Telemonitoring in the region: A collaboration between Rivas & Huisarts en Zorg (HenZ)

At Beatrixziekenhuis and the GP practices in the Dutch region around the city of Gorinchem, pressure on healthcare is being reduced through an innovative collaboration between Rivas Zorggroep en Huisarts en Zorg (HenZ).

People with chronic conditions such as COPD, asthma, heart failure and increased vascular risk enter their own measurements at home using the Patient Journey app. A digital team of district nurses closely monitors this data.
If necessary, patients are referred to their GP or a specialist. These hybrid care pathways lead to more efficient care and fewer unnecessary consultations.

The challenge

The increasing demand for care, which is caused by an ageing population and more complex conditions, is placing great pressure on healthcare organisations. Traditional care pathways are no longer sufficient to provide timely help to everyone. People with chronic conditions require regular check-ups, placing significant demands on healthcare providers. The need for solutions that make care simpler, more accessible and more efficient for these patients has increased.

The solution

Rivas and HenZ have developed hybrid care pathways, whereby home monitoring plays a central role. Through the Patient Journey app, people are able to monitor their own health at home. Measurements, such as respiratory rate or blood pressure, are sent to a digital team of district nurses via a secure platform. This team assesses the data and decides whether a GP or specialist should be consulted. This eases the pressure on healthcare, reduces the number of (outpatient) appointments and gives people more control over their health.

Mieke van der Wielen- Schmeits is Innovation Project Leader at HenZ.

Mieke van der Wielen-Schmeits, innovation project leader at HenZ, explains: “It’s unique that we have organised the care pathways in the Patient Journey app independently of the traditional lines between primary and secondary care. People who use the app and are referred from primary to secondary care, due to worsening symptoms (or vice versa), can continue using the same app. The measurement protocol changes and the information in the app is aligned with the patient’s health condition. The digital district team has a crucial role to play in this process, quickly directing people to the right healthcare provider.”

Since the introduction of these hybrid care pathways, more than 450 people in the Gorinchem region have used the app. This approach not only leads to fewer readmissions, but also to a significant reduction in follow-up appointments. For people with COPD, for example, using one app for both their GP and hospital is a major advantage. They no longer need to use different systems, which provides clarity and convenience.

General Practitioner Information System (HIS) link

To further optimise collaboration between the digital team and GPs, a link has been established with the General Practitioner Information System (Huisarts Informatie Systeem, or HIS). This gives GPs and practice assistants direct insight into their patients’ monitoring data, without any additional login or actions. This saves time and ensures smoother collaboration between primary and secondary care providers.

Appropriate care for the future

The success of these hybrid care pathways is in line with the ambitions of the Integral Care Agreement (Integraal Zorgakkoord, or IZA), which aims to ensure that 70% of care pathways are offered in hybrid form by 2026. This requires further collaboration between hospitals, GPs, health insurers and technological partners.

Han van ‘t Hof, manager of the Zorg Dichtbij (‘Care Close to Home’) programme at Rivas, adds: “We see this way of providing care as essential for the future. Not only does it allow us to help more people, it also makes care more personalised. In the future, we wish to expand the care pathways with new health conditions to serve even more people.”

We started with five care pathways and more than 450 people have since joined. The great thing is that people feel safe because of the constant monitoring and, in many cases, family members, such as children, also actively participate in the process.

Conclusion

The collaboration between Rivas and HenZ demonstrates that hybrid care pathways are an effective way to make healthcare more accessible and efficient. By using home monitoring, people gain more control over their own health, and the burden on healthcare providers is reduced. This innovative approach is an important step towards sustainable and future-proof healthcare.