1. Buurtzorg+: Integrated community care

2. Integrated Community Care Teams Cohesive care in the community through integrating the existing primary care services Close collaboration between district nursing, physiotherapy, occupational therapy and other primary care professionals

3. Intention To jointly contribute to the care and well- being of  Home dwelling (frail) elderly  Chronically ill clients  Terminally ill clients  Carers

4. Goals Prevention  Ensuring safety of clients and carers  Detecting risk factors early  Enhancing client self-help  Avoiding hospital (re)admission  Supporting the carer  Reducing the burden of care for DNs

5. Conditions for optimum collaboration  Commitment to collaborative working  Change from single to multi-professional focus  Buurtzorgteam and therapists know each other  And know each others professional skills  Innovative mindset  Effective communication - personal, digital, IT infrastructure

6. Referral process  Pivotal role of community nurses  Patient is informed of possibilities of PT/OT input  Early referrals. Easy to conduct  Use of simple 4 point referral checklist  Shared assessment and assessment form  Shared care goals  Skill and service mixing

7. Checklist integrated community care

9. Therapists focus Functional training of whole task, rather then separate exercises/movements Working on meaningful skills improves client motivation and achievement Training in the home environment rather then a clinic reduces ‘transfer problem’

10. Our approach 1.Team requests Buurtzorg+ 2.Information in Buurtzorg learning platform 3.Team selects PT and OT 4.CN, PT and OT prepare implementation through multidisciplinary Buurtzorg+ course 5.Getting started! Tools 6.Keep going! Self-monitoring process Collaboration is incorporated in BIS

11. Buurtzorg+ team Amsterdam

12. 1. Team requests Buurtzorg+  Whole team is motivated to start integrated collaboration  One District Nurse takes up development role

13. 2. Information in Buurtzorg learning platform  All team members read the relevant information on the digital Buurtzorg learning platform

14. 3. Selection therapists  Share Buurtzorg+ vision and responsibilities  Great affinity with client population  Proven knowledge and experience with target groups  Easily and reliably contactable  Readily available for patient visits  Good communication skills  Match with the Buurtzorg team

15. 4. Modular Post Graduate multidisciplinary course 5 Modules:  Implementing integrated community care  Collaboration in chronic care  Prevention, self management, reaching the vulnerable elderly  Palliative and terminal integrated care  Health and safety opportunities Buurtzorg+

16. 5. Getting started! Kick off meeting Buurtzorg+ team and therapists  Working agreements  Checklist  Referral criteria  Collaboration format  In-servicetraining

17. BIS example

18. 6. Keep going!  Continuing process of collaboration  Joint assessments and shared care goals  Fine tuning of the agreed objectives  Adjusting the process as and when needed  In-service training  Our support if needed

19. Evaluating the collaboration  Buurtzorg+ teams evaluate the quality and quantity of their collaboration using the Checklist Coordinated Action*  Evaluation is also used as a quality assurance tool for the therapists involved  Approved therapists can be found in BIS *(tool for partnerships to facilitate and evaluate community health promotion; Global health promotion 2010; 17(3))

20. Buurtzorg+ team Hilversum

21. Dutch community based PT/OT clinics Therapists run their own businesses They have contracts with various health insurers They have to work cost-effectively Joining Buurtzorg+ costs them time but generates work Health insurers expect community collaboration but have not increased the tariff (yet)

22. Buurtzorg+ development Initiating new Buurtzorg+ teams Maintaining and improving the quality of existing teams Educating community therapists Promoting and implementing integrated community care outside Buurtzorg Research by University of Amsterdam Academic Medical Centre

23. Thank you for your interest Further enquiries welcome Mieke Verberg m.verberg@buurtzorgnederland.com Janet Riezebos j.riezebos@buurtzorgnederland.com