Strategies for University Hospitals
How Maastricht UMC+ is moving into population health management
Population health management is the new mantra for many healthcare systems. Maastricht UMC+ in the Netherlands has been doing it for years, building a stronger primary health network called Primary 1.5. We talk to UMC+ CEO Helen Mertens.
By launching prevention programmes, ensuring the chronically ill are less likely to hit ER, UMC can also invest more in tertiary healthcare. And it has the results to prove the new models work.
Mertens is keen to make a point about the inhabitants of Maastricht and its province of Limburg: “Especially in the southern part of the province, people have the worst health compared to the rest of the country, the shortest life expectancy and the highest incidence of chronic disease in the country.” Worse still, the young leave for the larger coastal cities like Amsterdam, Rotterdam and Utrecht, leaving a rapidly ageing population who are only going to get sicker.
So, for the past 15 years Maastricht UMC+, the university hospital and its twinned research institute have focused on doing something about this. The goal is to achieve a 30% improvement in the life expectancy of the lowest decile within five years.
Primary 1.5
Over a decade ago, Maastricht came up with the idea of beefing up primary care so as to ensure that far fewer patients ended up in emergency wards, occupied hospital beds and attended outpatient clinics.
This covers a number of strategies: physician specialists seeing patients alongside family doctors in the so called ‘Stadspoli’ (City Outpatient), the introduction of apps to monitor chronic illness and enabling patients and their family to better look after themselves.
At its core is the idea that physician specialists from the university hospital will go out to the primary care practices and see patients alongside their primary care doctors. Mertens says that “most departments” do this today.
And that the results have been impressive. “It enables us to educate primary care doctors so they can do more. It also means that patients get more continuity and can stay under the care of their family doctor.” And above all it meant fewer frequent-flyer interventions.
Mertens says that initially there was resistance. “Physicians said it was more convenient for them if the patient came to them. And it also meant we got less money as a hospital, because there would be fewer patients attending. But, on the other hand, there is a financial advantage for individual Dutch patients, because they have to pay an initial fee (‘own risk’ fee) when they go to hospital, which they don’t have to pay to the family doctor. Also waiting times are often shorter at the GP.”
1.5 has also seen Maastricht roll out apps to enable patients to better control their condition. For instance, irritable bowel syndrome patients have an app that monitors their health. “We used to see each IBS patient every three months. The app means we can scratch that and only see the patient at the right moment.” The use of the app reduced hospital admissions and outpatient visits according to a Lancet article.
A month ago Dutch statutory insurers also approved the use of telemonitoring for arrhythmia patients. And the Dutch Care Authority has acknowledged this form of eHealth.
Maastricht has also done more to enable patients and their relatives to look after themselves, reduce hospital stays and pressure on home care organizations For instance, they are shown how to handle dressings and injections and how to apply eye-drops.
All this has led to some interesting results. A study showed major reduction in health care costs per patient and shorter waiting lists, plus an increase in patient satisfaction with no detrimental effects on health outcomes.
Using the data
Mertens says Maastricht has one big advantage. “We don’t have another general hospital in our city, so we are the only university hospital in the Netherlands that does all the secondary as well as all the tertiary care.” That means Maastricht can capture a total data set.
But this doesn’t mean there aren’t data silos. Mertens says each hospital district has been allowed to choose its own patient record system so far. And the primary care healthcare records are held separately.
Maastricht, however, is doing a lot of work on how clinical data can be best shared, both with primary care networks and with other providers by connecting together data pools.
Maastricht has also developed what it calls a FAIR (Findable, Accessible, Interoperable and Reusable) data sharing and federated learning infrastructure that does not require data to leave the hospital – called the Personal Health Train. This has reduced many of the ethical and other barriers to sharing health data. Users can then ask questions such as ‘Which data elements are most predictive of survival after lung cancer given all data in the Netherlands?’ or more specifically ‘Which data stations contain data about me?’
Prevention
For Mertens, the key word is prevention. “We need to do far more across the whole spectrum from providing education to patients following earlier diagnosis about diet and exercise to more general smoking and alcohol cessation programmes.” It is an area Maastricht already knows well, thanks to a cohort study of 10,000 Maastricht citizens, which is still being followed up on a decade later. “We are also developing lifestyle interventions with, say, diabetes where we can see and measure the impact of, say, giving patients a smart watch.” Maastricht has also pioneered a unique healthy-breakfasts-in-schools programme which assessed the health and educational attainment of supported children.
Here she says that the ministry has also asked UMCs to take a lead role in setting up regional health networks. “In our region we set up a knowledge and innovation agenda. Together with partners in our network (other hospitals, local government, insurers and industry) we looked at the future challenges in population health management and how we should address them.”
What of the future?
How far is what Maastricht is doing being shared across the Netherlands?
She says the ministry of health takes a keen interest and so do the insurers. But, ultimately, whether Maastricht’s best practice is shared comes down to the other university hospital groups in the Netherlands.
Mertens is optimistic: “Our goal is to evaluate what we are doing and to share it with the rest of the country and the world. We work closely with the six other UMCs in the Netherlands and we all adopt and share. For instance, other hospitals are rolling out our IBS app and we have adopted a system to monitor pregnant women at home from Utrecht UMC.”
But ask Mertens about cost savings and she sighs. “Our biggest problem is the very great number of patients who are coming to us. The truth is that bed occupancy hasn’t dropped. Yes, we can keep the cohort with chronic diseases on a better footing and with fewer hospital visits, but the beds are now filled with other patients. Because of the demography, I can see a lot of extra demand in the next decade. So, we’ll keep on investing in prevention and promoting a healthy lifestyle and, on the other hand, adding smart innovations and medical technology to improve our healthcare while keeping an eye on cost effectiveness.”
We would welcome your thoughts on this story. Email your views to Max Hotopf or call 0207 183 3779.
