A healthcare network providing high-quality exercise and lifestyle care for patients with NCDs
Chronisch ZorgNet is the expanded initiative of ClaudicatioNet; a proven nationwide VBHC network. ClaudicatioNet implemented stepped care for patients with peripheral arterial disease (PAD) in the Netherlands, meaning these patients receive supervised exercise therapy (SET) and lifestyle care by specialized ClaudicatioNet physical therapists as primary treatment. This has been achieved, amongst others, by proving the (cost)effectiveness of this therapy in several scientific studies (Fokkenrood, 2014; Hageman, 2018; Fakhry, 2018). Due to ClaudicatioNet, 87% of the PAD patients primarily received SET in 2017, compared to <3% in 2001. After 5 years, 83% of these patients is still free of vascular invasive interventions (based on national reimbursement data).
PAD patients often suffer from multiple non-communicable diseases (NCD) simultaneously due to similar risk factors. Unfortunately, many patients with NCDs in the Netherlands do not receive exercise and lifestyle therapy, because of financial regulations and the lack of specialized physical therapists. ClaudicatioNet, which currently consists of approximately 2200 physical therapists, is therefore upscaling to Chronisch ZorgNet; a healthcare network providing high-quality exercise and lifestyle care for patients with NCDs (e.g. PAD, COPD, coronary arterial diseases (CAD)), for whom this therapy is beneficial and recommended in (inter-)national guidelines.
All Chronisch ZorgNet physical therapists will be trained in the treatment of NCDs. This treatment consists of exercise and lifestyle therapy and is aimed at self-management: the patient should live a healthy lifestyle and be able to maintain this lifestyle on his/her own. This is also achieved by organizing weekly walking groups for patients, thereby increasing the patient’s physical activity and preventing social isolation.
The expansion to Chronisch ZorgNet is realized by collaborating with essential stakeholders, such as patient associations, relevant professional associations (physical therapists, physicians, dieticians) and health insurance companies.
As a network, we value high-quality and transparent care. The nationwide Chronisch ZorgNet is divided into 55 regions, thereby stimulating collaboration between therapists and other healthcare professionals. Furthermore, the Chronisch ZorgNet ‘Zorgzoeker’ (carefinder) enables physicians and patients to find nearby Chronisch ZorgNet therapists (based on postal code), search for their specializations and gain access to their publicly visible portfolio. Using this web-based carefinder ensures that patients find the closest specialized therapist as well as a timely follow up and start of the therapy program (on average within 3.2 days after referral).
PAD related outcome measures are currently collected in a national database, called the Chronisch ZorgNet ‘Kwaliteitssysteem’ (quality system). Every participating therapist contributes to this database. These outcome measures are used for scientific research, benchmarking, as well as providing feedback to participating therapists. By this the therapists are able to learn from their own data and improve the therapy they provide to their patients. The former ClaudicatioNet ‘Quality System’ is expanded to encompass additional NCD related outcome measures.
Besides scientific research and benchmarking, the gathered data (>32.000 patients) has been used to develop ‘KomPas’: an online tool which provides insight into patients’ individual prognosis of therapy. This supports patients and therapists in shared decision making and adapting care to the needs and priorities of the individual.