Neighborhood Care: A Model for Better Homecare
This is the third blog post in a series about cutting edge elder care in the Netherlands. In this blog post, we take a closer look at Buurtzorg.
When I traveled to Holland, I visited the head office of Buurtzorg, in Almelo, about two hours east of Amsterdam. I met with Buurtzorg founder Jos de Blok. We talked about the care philosophy of Buurtzorg. The company name translates literally as “neighborhood care.” Buurtzorg is a homecare company that started in 2007 with one team of nurses. The company has since grown to employ 9,700 nurses, organized into 850 teams. Buurtzorg nurses care for over sixty five thousand people. The organization is spreading outside of Holland to countries such as Sweden, Norway, and Japan. About thirty other countries are looking into adopting the neighborhood care model. (Click here to visit the Buurtzorg USA website.)
Clients who receive care from Buurtzorg report high levels of satisfaction. Buurtzorg has been recognized as the Dutch company with the most satisfied employees, among companies with over one thousand employees. This is truly quite a remarkable achievement, since we are talking about a homecare organization. Homecare organizations have traditionally been associated with high levels of staff turnover, with employees repeatedly reporting burnout and high levels of care burden.
Even more, individuals who receive homecare from Buurtzorg report greater satisfaction than those who received care from other organizations. I went down to Holland talk to the founder of Buurtzorg to understand the importance of self governing teams of nurses, neighborhood resources, and the role of nurse coaches. I left my meeting and inspired, self critical, and convinced that this is an extraordinary organization that can teach us all how to improve homecare.
Buurtzorg focuses first on building relationships with the person who is receiving care. If you are a client, your relationship with Buurtzorg starts with a meeting. The nurses sit down for coffee with you and talk about what matters to you. The nurses talk about your family members and friends in the neighborhood that may be able to help you. The nurses find out whether your neighbors may be able to assist in the care process. The nurses get to know you properly. In this way, the nurses will be able to tailor homecare specific to you, drawing on your resources and network to make sure that you can be as independent as possible, even though you need homecare.
For Buurtzorg, this initial investment costs more than the traditional care plan meetings that most homecare organizations conduct. However, by spending time getting to know each individual, the nurses are able to prevent complications and illnesses further down the road since they know each person quite well. When the nurses enter your home, they can immediately see if something is wrong and whether you are suffering in some way. The nurses can immediately address problems that other homecare organizations may miss. In this way, the initial investment saves costs further down the line. It also reduces suffering since clients get the help they need more quickly.
Even though most Buurtzorg nurses make the home visits alone, many nurses report that they feel a strong team spirit. The nurses feel part of the larger team even though they work alone most of the time. I think the smaller teams of around ten nurses create this feeling of peer support and belonging. The smaller teams also create a transparent organization, where every team member is informed about a person’s care.
This approach likely leads to fewer care mistakes as well, due to the directness of communication channels between staff members responsible for providing care. The nurse who cares for you in the morning communicates directly with the person who provides your care in the afternoon. There are no external managers or planners who transfer information or schedule visits. These direct lines of communication improve the quality of care. Up to seven individuals can care for one person per week in Buurtzorg. In Sweden, this figure can easily be twice as high and, in some organizations, three times as high.
Buurtzorg delivers greater continuity of care than we do in Sweden, and pretty much everywhere else. Many studies show that care continuity is one of the key elements of improving the quality of homecare. When fewer people care for you, you become familiar with your care team. You do not need to meet new people every week.
The continuity of care is one of the aspects of the neighborhood care model in Holland that I like the most. I have been looking for an organization that can deliver a high level of care continuity. For those setting up new homecare organizations around the world, I think continuity of care will be a critical factor of success for these startups. If homecare organizations with low continuity of care can improve this aspect, these organizations will have an opportunity to improve significantly the quality of homecare they provide.
Buurtzorg allows nurses to do what other homecare organizations may prevent them from doing: Buurtzorg nurses are allowed to take a holistic approach to the care that they give. If you end up in the hospital for a couple of days, your nurses can come and visit you in the hospital. Few homecare organizations today receive reimbursement for their nurses to visit clients in the hospital. As long as Buurtzorg receives enough reimbursement to cover costs, nurses can perform these kinds of added services.
To check up on the client the hospital may be critical to understanding how care needs change following hospitalization. Doctors and nurses at the hospital may report that you can shower independently after your hospital stay. Your homecare nurse will be able to pick up easily on whether or not you can do this. Your nurse can prepare and plan for the care you will need at home after the hospital visit. Such a small and seemingly unimportant task like checking up on a client in the hospital can improve the quality of homecare services significantly. Buurtzorg nurses can also keep in touch with your relatives, since they established a relationship with them early on. Other homecare organizations may not reimburse the nurses for making phone calls and sending email updates to relatives while a client is in hospital.
These are just a few examples of what the many nurses who work at Buurtzorg are able to do to improve the quality of homecare. I believe that this independence contributes to a more satisfied workforce. This freedom allows nurses to care fully for all of their clients’ needs without feeling constrained by having to log every single minute of service and without having to worry about not being reimbursed for certain tasks.
I think that this cuts to the core of the philosophy of care of Buurtzorg: It is not about logging every minute of service. The idea is to provide individuals with the assistance they need and to allow individuals to care for themselves and be autonomous. It takes a lot of courage to build an organization and, at the same time, admit that the nurses are most successful when their services are not required. In other words, Buurtzorg nurses have succeeded when individuals can live independently and care for themselves as much as possible. This is another aspect of the neighborhood care model that stands out.
The concept of self organizing teams of nurses requires that nurses agree among themselves, solve any disagreements that they may have, make recruitment decisions jointly, and use a consensus decision making approach. In the beginning, many nurses may be attracted to Buurtzorg because they do not have a manager to tell them what to do every day. Some nurses may think that not having a manager will mean more freedom. In reality, the nurses probably are more free, but they must also assume a great deal of responsibility. Buurtzorg nurses must plan in advance to a greater extent than nurses and other organizations that may follow plans set forth by a dedicated homecare planner or manager. Nurses at Buurtzorg must rise to the task of assuming greater responsibility, planning in advance, continuously discussing issues that arise, and finding constructive solutions with their peer nurses. This process must present a great personal challenge as well as a great source of motivation for the nurses at Buurtzorg.
When a team needs to recruit a new team member, it is up to the team to design and implement a recruitment strategy. Some teams interview new nurses in a group interview. Some teams may appoint a committee that recruits new team members. The nurses at Buurtzorg are independent from any management team. This independence creates a leaner organization, but, as I said earlier, the nurses must also assume greater responsibility. They must be able to work out any disagreements that arise. Nurses must communicate to their colleagues why or why not they believe that the candidate is suitable to join the team. I also believe that this added responsibility helps explain why nurses are more satisfied when they work at Buurtzorg.
Many homecare organizations around the world have already been inspired by the neighborhood care model. Some organizations have adopted the model. Some have adopted it but failed. As I join one of the neighborhood care teams in Sweden next week, I may be able to understand even better how the nurses operate. Considering the great continuity of care, the additional tasks that nurses can perform, the holistic approach to homecare, and the high levels of staff satisfaction, it is worth studying Buurtzorg homecare in greater detail.
Even though countries differ greatly, we see many of the same challenges arise in homecare in different contexts. Buurtzorg can help us think about homecare in a creative way.