Q&A: Nurse-led 'neighborhood care' in the Netherlands

Jos de Blok, CEO of Buurtzorg

PCP shortages, patient complexity, ineffective payment models, and care fragmentation are often blamed for quality, access, and utilization problems.

One organization that has worked to solve these challenges is Buurtzorg—which translates to neighborhood care in English. It's a Dutch home care organization that has attracted international attention for its innovative use of independent nurse teams in delivering high-quality, relatively low-cost health and preventative care. The model has been adapted across various countries, including the U.S.

The value proposition of the Buurtzorg model is to swap a traditional care team for tenured nurses to provide comprehensive care management, reduce fragmentation, and keep patients independent and at home for as long as possible.

We spoke with Jos de Blok, CEO of Buurtzorg, about the organization's history and goals, as well as their keys to success. What follows is an edited transcript of the highlights of our conversation.

Q: Why did you start the Buurtzorg model?

A: In Holland, during the 1990s, we developed a new payment system that caused fragmentation in the elderly and health care systems. Before then, the Netherlands had a primary care system focused on community care and prevention; after, primary care became task-oriented and prevention became secondary. Providers were paid for activities rather than holistic care.

Many organizations restructured. They shifted their attention from identifying health care problems and solutions to performing the activities they were paid for.

As a result, healthcare service provision deteriorated. Patients started to receive much longer and more care than they should have, had doctors intervened earlier. Quality went down.

The change in payment structure also brought about administrative burdens and complexity around choosing the right care approach due to multiple payment layers and transaction costs. This was highly frustrating to nurses, who couldn’t provide the care they wanted and needed, but were pressured to make care decisions based on funding.

With a focus on cost and activity, rather than quality, many nurses felt less fulfilled in their jobs. It actually got worse as time went on because patients increasingly complained about the quality of care they received. Nurses became the target.

Then in 2006, I realized that things had to change. This was the starting point for Buurtzorg.

Q: What type of change did you envision?

A: I decided to launch an organization to improve care provision and staff satisfaction, based on the principles of community-based care. The new organization was built on integrated budgets, horizontal organizational structures, and a solid IT system.

The solution I envisioned wasn't only one that would improve care quality and stakeholder satisfaction, but also allow for cost savings. The goal was to pay little for overhead cost by streamlining administrative tasks through IT capabilities and reducing care team participants to one point of contact.

We switched from care provision by a team comprised of lower-skilled medical support staff and doctors to care managed by tenured nurses who could provide comprehensive care and keep patients independent and at home for as long as possible.

It took more than six months to move from vision to operation. We were careful not to launch another home care organization similar to those that already exist but create a system change instead.

There were already too many home care organizations in Holland, and they all shared the same problems—high cost and low quality care provision. Their overhead costs were around 30%. Our goal was to decrease these costs to around 5%-10%. And we did. Over time, our overhead costs became significantly lower than the average of home care organizations within the Netherlands, allowing us to reinvest money into highly skilled labor. The experience and skill level of our nurses allows them to work at top of license, replacing the need for a primary care doctor and a bigger care team.

Q: How were you able to reduce the overhead cost?

A: Probably the most important factor is that we work with self-governing teams of 10 to 12 highly-trained nurses. They take responsibility for the home care of 50 to 60 patients in a given neighborhood. There's no central management body or corporate administration.

Additionally, part of our initial idea was to develop an IT system that would support our nurses with administrative tasks in order to allow them to spend more time with patients. During the first year of operations, we worked closely with our nursing staff to get a good understanding of what they needed for their daily work and how we could support them to reduce administrative time and share learnings.

We then took these learnings to an IT company, who helped us build a system to reduce administrative burdens, streamline care provision, and reinvigorate the focus on problem identification and health outcomes for our patients.

You probably wonder what makes it work. The registration is very simple and quick, but more importantly, the system allows nurses to learn from each other about effective patient care, based on the data we collect.

Our platform for patient care planning is built on the Omaha system. It's a classification system that captures descriptive and health care data to support home nursing. Every nurse in our system has access to a comprehensive data set, which is how they can learn from each other and streamline the care they provide. All aspects of home care provision are integrated within that one system—care billing, nurse salary, client data, and administrative information.

While the data is only available to our staff right now, we're working on a patient portal. The goal will be to enable our patients to access information about their care team, their upcoming appointments, as well as self-support and self-management to gain the knowledge and ability they need to care for themselves.

Q: How exactly do you determine what type of care patients need?

A: Patient care is determined based on a two-step approach. First, we conduct a comprehensive assessment of physical, psychological, social, and environmental factors. Then, we identify appropriate interventions based on the collected data, as well as internal and national care provision guidelines.

Throughout treatment, we track patients' knowledge, health status, and behavior to carefully monitor their well-being and ability to care for themselves. If no improvements are observed, patients receive extra support in order to facilitate treatment gains. Nurses can focus on addressing immediate patient needs and providing quality care, rather than seeing a high case load. It has improved their job satisfaction.

This is actually how the health care system worked in the 80s prior to the financial and structural changes I mentioned earlier. Back then, nurses were more satisfied with their job than the average Dutch nurse is today. Everyone who joins our system is very positive from the start because they can focus on the job they were trained to do.

Q: Are all your services focused on intervention or do you also run preventative services?

A: When we go into patients' homes, our nurses provide not only medical services, but also support services, such as dressing and bathing, and anything else to meet patients' needs.

We identify risk factors during our intake and assess for positive and negative gains during subsequent visits. Our goal is to keep patients healthy and to avoid unnecessary hospital utilization by identifying and addressing patient needs early.

Based on interactions with health care leaders in 30 different countries, I estimate that 40%-50% of patients in hospitals could be served and monitored at home if they received the right care and proactive management. This includes a lot of patients with chronic illnesses.

Patients with dementia, COPD, and cardiac failure often reside in the hospital when they don't need to. We want to prevent unnecessary hospitalizations for these patients because their conditions are known to worsen in the acute care setting.

We are able to do so by equipping patients with tools to remain in the community. Specifically, we help them to increase mobility, knowledge, and lifestyle. Based on research we've conducted in collaboration with the university.

Q: What are some of the specific initiatives you organize?

A: A lot of people, especially once they get older, become isolated and lonely. They end up in the hospital for social rather than physical reasons. When we identify immobility or loneliness as a concern, we focus on improving those factors specifically. For example, we set up volunteer networks for patients in order to increase social contact and improve quality of life.

One interesting event we run is our Rollympiates. It's a walker race in the Amsterdam Olympic Stadium. The event emphasizes and focuses on ability rather than disability. We want patients to know that a healthier lifestyle and increased mobility lead to positive outcomes. Events like these bring people together—not only patients, but it further connects formal and informal care givers.

We run additional projects. For example, we have virtual networks for specialists, nurses, and families to come together to discuss treatment processes, goals, and barriers. It has improved the dynamic between professionals, patients, and their families.

Q: What do you think led to the fast growth of the Buurtzorg model in Holland and across the globe?

A: Buurtzorg is not one big company or organization, but rather built on small regional initiatives. This allows for a personalized setup. Our nurses are responsible for quickly increasing clientele within their region because they can develop this personalized approach based on existing networks and a good reputation. We receive other referrals through primary care doctors who realize that we provide higher quality care than some home care organizations.

Hospitals have been the hardest to convince of our work. They were skeptical because of the way we are organized—nurse-led rather than physician-led home care. However, eventually acute care doctors warmed up to us, because they have recognized they can speak to our highly skilled nurses and easily exchange patient information. Other home care organizations use call centers for these types of interactions.

The Buurtzorg model allows for an improved experience for all stakeholders in the system—from patients to hospital specialists.

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