might think that they are not capable of carrying out the extra responsibilities.
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The organization needs other real estate: a big central office is not necessary anymore. The teams need a place where they can meet and discuss, preferably in the same building as the PCP and other local caregivers. The roles of many employees will change or disappear. To transform an organization to work with self-managed teams, Nijhof described a step-by-step approach:
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Design the ideal team. This step includes projecting the preferred number and competences of team members, the number of clients, the number of hours each member is working, the average number of care hours per team member, the management tasks and other tasks like planning, communication, intakes, finance, etc., the analyses of the working area, and the budget of the team. Design the new organization. The new organization chart shows the abolishment of management layers. The employees in the supporting departments need new job descriptions: the self-managed teams carry out many tasks of supporting departments. Organize the prerequisites. The communication patterns, the way information is being shared and the administration process is organized, need to adapt to a self-managed way of working. Teams need information about their results. Replace the position of the team leader. Teams need a coach; especially in the implementation phase a coach can help to build expertise on planning, budgeting, contacts with clients, etc. Starting with the new way of working of self-managed teams. Once the ideal teams and new organization are designed and the new vision on giving care is developed, the new organization and vision have to be communicated clearly. Development of the team. The route to implement the self-managed teams contains several phases of broadening of tasks and responsibilities. The time before the new way of working is implemented can take between two and five years.
This step-by-step approach is based on the experiences of six home-care organizations in the Netherlands. The approach does not stand on its own. It is part of a process of change. A sense of urgency to change and enough support in your organization is needed and a team that gives guidance to the process of change. 20 In Belgium, the process of change was not easy. However, knowing that it can be done helped policymakers to move forward. 19
Footnotes
Acknowledgments
I would like to thank Richard Frank, Katie Dean, Robin Osborn, Bradford Gray, Chloe Anderson, Dana Sernak, Linda Elam, Adam Darkins, and two anonymous reviewers for helpful comments.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this research was provided by The Commonwealth Fund.