Een ontwerp voor transmurale telebegeleiding van patiënten met hartfalen
Keeping future care good, accessible, and affordable: that is the major challenge the healthcare sector faces. To achieve this, efforts are needed, among other things, to provide the right care in the right place and to promote regional collaboration among healthcare institutions.
Deventer Hospital, home care organization Carinova, Huisartsen Coöperatie Deventer en Omstreken (HCDO), and the healthcare insurer Salland Zorgverzekeringen are collaborating to improve the care for patients with heart failure. They formulated the following ambition: "To provide high-quality and cost-effective care in the right place and by the right professionals for heart failure patients in the Salland region and its surroundings through the use of telemonitoring." This ambition has been translated into a design for localized and integrated care.
The process began with an analysis based on literature and benchmarking on regional telemonitoring. In a client panel, experienced individuals provided insight based upon experience on the desires and needs of patients. Subsequently, the healthcare partners in the Salland region collectively designed a telemonitoring program for patients with heart failure. Design choices were made regarding the care process and the necessary data exchange. The design of the transmural care pathway was implemented in a pilot program. Monitoring of the objectives and their follow-up was established, and steps are taken to sustain the care pathway.
The transmural care pathway for telemonitoring patients with heart failure was evaluated using the NASSS framework (Greenhalgh et al., 2017). Barriers and enablers, together with lessons learned from the project itself, were translated into a general guideline for organizing telemonitoring in collaboration with regional partners.
Finally, recommendations were made for the sustainability and upscaling of telemonitoring in the Salland region and these might be applicable in other regions.