On the completion of the support program In voor zorg!, commissioned by the Ministry of Health and conducted from April 2009 – 2017 by the Vilans knowledge institute for long-term care, a concluding publication has now seen the light. The introduction to this publication has been translated into English.
Besides this, an evaluation of the effectiveness of In voor zorg!, carried out under the auspices of the Vilans by an independent research team from SIOO (inter-university center for organisational studies and change management), has been investigated. A summary of this investigation has been translated into English.
- Download: the poster Results of In voor zorg! – Into care program
- Download: the flyer Results of In voor zorg! – Into care program
- Download: the presentation Results of In voor zorg! – Into care program
- Download: the Introduction Wat is In voor zorg!? (What is In voor zorg!?)
- Download: the Summary SIOO Evaluation Report Doen wat nodig is (Do what is necessary)
Healthcare in the Netherlands
For general information about the Dutch Healthcare System, download the leaflet ‘Healthcare in the Netherlands’ or visit the english website of the Ministry of Public Health, Welfare and Sport.
The reason for In voor zorg!
In 2009, organisations in long-term care felt the need for change, in response to social developments. Although many innovations and improvements were known, organisations were insufficiently aware of them or wondered how they could introduce these into their own organisation. Therefore, the structure of long-term care was not considered ‘future-proof’: the aging population would soon cause an increasing need for long-term care. Without intervention, long-term care would be financially unsustainable, while at the same time the workforce would decrease. In 2009, clients began demanding a more client-centered approach, rather than the customary supply-driven care. In response, system changes were implemented in order to achieve a change of behavior in the long-term care: more focus on the client, more room for professionals, better quality, and better prices. But this was not enough. The In voor zorg! incentive program was launched in October 2009. Its aim was to prepare organisations for those new demands as a reaction to requests from HMOs for support.
In voor zorg! – An implementation program
Before 2009, several programs for development and improvement in long-term care were carried out. Examples are the Nationaal Programma Ouderenzorg, Transitieprogramma Langdurige zorg, Landelijk Dementieprogramma, Zorg voor Beter. These programs originated from an inherent necessity and actuality, and have one thing in common: an attempt to develop the new knowledge necessary for the sustainability of long-term care. This new knowledge did not automatically find its way into practice, so that a logical next step was the implementation of this knowledge. This meant linking it to policy, and this to quick results in quality improvement, effectiveness, and skills for the future/sustainability of long-term care. In voor zorg! was supposed to provide the sector with support in this process.
In voor zorg! had a threefold objective:
- Support for healthcare providers in long-term care in their pursuit of skills for the future-proof skills/sustainability.
- Setting up and maintaining a knowledge platform for the compilation, distribution, and implementation of both existing and program-generated knowledge about sustainable long-term care.
- Strengthening the relationship between the government and healthcare (creating a different and closer relationship between government and the field, initiating a development in this respect).
During the realization of these objectives the direction of the program was adjusted to current policy requirements or urgency. For example, in November 2012 the new cabinet’s coalition agreement presented a far-reaching transition: the reform of long-term care. The initial focus, optimizing the existing situation within the AWBZ, was no longer sufficient. This made the task for healthcare providers more specific, also for In voor zorg!, which supported care providers and their partners in making the required transition.
Results of the In voor zorg! program
While In voor zorg! was in effect, 433 routes were finalized. These organisations, chains, networks, and partnerships in the long-term care — and in the social domain — were supported in kind by an In voor zorg! route, usually for approximately 18 months. The method and support process were standardized, but care organisations received a customized implementation. Those who volunteered for participation were healthcare providers who welcomed organisational change, and they entered into a voluntary but binding cooperation agreement with In voor zorg! They worked as partners to achieve their common goals. The implementation of changes in healthcare organisations led to a demonstrably better quality of care with a more efficient use of resources.
The implementation of the project was customized per organisation, which means that direction and purpose of the routes differed. In addition, In voor zorg! underwent a development because of policy changes during the process. This is partly reflected in the results for the routes. Three types of results can be recognized:
- Results regarding cultural and behavioral changes (motion triggers)
- Hard actual results (effecting more by doing less)
- Results regarding quality of care
In voor zorg! has enhanced the change capacity of the long-term care sector in order to achieve a sustainable sector that is focused on the client. In this transition the sector was supported: 433 healthcare organisations received support by an In voor zorg! route. The accumulated knowledge and experience were made available to the entire sector. A wide movement has started; a culture change has occurred; challenges were embraced by organisations in a more proactive manner, which proves that change is possible.
An analysis of similar results in more than one-third of the routes yields the following picture, by theme.
Organisations operated more efficiently and more demand-driven, by tilting their business processes from checking the primary process to facilitating it. Among other things, this led to a smaller administrative load and fewer overhead costs, for example by reducing management. Overhead costs decreased by 27-50% within eighteen months.
Efficiency gains showed an increase of 5-15% in eighteen months, while the quality of care remained constant. This percentage includes more production, less waste and management pressure, more norm-compliant care, and use of fewer resources.
In the primary process we saw a movement toward more direct hours in relation to the number of indirect hours. The primary process moved to a more central position and productivity increased, because client contacts were arranged more efficiently. Organisations managed to substantially reduce the time needed for drawing up an individual care plan to six weeks, sometimes even to fewer than 35 days. It was possible to increase direct client time by 80%. The reduced management and administration load for professionals made it possible to support more clients and/or have more face-to-face client contacts within eighteen months. In addition, we saw a higher employee and customer satisfaction.
Employee costs decreased as a result of reduced absenteeism, the use of volunteers and clients’ social networks, and by dismissals. Organisations that had chosen to expand informal care managed to increase the role of the client’s family and social network by 22% within eighteen months.
Intramural locations were closed, and organisations achieved less complex care closer to the people in their districts (more decentralized, extramural care for care intensity package (ZZP, self-employed persons) 1-4). We already saw that 20% more extramural service within eighteen months was attainable. In voor zorg! routes achieved a reduction of waste: organisations worked more effectively through a better connection between care and ZZP indication. A 42.6% deviation reduction on a ZZP indication was realized.
Theme: Room for professionals
Overall, we saw an increase in employee satisfaction of 7.2-8.4. By working in small independent teams employees experienced more job satisfaction through increased control and responsibility. We saw downward trend in a absenteeism of 15% -46% within six months to a year. In one care organisation, a decrease in absenteeism of 75% was realized.
At the moment, 76-100% of the clients in six organisations have an actual individual care plan , drawn up in accordance with norm-compliant care, and fitting the ZZP scheme. In some cases this used to be only 5-8% . It was also possible to draw up an individual care plan in only 23% of the time.
The introduction of self-managing teams often resulted in a decreased overhead (from 1-10% to 60%) and an increase in productivity (6-25%). In addition we saw structural savings by smarter working methods, less consultation, and less administration. One participating care organisation saved € 450,000 on an annual sales of € 79,000,000, a saving of approximately 19,000 man hours. Employees contributed to an increased productivity by taking more personal responsibility.
Professionals changed from ‘providing care to’ to ‘taking care of’ people . By developing a more client-oriented behavior employees ensured that, in eighteen months, 15-50% more clients than before were involved in decisions about their care and when care was delivered, and managed to cope with the help of home care. Clients saw fewer different care givers, which they much appreciated.
We also saw an increase in client satisfaction regarding personal influence, individual attention, and the extent to which their wishes were taken into account. According to the CQ measurement scores were between 7.7 and 9.1. In addition, some HMOs developed their own instruments to assess client and employee satisfaction.
In several In voor zorg! routes we saw an expansion of clients’ social networks, increased involvement of those networks, and improved independence and self-direction. Care quality received a new impulse by for instance emphasizing capacity allocation, working in smaller teams, a different distribution of competencies in teams, and increasing the level of expertise of the healthcare workers. In a number of organisations people’s ability to learn and develop improved, for instance by training – including e-learning -, dialogue, and reflection. Several organisations worked on a further development of their visions, translating these into mission statements and implementation plans. In addition, organisations became more visible (e.g., on district level), and the local involvement increased.
In the technology theme the focus lay on technology deployment such as remote care, domotics, and monitoring lifestyle through the internet. ‘Screen care’ has resulted in a reduction of travel expenses by at least 17% (17-34%) in several healthcare organisations. Travelling time decreased by at least 16% (16-32%). The use of technology increased the number of clients per professional. In some cases, we saw a decrease of indirect time by 18%, in favor of direct client time. Remote care led to physical care being replaced by digital coaching for clients.
Within eighteen months, a number of participants managed a reduction in labor costs of 26%, a total FTE reduction of 16%, and a proportion of digital care delivered of 14%.
Many organisations introducing remote care reported an increased independency in their clients (this was echoed by about 80% of the clients); they could live at home longer, more safely, and independently. Their social network was more involved because making contacts became easier, so that family was better informed about their relative’s life. This reduced loneliness, and clients experienced more calm and the freedom to structure their days.
Clients and employees of the organisations experienced an increased quality of care and life thanks to the use of technology; as many as 86% of the clients experienced this increased care quality within eighteen months. Employees reported improved control. Some In voor zorg! routes reported that 90% of family and clients recommended video calls to others.
The use of smart optical sensors showed that only 22-23% of the alarms needed a response. This means a decrease of alarm responses of more than 75%.
In the cooperation theme the focus was on deduplication of management. In many circuits we saw a 50% reduction of consultation hours after eighteen months thanks to the integration of care for the client and local socializing in neighborhoods. Important steps were clear agreements on legal matters, joint budgets, annual plans, and the way personnel was deployed. In many In voor zorg! routes HMOs initiated intensive contacts with municipalities. More knowledge was shared between organisations and employees within partnerships.
Within the cooperation theme, the In voor zorg! routes led to the development of a common vision, joint service portfolios, and healthcare concepts under the new WMO. In some cases these were drawn up in consultation with clients and residents.
Integrated care and partnerships strengthened the signaling function in case of vulnerable groups. This led to more prevention. In addition, an updated and qualitatively better care was offered. The ultimate goal was the prevention of heavy, formal care at too early a stage. In several routes we saw a reduction in hospital admissions, more home care, and a better match between the care offered and the needs of the client.
Partners realized a better care alignment, which led to less waiting time for clients. Within eighteen months, waiting times were reduced to 10 days instead of 3-4 months.