In 2015 the United Nations’ [1] (UN) sustainable development agenda was launched containing seventeen sustainable development goals (SDG) aiming to promote prosperity and well- being for all over the next fifteen years. Although all goals can be seen as interrelated to each other, one goal is of particular importance here, namely ‘ensuring healthy lives and promote well-being for all at all ages’ [2]. In realizing the SDG agenda, an integrated approach is considered of utmost importance. Integrated health care (IHC) has also become an important focus in the health care sector on a global scale, since the world is confronted with a disease burden shift from communicable diseases to non-communicable diseases [3]. In addition, population ageing and thereby an increase in the number of people who suffer from complex and/or multiple (chronic) health complaints is steadily increasing the burden on health care expenditures worldwide [4]. As a response to this, Berwick and colleagues [5] formulated the Triple Aim goals to improve health system performance by improving the health of populations, enhancing the patient experience of care and reducing per capita cost of health care. In addition Bodenheimer and colleagues [6] proposed one more dimension to expand the Triple Aim goals to the Quadruple Aim goals, by adding the goal of improving the work life of health care providers, including clinicians and staff.
In the Netherlands, the average amount of money spent on health care per person was considerably higher than the OECD average [7]. These developments seriously threaten future accessibility, affordability and, hence, sustainability of Dutch health care [8]. Health and social care in the Netherlands is the shared responsibility of both the central government and the municipalities. Four basic healthcare related acts form the foundation of the Dutch healthcare system: the Health Insurance Act (Zorgverzekeringswet), the Long Term-Care Act (Wet langdurige zorg), the Social Support Act (Wet maatschappelijke ondersteuning) and the Youth Act (Jeugdwet) [8, 9]. In addition (1) the Participation Act (Participatiewet) supports mentally or physically challenged citizens’ participation in society and (2) the Public Health Act (Wet Publieke Gezondheid) is responsible for public health, prevention, health promotion and health protection by the municipalities at a local authority level. Every 4 years municipalities have to formulate a public health strategy for their area. Figure 1 shows an overview of the basic health and social care Acts and their responsibilities [8,9,10].
In order to understand the current Health and Social care system a few recent changes have to be explained.
First, in 2006, the new Health Insurance Act entered into force and transformed the Dutch healthcare system to a demand-driven system from a supply-driven system. As a consequence, every citizen living or working in the Netherlands is obliged to have a basic statutory healthcare insurance, purchased at a private insurance company, which covers basic healthcare [10]. Additionally, supplementary private (voluntary) health insurance differs per person and depends on the needs and wishes of the person. There are a total of 24 healthcare insurers active in the Netherlands. Although the healthcare system in the Netherlands can be considered as a semi-free market system, the government plays, among others, a controlling role.
Second, up to 2015 social health care was mainly the responsibility of the central government. Since 2015, health and social care in the Netherlands has transitioned from a centralized system to a decentralized system. The motivation for this transition is to promote an integrated approach tailored to people’s needs and their living condition at the local or neighbourhood level and to keep healthcare affordable. Moreover, the transition aims to encourage people to draw on their own network, resilience and resources for support. As a consequence of the transition in 2015, all 380 municipalities in the Netherlands have their own responsibility over the social domain (Social Support Act, the Youth Act and the Participation Act) and develop their own policies, based on local population needs.
The recent transition of 2015, in the health and social care domain poses challenges to local authorities in terms of sustainability of care, particularly in the South Limburg region in the south of the Netherlands. Population ageing is especially pronounced there and the population suffers from decreased health and a lower life expectancy compared to the province of Limburg and the Netherlands as a whole [11]. Among others, complex care consumers often need care financed under both the healthcare as well as the social care domain, which is argued to be challenging due to fragmentation of care and silo thinking of professionals involved. Moreover, fragmentation in health and social care systems is one of the reasons worldwide that health and social care cannot live up to the needs of the patients [12]. Hence, worldwide, in western countries, there is a focus on diminishing the gap between health care systems and social care services [13]. For example the Accountable Health Community (AHC) model in the United States, which is implemented by the Centers for Medicare and Medicaid Services (CMS), aims to connect healthcare to social services, as a result reducing emergency department visits by 9% [14]. Similarly, the U.K. aims to fully offer effective integrated health and social care services to their population by 2020 to meet the rising demands of the population [14, 15]. By integrating both the health and the social care domain the patient is staged in the center again, instead of positioned in between different services and organizations.
In order to create a sustainable healthcare system in the Netherlands, the Ministry of Health, Welfare and Sport selected nine innovative regions as pioneer sites to experiment with population management [16] to achieve the Quadruple Aim goals. Blue Care in the Maastricht-Heuvelland region in the southern part of Limburg province is one of the nine pioneer sites appointed by the Ministry of Health, Welfare and Sport. The term Blue Care represents sustainable care, since the term ‘Blue’ is inspired by the frequently used color for sustainability ‘Green’.
At the pioneer site Blue Care, health care organizations, patient organizations and the health care insurers’ providers have committed themselves to achieving the Quadruple Aim goals and pledged that they will prioritize population health above their organizational goals.
The integrated community approach blue care
One of the initiatives developed as part of the Blue Care pioneer site is the Blue Care integrated community approach (ICA), implemented in four low socio-economic status neighbourhoods in Maastricht, a city in the south of the Netherlands. Before the starting phase of the Blue Care ICA in 2016, stories and cases were collected based on conversations with citizens and health and social care professionals in the four neighbourhoods to gain an understanding of the current facilitators and barriers regarding the health and social care domain in the four communities.
As a result of these findings, sub-projects are initiated in the Blue Care ICA in which suggested improvements are being put into practice on a small scale while using a bottom-up approach. These various sub-projects need to fulfill the following criteria: the project needs to cover both the health and the social care domain; the project needs to correspond with the needs of citizens and professionals; and the project needs to be sustainable over time (in terms of continuation after the implementation period). Furthermore, projects are developed ‘on the go’, meaning that feedback is gathered during the implementation process and improvements and adjustments are made for the project to fit to citizen’s and professional’s needs.
The Blue Care ICA is implemented in four neighbourhoods with low socioeconomic status (SES): Limmel, Nazareth, Wittevrouwenveld and Wyckerpoort [17]. Low socioeconomic status is often linked to decreased health and lower life expectancy, which often affects, among other things, the ability of people to participate in society [18]. Also, low socioeconomic status communities appears to have lower social cohesion [19], which is a possible mediator between neighbourhood deprivation and health [20]. For example, less socially cohesive neighbourhoods are associated with increased depression and lifestyle problems (i.e., smoking, lack of exercise) [21]. Furthermore, poverty and unemployment are significantly associated with the duration of episodes of common mental disorders such as anxiety and depression. Therefore, the need to stimulate participation and to address the health and well-being of citizens is especially important in low socioeconomic status communities to decrease socioeconomic health inequalities and inequities [22] and to decrease costs of care [23, 24].
Positive health as a shared ideology
The aim of Blue Care ICA is to improve population health and the perceived quality of life by implementing a community approach, based on the ideology of Positive Health. Positive Health is based on a new vision on health, where health is described as ‘the ability to adapt and self – manage’ [25]. The new description of health was introduced in 2011, since the traditional World Health Organization (WHO) definition of health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ was no longer suitable, with the rising numbers of non-communicable diseases. Additionally, according to the traditional WHO description of health, almost everybody can be considered ill to some extent, since the description uses a static state of health. The new description of health considers health from an asset-based perspective that goes beyond focusing of disease/illness by also including the individual’s perceived sense of control and coping with life events [25, 26]. Based on this line of reasoning, Positive Health aims to enhance citizens’ strengths and self-reliance and consists of six dimensions (Fig. 2), which together encompasses a holistic view of health [27]. In the Blue Care ICA approach, sharing and implementing the ideology of Positive Health among citizens, professionals and policymakers may contribute to decreasing fragmentation in health, since Positive Health combines both aspects of health and social care, and creates a collective language between the professionals working in the different domains.
Three core elements
Positive Health is used as an overarching ideology that runs through the veins of Blue Care. Apart from that, three core elements are designated that encompass the building blocks of Blue Care.
Citizens in action
The first core element aims to change citizens’ attitude, self-efficacy and behavior to give meaning to their own lives and stimulate societal participation (‘citizens in action’). Citizens are actively involved in Blue Care and are stimulated to address bottlenecks and develop projects which address these bottlenecks. Recent findings in the intervention neighbourhoods from the perspective of the citizens showed that there is a lack of communication between health and social care professionals, there is too much bureaucratic delay, and rules and regulations are considered to be inflexible with insufficient attention to the needs of citizens. In addition, citizens are consulted on a regular base during Blue Care by a citizen panel which comes together two times a year facilitated by the researcher and a member of the Blue Care coordination team. Hence, these meetings serve both as a research and a practical implication tool to diminish the burden on the citizens.
Professionals in action
The second core element aims to enable and support the professional freedom of health and social care providers to organize (preventive) support in the main interest of the individual citizen, above and beyond organizational interests or financial reason (‘professionals in action’). One of the important bottlenecks mentioned by the professionals during the starting phase of the Blue Care ICA in 2016 was that there is a lack of communication between the different health and social care providers. Contradictions in treatment and advice given between professionals treating the same patient are more the rule than the exception, which is frustrating for professionals involved. Furthermore professionals mentioned ‘being tied up by inflexible rules, regulations and bureaucracy created by the municipality and health care insurer’ as an enormous bottleneck in treating patients efficiently.
Combining budgets
The third core element, ‘combining budgets’, will build a reimbursement system in which the budgets for health and social care are combined on a population level. Therefore, the budgets of the dominant health insurer in the south of Limburg (VGZ, Health Insurance Act) will be combined with the budgets of the social care domain (Social Support Act, Youth Act and Participation Act).
The financial reimbursement system is agreed upon at the macro (policy) level and is considered to be a prerequisite for enabling and facilitating the implementation of initiatives at the micro and meso (community and organizational) level. The national budgets of the Long –Term Care Act will not be included in the budget of the Blue Care ICA, even though the costs in this area will be monitored along the way. The objective is that the costs of health and social care, following the implementation of projects within the Blue Care ICA, will be in accordance with available financial budgets (thereby breaking the trend of increasing costs) or, ideally, that projects will lead to a decrease in costs. To judge this, the reimbursements of 2015 in these domains will be used as an upper limit.
Hypothesis and research questions
The Blue Care integrated community approach aims to improve the health-related quality of life of citizens living in four low socioeconomic status neighbourhoods of Maastricht and thereby reduce socioeconomic health inequalities. We hypothesize that the Blue Care ICA, using a bottom-up approach and Positive Health as the shared ideology, will lead to an improvement of the Quadruple Aim goals.
The research questions are:
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1.
What are the outcomes of the Blue Care ICA in terms of:
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a.
effects on the health-related quality of life (18+ years);
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b.
effects on the perceived quality of care of the citizens;
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c.
changes in the work satisfaction of professionals working in the four neighbourhoods;
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d.
changes in total reimbursements at a (sub)population level in the four neighbourhoods and substitution in different types of reimbursements?
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2.
How is the Blue care ICA embedded in the four neighbourhoods in terms of:
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a.
inter-professional and inter-organizational collaboration;
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b.
application of Positive Health and integration into working routines of professionals;
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c.
delivering person-centred care and support from a generalist perspective;
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d.
implementation of a combined budget (bundling of budgets in the health and social care domain)?
