Regional care requires a director

The pressure on healthcare is increasing. We want to keep healthcare affordable, improve the patient experience and reduce the burden on healthcare providers. At the same time, the focus is increasingly shifting from illness to health, and from treatment by individual healthcare organisations to collaboration in the region. During the Zorg & ICT (Care & ICT) event, Fleur Maagdenberg and Glenn Bruins from Enovation (part of Legrand Care) outlined why regional collaboration is essential.

The need for regional collaboration

In the session ‘Regional collaboration starts with the foundation’, Glenn and Fleur explained that there are several reasons to strengthen collaboration across the region. Working together enables diagnoses to be shared more easily and helps prevent double examinations. For patients, this means less ‘being passed from pillar to post’ and greater consistency in their care pathway. For healthcare providers, it results in a more complete picture of the patient and less switching between separate applications.

Fragmentation

That is precisely where the problem often lies today: a lack of coherence in the care pathway. Many healthcare providers work from their own electronic patient records, while also needing to communicate via separate platforms and access data in various viewers. In addition, they must then track patients using other applications for care pathways or home monitoring. The result is fragmentation, extra steps and an increased risk of losing vital healthcare information.

A single platform for healthcare providers

The ambition is clear: healthcare providers should have access to everything they need to deliver care beyond the walls of their own organisation, using a single login. This includes not only viewing patient data from multiple sources, but also reviewing care pathways, communicating with patients and collaborating with colleagues outside their organisation. Within this model, the healthcare provider always works from the patient context. The source system provides a 360-degree view of ongoing care pathways, recent communication, care tasks and relevant file information. This supports collaboration and prevents information from becoming scattered across different systems.

The rise of the director in the region

To organise care at regional level, a new and increasingly important role is emerging: that of director. This is not a general practitioner or medical specialist, but, for example, a nurse telecoach, care coordinator or employee at a regional coordination centre. The care coordinator takes a holistic view of the care for all clients or residents within a region, looking beyond medical care alone. The care coordinator also considers wellbeing and the social domain, as well as recognising when a conversation with a coach or a referral to another care or welfare partner is needed.

For the role of care coordinator, overview is crucial. The director works from a kind of cockpit. It is always clear which clients are being monitored, which care pathways are active, which signals or alerts are being received, and where action is required.

Practical examples of regional care

This way of working is already being applied in various regions. A good example of the care coordinator in the role of telecoach can be found at the Digital Health Centre. Here, care pathways are organised regionally between the hospital, nursing and care home organisations, and general practitioners. Thousands of patients are already being supported, with the telecoach increasingly fulfilling a true directorial role, focusing on care and wellbeing in the broadest sense.

Video care also shows how powerful regional collaboration can be. In the Northern Netherlands, video care is widely used for warm transfers of patients with complex needs. Nurses do not need to travel to an academic centre but can join appointments digitally. Technically, this is straightforward, but organisationally it requires joint agreements and trust. These are precisely the aspects that make regional collaboration successful.

Telecare alarm monitoring and the regional network

The second example of a role that the care director can take on is that of the care mediator. As the focus in healthcare shifts towards living independently at home for longer, there is a growing need for a coordinating role to respond to various care signals. These may include virtual wards and eHealth in the event of an accident, home monitoring or medication monitoring. These signals now converge in one place, and where necessary, coordination with the regional healthcare network is organised.

By bringing care signals together in one central environment, nursing staff can respond more quickly and effectively. This involves smart triage: which signals are urgent, which can wait and who needs to act? Enovation already offers this form of large-scale aggregation and management of care signals for various healthcare centres, such as Medical Service Centre Altide.

The right care in the right place

Another example of how the role of care director is being put into practice can be seen at regional coordination points, which are becoming increasingly important. For example, at Verwijspunt020 and Verwijshulp010 in Amsterdam and Rotterdam, respectively. These centres focus not only on the transfer, but specifically on mediation: where capacity is available, which setting best suits the patient and what information is needed to make a well-informed decision. There is no single blueprint for the whole of the Netherlands. Each region organises care differently, depending on the local context. What remains true everywhere is that without proper integration and access to data, coordination remains slow and prone to errors.

Data as the key to success

Collaboration depends on data. In the Netherlands, numerous information systems, standards and infrastructures exist alongside one another, for example, of FHIR, XDS, LSP and various national facilities. In practice, this means that information can sometimes be available via different routes. The key is to connect all those sources. Integrating and standardising healthcare data creates a single coherent whole, independent of the underlying systems. For healthcare providers and coordinators, this mainly means that they can perform their tasks more easily. They do not need to know where the data comes from, as long as it is available when needed.

Regions such as Land van Cuijk and North Limburg demonstrate how existing infrastructure can be used effectively. There, healthcare workers use XDS not only for medical images but also for data services. This creates a network in which hospitals, general practitioners, pharmacists and paramedics collaborate based on shared information.

Integration makes the difference

Technological advances are accelerating the development of new healthcare applications. However, without connections to local data sources, they remain little more than empty shells. The real value of these healthcare applications lies in their integration into the care process: no duplicate registrations, no phone calls to track down information, but collaboration based on a single shared view. Regional care requires direction. That direction does not emerge by itself, but through the effective combination of technology, data and collaboration. That is the key to future-proof, integrated care.