Quality management of integrated stroke services

Warum wurde diese Initiative implementiert?

The key message in stroke services is “no time to lose”. In the mid 1990s, research showed that mortality from a stroke was relatively high in the Netherlands. Another problem was the flow of patients. Patients stayed in hospital longer than necessary, simply because there was no place available in a care home. When patients stayed in a hospital longer than necessary, there were no or insufficient beds available for new admissions.

To develop new pathways, the performance indicators and criteria for effective stroke service were set up by the Dutch Stroke Network (2001) as a supplement to the Edisse study. The indicators and criteria refer to the acute period, rehabilitation, chronic care and patient satisfaction of the care given.

The criteria for effective stroke service act as a checklist and guideline for implementation. Integrated stroke care focuses on logistics and coordination of treatment between and within institutions, so that the patient gets the right care, at the right time, in the right place from the right professional. In the pathway for cerebra-vascular accidents, this improved satisfaction among patients and carers.  

Beschreibung

The example is about one particular stroke service in the centre of the Netherlands, near Hilversum. Two hospitals and a care home started with integrated stroke services in 2001 with the performance criteria as their starting point.

Criteria for good stroke services are:

• Hospitals have earmarked beds for new patients.
• Professionals work with evidence based protocols / guidelines and use standard working methods for observation, for example: the Glasgow Coma Scale.
• Presence of specialised nurses in hospitals and rehabilitation centres. After discharge, they guide the patients at home.
• A weekly multidisciplinary consultation in hospitals, nursing homes and rehabilitation centre.
• Structured way of transferring information about patient data, methods and protocols.
• After-care for patients and their carers when leaving residential care, performed by specialist nurses.

They used the criteria as a checklist and they concluded that there was a lot of work to do. Partners made agreements to make care more effective. For example, they have implemented:

• Thrombolytic treatment, possible in the Accident and Emergency department (door-to-needle time  thrombolysis <6 hours)
• Stroke-units in hospitals
• Triage in nursing homes
• Stroke pathway or ‘chain’ monitoring and overview: the Stroke chain coordinator has an important role in anchoring and securing thestroke pathway. Without such a coordinator, disruptions are not properly noticed and the chain runs the risk of becoming fragmented. The stroke chain coordinator, operates at the tactical level, maintains contact with the pathway, and is (partly) responsible for the process of monitoring its performance and quality. 
• Multidisciplinary transfers: information from the disciplines involved in the treatment is merged, and sent to the receiving organisationor to the general practitioner. This prevents information loss.
• Agreements about patient referrals and movement between primary care and hospitals; a general practitioner can easily refer a patient for diagnosis.

The stroke service in the centre of the Netherlands was also a member of the Dutch Stroke Network. 

Welche Effekte wurden erzielt?

After a few years of hard work the integrated stroke service was very successful. They have a lot of partners: hospitals, nursing homes, general practitioners, specialised nurses, a centre for rehabilitation and policymakers, linked together by a chain manager.

Using the criteria for integrated care on stroke services helps to achieve better cost outcomes, patient outcomes, quicker and more appropriate care and satisfaction from patients, carers and professionals. The most integrated stroke services in the Netherlands shows good results on using the criteria. Generally we see that in those regions:

• Hospital stays have reduced from average of 2-6 months in 2000 to a maximum of 10 days in 2006 with reduced costs
• Greater and quicker attention to rehabilitation
• Functional recovery is higher
• Faster thrombolytic treatment
• The realisation of regional agreements between general practitioners, hospitals and ambulance about what to do with a stroke, led to faster access to care and less uncertainty for patients and carers.
• TV-advertising is evident to make people more alert to how to handle stoke related situations
• Regional differences when treating a stroke are reduced 
• There is organised after-care and support for patients and their carers
• Patients and carers are more satisfied about the care given
• The flow in the chain is better; patients get quicker and more appropriate care

The Dutch Stroke Network is very active. They organise meetings, provide yearly benchmarks between the regions anddisseminate the results. When regions are having problems, such as with getting agreements or having long waiting times for rehabilitation, they can appeal to the network for support.

Worin bestehen die Stärken und Schwächen der Initiative?

Strengths

• Cooperation between all kinds of disciplines and institutions.

Weaknesses

• Shorter stays in hospitals reduce hospital costs, but costs are higher in other places (residential care). The funding in the Netherlands is complex; funding for hospital is through the ‘Health Insurance Act’ (Zorgverzekeringswet), all the people living in the Netherlands are compulsorily insured.  Residential care is funding by ‘AWBZ’ (the exceptional medical expenses act). 
• Sometimes, patients stay too long in hospital, because there is no place available in the rehabilitation centre of a nursing home. Hospitals are not sufficiently able to provide good care for a longer stay, because there are insufficient opportunities for therapy (eg physiotherapy). This has a negative effect on the condition of the patient.
• In times of scarcity the focus is not always on the best outcome for the client, but to reduce the costs.

Opportunities

• More use of technology in homecare; telemedical health services
• Health link (from Canada: www.Albertahealthservices.ca)
• Reviews with caregivers about the care received, so that better care can be arranged

Threats

• Less funding, less professional care according to age
• There is less funding for rehabilitation because of the economic crisis and there are not enough professionals to carry this out. As a consequence, it might take longer for the right treatment to be started after a stroke, with all its consequences on patient outcomes. 

Impressum

Externe Links und Literatur

Websites:

• www.handreikingketenzorg.nl
• www.zonmw.nl, for Edisse: Evaluation Dutch integrated stroke service experiments.
• www.kennisnetwerkcva.nl
• www.vilans.nl
• www.ski-ketenzorginnovatie.n

For information of the indicators, contact the coordinator of the Dutch Stroke Network: tonnie.vd.laar@catharina-ziekenhuis.nl l

Literature

• Minkman MM, Schouten LM, Huijsman R, van Splunteren PT (2005) 'Integrated care for patients with a stroke in the Netherlands: results and experiences from a national Breakthrough Collaborative Improvement project' in: Int J Integr Care, vol. 5:e14. Epub 2005 Mar 23. 
• van Wijngaarden JD, de Bont AA, Huijsman R. (2006) Learning to cross boundaries: the integration of a health network to deliver seamless care' in: Health Policy, Vol. 79(2-3): 203-13. Epub 2006 Feb 9. 
• Heijnen RW, Evers SM, van der Weijden TD, Limburg M, Schols JM. (2010) 'The cost effectiveness of an early transition from hospital to nursing home for stroke patients: design of a comparative study' in: BMC Public Health, vol.10:279.

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