Home Care by Self-Governing Nursing Teams: The Netherlands' Buurtzorg Model

The Dutch home-care provider Buurtzorg Nederland has attracted widespread interest for its innovative use of self-governing nurse teams. Rather than relying on different types of personnel to provide individual services—the approach taken by most home health providers—Buurtzorg expects its nurses to deliver the full range of medical and support services to clients. Buurtzorg has earned high patient and employee ratings and appears to provide high-quality home care at lower cost than other organizations. This case study reviews Buurtzorg’s approach and performance thus far and considers how this model of care might be adapted for the United States. BACKGROUND Buurtzorg Nederland, a nonprofit Dutch home-care organization, has garnered international attention for delivering high-quality care at lower cost than most competing organizations through the deployment of self-governing nurse teams. When they go into a patient’s home, Buurtzorg’s nurses provide not only medical services that require nursing training but also many support services that lessertrained (and cheaper) personnel usually provide in other home-care organizations. By many measures, Buurtzorg Nederland has been an extraordinary success. Starting with one team in 2007 in the small city of Almelo, Buurtzorg (Dutch for “neighborhood care”) has grown into a national organization that by 2015 employed 8,000 nurses in 700 teams. These nurses cared for 65,000 patients in 2014.1 Early efforts are under way in several countries, including Japan, Norway, Sweden, the United Kingdom, and the United States, to adapt the Buurtzorg approach to local circumstances, and many other Dutch home-care organizations have begun adopting aspects of the Buurtzorg model. According to Sharda S. Nandram, a Dutch management professor, Buurtzorg has created a new management approach—“integrating simplification,” characterized by a simple, flat organizational structure through which a wide range of services, facilitated by information technology, can be provided.2 Government surveys have repeatedly shown that Buurtzorg’s patients are highly satisfied. Moreover, surveys of employees over several years indicate the organization has the most satisfied workforce of any Dutch company with more than 1,000 employees.3 The model also appears to achieve savings. In the To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. 1818 Vol. 14 The mission of The Commonwealth Fund is to promote a high performance health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. For more information about this brief, please contact: Bradford H. Gray, Ph.D. Senior Fellow Urban Institute bgray@urban.org May 2015 2 The Commonwealth Fund Netherlands, insurers pay for home care on an hourly basis, and Buurtzorg’s teams of nurses have used fewer hours to meet patients’ needs than have other organizations. As Buurtzorg has grown, however, so too have suspicions that this success is at least partly based on cherry-picking the most profitable patients.4 In response, the Dutch Ministry of Health, Welfare, and Sport commissioned the consulting firm KPMG to conduct a study comparing Buurtzorg to other home-care providers, controlling for differences in patient characteristics. The results, published in January 2015, offer the best available evidence of Buurtzorg’s performance on measures of cost.5 They show that Buurtzorg is indeed a low-cost provider of home-care services, and that this effectiveness is not attributable to its patient mix. However, when patients’ nursing home, physician, and hospital costs were added to the analysis, Buurtzorg’s total per-patient costs were about average for the Netherlands. Our examination of the Buurtzorg approach and its possible applicability to the United States is based on published information and on telephone and in-person interviews conducted in February and March 2015 with Buurtzorg’s CEO, colleagues, and members of a Buurtzorg nursing team. Additional interviews obtained perspectives from Dutch government officials and insurers, the nation’s leading patient advocacy organization, a competing home-care provider, the Dutch primary care physician association and home-care trade association, the principal investigator at KPMG, and people involved in the early effort to implement a Buurtzorg program in Minnesota. (For a complete list of individuals interviewed, see Appendix A.) BUURTZORG CARE MODEL Home care in the Netherlands is provided to patients needing temporary services following hospital discharge, patients with chronic conditions requiring medical services, people with dementia, and individuals in need of end-of-life care. Home-care organizations contract with government-funded insurance companies to provide 10 different home-care services.6 The number of authorized hours is based on individual patient assessments.7 Some home-care services require nursing expertise, but many others, such as help with activities of daily living (e.g., dressing, bathing, or toileting), can be provided by less trained, less expensive personnel.8 Home-care organizations typically have deployed nurses to provide only those services that require their knowledge and skill, while sending less costly personnel to perform other services. With various caregivers coming at different times on different days to provide services, such an approach can jeopardize continuity of care. By several accounts, both patients and nurses were often dissatisfied with the traditional home-care model. Buurtzorg has taken a radically different approach, reflecting the vision of its CEO and cofounder, Jos de Blok, an experienced home-care nurse with management training. The goals of the model are to bring a holistic, neighborhood-based approach to the provision of services; maximize patients’ independence through training in self-care and creation of networks of neighborhood resources; and rely on the professionalism of nurses (Exhibit 1). One of de Blok’s oft-stated mottos is “humanity over bureaucracy. ” The care model that grew out of these ideas gives self-governing teams of 10 to 12 highly trained nurses responsibility for the home care of 50 to 60 patients in a given neighborhood.9 The teams work with the patients and their families, primary care providers, and community resources to meet patients’ needs and help them maintain or regain their independence. Home Care by Self-Governing Nursing Teams: The Buurtzorg Model 3 Buurtzorg nurses are responsible for the entire range of home-care services: assessing patients’ needs, developing and implementing care plans, providing services or scheduling medical visits as needed, and generating the documentation needed to facilitate continuous care and billing. Buurtzorg collects information about patients’ satisfaction at the completion of the course of care (in addition to the patient surveys carried out by the health ministry). A modern information technology (IT) system and intranet enable online scheduling, documentation of nursing assessments and services, and billing as well as the sharing of information within and across teams.10 Coaches—not managers—are available to solve problems.11 There were 15 coaches for the 700 teams in early 2015. Arend Jan Zwart, a Buurtzorg coach, said that more of his work pertains to helping teams function than to providing advice about patient care.12 Nurses do not report to managers, though their work hours are tracked.13 The small back office (with fewer than 50 people in early 2015) carries out functions such as salary administration, contracting for teams’ offices, and financial administration. Under a union agreement, the nurses are paid according to their education level, with a standard annual increase and bonuses based on years working for Buurtzorg.14 Surplus revenues are used for continuing education of nurses, team projects to improve community health, and organizational innovations.15 The use of self-regulating teams provides flexibility in work arrangements to meet both nurses’ and patients’ needs. For example, the six nurses in a team we visited in Haaksbergen, a Dutch town of about 19,000 people a few miles from Almelo, work 16 to 24 hours per week (though 32 hours is said to be more typical). Two nurses share responsibility for six to eight patients at a given time, making visits mostly in the mornings and evenings. Every other week, the team meets to review patients’ cases and discuss problems. It shares a small two-office building with another six-person team from which it had amicably split. Two other Buurtzorg teams, one of which specializes in dementia patients, work in the community. BUURTZORG’S PERFORMANCE Buurtzorg’s rapid growth appears to be rooted in several factors. First, the model of care is popular among nurses with home-care experience, enabling recruitment of talented staff.16 Second, the high patient and family satisfaction ratings (see Appendix B) and good health outcomes have helped teams obtain referrals from physicians and hospitals as well as word-of-mouth recommendations. In addition, a 2009 Ernst and Young study found that Buurtzorg—then a much smaller organization—was able to meet patients’ needs while using 40 percent of the authorized patient care hours, compared Exhibit 1. Buurtzorg Care Model: Goals and Structure