HomeCarebySelfGoverningNursingTeams:The

Netherlands'BuurtzorgModel

Toplines
ADutchhomecareorganizationusesindependentnurseteamstodeliverhighquality,lowercostcare.
InaDutchmodelofhomecare,nursesprovidemedicalandsupportservices,withgoodresults
Abstract

TheDutchhomecareproviderBuurtzorgNederlandhasattractedwidespreadinterestforitsinnovativeuse
ofselfgoverningnurseteams.Ratherthanrelyingondifferenttypesofpersonneltoprovideindividual
servicestheapproachtakenbymosthomehealthprovidersBuurtzorgexpectsitsnursestodeliverthe
fullrangeofmedicalandsupportservicestoclients.Buurtzorghasearnedhighpatientandemployee
ratingsandappearstoprovidehighqualityhomecareatlowercostthanotherorganizations.Thiscase
studyreviewsBuurtzorgsapproachandperformancethusfarandconsidershowthismodelofcaremight
beadaptedfortheUnitedStates.
BACKGROUND
BuurtzorgNederland,anonprofitDutchhomecareorganization,hasgarneredinternationalattentionfor
deliveringhighqualitycareatlowercostthanmostcompetingorganizationsthroughthedeploymentofself
governingnurseteams.Whentheygointoapatientshome,Buurtzorgsnursesprovidenotonlymedical
servicesthatrequirenursingtrainingbutalsomanysupportservicesthatlessertrained(andcheaper)
personnelusuallyprovideinotherhomecareorganizations.
Bymanymeasures,BuurtzorgNederlandhasbeenanextraordinarysuccess.Startingwithoneteamin
2007inthesmallcityofAlmelo,Buurtzorg(Dutchforneighborhoodcare)hasgrownintoanational
organizationthatby2015employed8,000nursesin700teams.Thesenursescaredfor65,000patientsin
2014.1Earlyeffortsareunderwayinseveralcountries,includingJapan,Norway,Sweden,theUnited
Kingdom,andtheUnitedStates,toadapttheBuurtzorgapproachtolocalcircumstances,andmanyother
DutchhomecareorganizationshavebegunadoptingaspectsoftheBuurtzorgmodel.AccordingtoSharda
S.Nandram,aDutchmanagementprofessor,Buurtzorghascreatedanewmanagementapproach
integratingsimplification,characterizedbyasimple,flatorganizationalstructurethroughwhichawide
rangeofservices,facilitatedbyinformationtechnology,canbeprovided.2
GovernmentsurveyshaverepeatedlyshownthatBuurtzorgspatientsarehighlysatisfied.Moreover,

surveysofemployeesoverseveralyearsindicatetheorganizationhasthemostsatisfiedworkforceofany
Dutchcompanywithmorethan1,000employees.3Themodelalsoappearstoachievesavings.Inthe
Netherlands,insurerspayforhomecareonanhourlybasis,andBuurtzorgsteamsofnurseshaveused
fewerhourstomeetpatientsneedsthanhaveotherorganizations.
AsBuurtzorghasgrown,however,sotoohavesuspicionsthatthissuccessisatleastpartlybasedon
cherrypickingthemostprofitablepatients.4Inresponse,theDutchMinistryofHealth,Welfare,andSport
commissionedtheconsultingfirmKPMGtoconductastudycomparingBuurtzorgtootherhomecare
providers,controllingfordifferencesinpatientcharacteristics.Theresults,publishedinJanuary2015,offer
thebestavailableevidenceofBuurtzorgsperformanceonmeasuresofcost.5TheyshowthatBuurtzorgis
indeedalowcostproviderofhomecareservices,andthatthiseffectivenessisnotattributabletoitspatient
mix.However,whenpatientsnursinghome,physician,andhospitalcostswereaddedtotheanalysis,
BuurtzorgstotalperpatientcostswereaboutaveragefortheNetherlands.
OurexaminationoftheBuurtzorgapproachanditspossibleapplicabilitytotheUnitedStatesisbasedon
publishedinformationandontelephoneandinpersoninterviewsconductedinFebruaryandMarch2015
withBuurtzorgsCEO,colleagues,andmembersofaBuurtzorgnursingteam.Additionalinterviewsobtained
perspectivesfromDutchgovernmentofficialsandinsurers,thenationsleadingpatientadvocacy
organization,acompetinghomecareprovider,theDutchprimarycarephysicianassociationandhomecare
tradeassociation,theprincipalinvestigatoratKPMG,andpeopleinvolvedintheearlyefforttoimplementa
BuurtzorgprograminMinnesota.(Foracompletelistofindividualsinterviewed,seeAppendixA.)
BUURTZORGCAREMODEL
HomecareintheNetherlandsisprovidedtopatientsneedingtemporaryservicesfollowinghospital
discharge,patientswithchronicconditionsrequiringmedicalservices,peoplewithdementia,andindividuals
inneedofendoflifecare.Homecareorganizationscontractwithgovernmentfundedinsurancecompanies
toprovide10differenthomecareservices.6Thenumberofauthorizedhoursisbasedonindividualpatient
assessments.7
Somehomecareservicesrequirenursingexpertise,butmanyothers,suchashelpwithactivitiesofdaily
living(e.g.,dressing,bathing,ortoileting),canbeprovidedbylesstrained,lessexpensivepersonnel.8
Homecareorganizationstypicallyhavedeployednursestoprovideonlythoseservicesthatrequiretheir
knowledgeandskill,whilesendinglesscostlypersonneltoperformotherservices.Withvariouscaregivers
comingatdifferenttimesondifferentdaystoprovideservices,suchanapproachcanjeopardizecontinuity
ofcare.Byseveralaccounts,bothpatientsandnurseswereoftendissatisfiedwiththetraditionalhomecare
model.
Buurtzorghastakenaradicallydifferentapproach,reflectingthevisionofitsCEOandcofounder,Josde
Blok,anexperiencedhomecarenursewithmanagementtraining.Thegoalsofthemodelaretobringa
holistic,neighborhoodbasedapproachtotheprovisionofservicesmaximizepatientsindependence
throughtraininginselfcareandcreationofnetworksofneighborhoodresourcesandrelyonthe
professionalismofnurses(Exhibit1).OneofdeBloksoftstatedmottosishumanityoverbureaucracy.
Exhibit1.BuurtzorgCareModel:GoalsandStructure
Goals

Structure

Createselfgoverningteamsofnursesto
providebothmedicalandsupportivehome
careservices
Becomeasustainable,holisticmodelof
communitycare
Maintainorregainpatientsindependence
Trainpatientsandfamiliesinselfcare
Createnetworksofneighborhoodresources
Relyontheprofessionalismofnurses
(Howdoyoumanageprofessionals?You

Independentteams(withamaximumof12nurses)
takeresponsibilityforallaspectsofcarefor5060
patients
ReliesonITsystemforonlinescheduling,
documentationofnursingassessmentsand
services,andbilling
Coachesareavailabletoproblemsolveforeach
team
Smallbackofficehandlesadministration

dont!)

Source:K.MonsenandJ.deBlok,BuurtzorgNederland,AmericanJournalofNursing,Aug.2013
113(8):5559.
Thecaremodelthatgrewoutoftheseideasgivesselfgoverningteamsof10to12highlytrainednurses
responsibilityforthehomecareof50to60patientsinagivenneighborhood.9Theteamsworkwiththe
patientsandtheirfamilies,primarycareproviders,andcommunityresourcestomeetpatientsneedsand
helpthemmaintainorregaintheirindependence.
Buurtzorgnursesareresponsiblefortheentirerangeofhomecareservices:assessingpatientsneeds,
developingandimplementingcareplans,providingservicesorschedulingmedicalvisitsasneeded,and
generatingthedocumentationneededtofacilitatecontinuouscareandbilling.Buurtzorgcollectsinformation
aboutpatientssatisfactionatthecompletionofthecourseofcare(inadditiontothepatientsurveyscarried
outbythehealthministry).Amoderninformationtechnology(IT)systemandintranetenableonline
scheduling,documentationofnursingassessmentsandservices,andbillingaswellasthesharingof
informationwithinandacrossteams.10
Coachesnotmanagersareavailabletosolveproblems.11Therewere15coachesforthe700teamsin
early2015.ArendJanZwart,aBuurtzorgcoach,saidthatmoreofhisworkpertainstohelpingteams
functionthantoprovidingadviceaboutpatientcare.12Nursesdonotreporttomanagers,thoughtheirwork
hoursaretracked.13Thesmallbackoffice(withfewerthan50peopleinearly2015)carriesoutfunctions
suchassalaryadministration,contractingforteamsoffices,andfinancialadministration.Underaunion
agreement,thenursesarepaidaccordingtotheireducationlevel,withastandardannualincreaseand
bonusesbasedonyearsworkingforBuurtzorg.14Surplusrevenuesareusedforcontinuingeducationof
nurses,teamprojectstoimprovecommunityhealth,andorganizationalinnovations.15
Theuseofselfregulatingteamsprovidesflexibilityinworkarrangementstomeetbothnursesandpatients
needs.Forexample,thesixnursesinateamwevisitedinHaaksbergen,aDutchtownofabout19,000
peopleafewmilesfromAlmelo,work16to24hoursperweek(though32hoursissaidtobemoretypical).
Twonursesshareresponsibilityforsixtoeightpatientsatagiventime,makingvisitsmostlyinthemornings
andevenings.Everyotherweek,theteammeetstoreviewpatientscasesanddiscussproblems.Itsharesa
smalltwoofficebuildingwithanothersixpersonteamfromwhichithadamicablysplit.TwootherBuurtzorg
teams,oneofwhichspecializesindementiapatients,workinthecommunity.
BUURTZORGSPERFORMANCE

Buurtzorgsrapidgrowthappearstoberootedinseveralfactors.First,themodelofcareispopularamong
nurseswithhomecareexperience,enablingrecruitmentoftalentedstaff.16Second,thehighpatientand
familysatisfactionratings(seeAppendixB)andgoodhealthoutcomeshavehelpedteamsobtainreferrals
fromphysiciansandhospitalsaswellaswordofmouthrecommendations.Inaddition,a2009Ernstand
YoungstudyfoundthatBuurtzorgthenamuchsmallerorganizationwasabletomeetpatientsneeds
whileusing40percentoftheauthorizedpatientcarehours,comparedwiththeaverageamongotherhome
careorganizationsofabout70percent.ThestudyalsofoundthatBuurtzorgspatientsrequiredcareforless
time,regainedautonomyquicker,hadfeweremergencyhospitaladmissions,andshorterlengthsofstay
afteradmission.Inaddition,thecompanyhadloweroverheadcoststhanotherhomecareproviders(8%of
totalcosts,comparedwith25%)andlessthanhalftheaverageincidenceofsickleaveandemployee
turnover.17
DeBlokhimselfbecameavisibleandeffectiveadvocateforthecompanyinpolicycirclesandpopular
media.InadditiontotoutingBuurtzorgshighlevelsofpatientandnursesatisfaction,hecouldpointto
evidencethatitsnurseswereabletomeetpatientsneedsinfewerhoursthanotherhomecare
organizationsleadingtobettercareatlowercost.18Thisclaimhelpeddrivetheorganizationsgrowthand
earneditgovernmentsupport.19
CriticismsoftheBuurtzorgModel

Buurtzorgsrapidgrowthwasaccompaniedbycriticismfromsomequarters,particularlycompetitors.In
interviews,detractorsclaimedthatBuurtzorgpatientsneedingunplannedcaresometimeshadtoseekhelp
fromotherhomecareorganizationsorhospitalemergencydepartments.Inaddition,Buurtzorgteams,
accordingtoothercritics,selectedcomplexpatientswithmultipleneedsmeaningmorebillablehoursper
homevisitandlesstimespentontravel,whichisnotreimbursed.20
Wedidnotfindevidencetosubstantiateeitherclaim.Regardingthefirst,deBlokarguesthateffectivehome
careminimizestheneedforunplannedcare,andthatonlyrarelyhaveotherhomecareorganizationsbeen
calledontohelpcareforBuurtzorgpatients(ashisteamshavesometimesdoneforothergroups).Wedid
notlearnofanyphysicianorpatientcomplaintsaboutBuurtzorgsteamsbeingunresponsivetopatients
needsforunplannedcaremoreover,itisdifficulttoseehowanunresponsiveorganizationcouldachieve
Buurtzorgshighpatientsatisfactionratings.21
AsfortheclaimthatBuurtzorgteamsselectcomplexpatientstomaximizerevenue,deBloknotesthat
BuurtzorgspatientmixreflectsreferralsfromphysiciansmanyofwhomareawareofBuurtzorgssuccess
andthusmorelikelytorefertheircomplexpatientstotheorganization,apointborneoutina2009study.22
HealsonotesthataveragepatientvisitsbyBuurtzorgnurseslast25minutes,comparablewiththeaverage
forcompetinghomecareproviders.Itisalsodifficulttosquaretheallegationwiththefindingthat
Buurtzorgspatientsreceivecareforlesstime.
LatestResearch

BuurtzorgsincreasingprominenceandcriticismsaboutcherrypickingledtheDutchMinistryofHealth,
Welfare,andSporttocommissiontheconsultingfirmKPMGtocompareBuurtzorgsperformancewiththat
ofpeerorganizations.PublishedinJanuary2015,thestudyfoundthatBuurtzorgrankedamongthebest
homecareagenciesinthecountryonmeasuresofpatientreportedexperiences,whileproviding
substantiallyfewerhoursofcarethantheaveragehomecareorganization(108hoursvs.168hoursper
patientyear)(Exhibit2).23Itscasemixadjustedcostswererelativelylow(atthe38thpercentile,meaning

that62percentofhomecareprovidersweremoreexpensive),eventhoughitspersonnelcostsperhour
weresubstantiallyhigherthanaverage(54.47vs.48.74[$59.24vs.$53.00]).Thecasemixadjustments
inthedataanalysiswereaimedatminimizingthepossibilitythatcostdifferencesweretheresultofpatient
selectioneitherbyBuurtzorgorotherproviders.24
Exhibit2.CostComparison:Buurtzorgvs.OtherDutchHomeCareProviders
OtherDutch
Buurtzorg

homecare
providers

Averagehoursofhomecare(perclientperyear)

108hours

168hours

Averagehomecarecosts(excludingfollowupcosts)

6,428($6,990)

7,995($8,695)

2,029($2,207)

2,510($2,730)

7,787($8,468)

5,187($5,641)

AveragefollowupcostsintheExceptionalMedicalExpense
Act
(mainlynursinghomecost)
Averagefollowupmedical(physicianandhospital)costs
Totalcasemixadjustedcostperclient,includinghomecare
and
followupcosts

15,357*
($16,701)

15,856*($17,243)

*Onlythetotalcostsincludecasemixadjustment.
Source:KPMG,TheAddedValueofBuurtzorgRelativetoOtherProvidersofHomeCare:AQuantitative
AnalysisofHomeCareintheNetherlandsin2013[inDutch],Jan.2015.
KPMGextendedthisanalysisbylookingatthenursinghomeandcurative(physicianandhospital)costs
forhomecarepatients.Comparedwiththeaveragehomecareorganization,Buurtzorgpatientswereless
likelytogointonursinghomesbutsubsequentcostsforcurativecarewerehigher(atthe91stpercentileof
homecareorganizations).Whenallofthesecostswereincluded,Buurtzorgscasemixadjustedtotalcosts
perclientwerejustbelowthenationalaverage(49thpercentile).
TheKPMGreportdidnotspeculateonthereasonforlownursinghomecostsandhighcurativecarecosts,
callingitaquestionforfollowupresearch.Thefindingsappearcontradictory,becausetheformeris
suggestiveofgoodhomecarewhilethelattermaynotbe.Yetthenurseshighlevelofcredentialing,the
growthofreferralstoBuurtzorgteams,andtheorganizationshighsatisfactionratessuggestthatBuurtzorg
delivershighqualitycare.Perhapshighlytrainednursesareparticularlylikelytospotproblemsrequiringa
physiciansattention.
Itisalsopossible,however,thatBuurtzorgspatientpopulationthecompositionofwhichisheavily
influencedbyphysiciansreferralpracticesmayincludeadisproportionateshareofpatientsona
downwardhealthtrajectory(owingtoAlzheimersdisease,forexample)comparedwithpatientsrequiring
shorttermcarefollowinghospitaldischarge.Iftrue,thiswouldexplainthehighercurativecosts.
Unfortunately,althoughKPMGsanalysisadjustedforcasemix,itdidnotdescribehowBuurtzorgspatient
mixcomparedwiththatofotherDutchhomecareproviders.

Insum,theKPMGstudyconcludesthatBuurtzorgshighlysatisfied,selfmanagingteamsofnursesprovide
lowcosthomecarethatisbothefficient(fewerhoursperpatient)andofhighquality(asmeasuredby
patientsatisfaction),butatatotalcostincludingnursinghome,physician,andhospitalcoststhatisabout
averageforDutchhomecareproviders.
APPLICABILITYTOTHEUNITEDSTATES
IntheUnitedStates,anefforttocreateahomecareorganizationmodeledonBuurtzorgbeganin2014in
Stillwater,Minnesota,withfinancialsupportandguidancefromBuurtzorgNederland.25Byearly2015,
BuurtzorgUSAhadbecomealegallyconstitutednonprofitorganizationwitharudimentaryadministrative
structureandaMinnesotaComprehensiveHomeCareLicense.Theneworganizationhadfournurse
employeesandacontractwithaHumanasubsidiarytoprovidecarecoordinationservices,andhadcared
foritsfirstfewhomecareclientsonaprivatepaybasis.26Effortswereunderwaytoraiseawarenessof
Buurtzorgasahomecareprovideramonglocalhealthcareandsocialserviceorganizations,establish
eligibilitytobillMedicareandMedicaid,andadaptBuurtzorgNederlandsinformationtechnologysystemfor
useintheU.S.
BuurtzorgUSAfacesseveralchallenges,includingtheneedtodevelopareferralnetworksinceitdoesnot
haveabuiltinsourceofreferrals,asmightasubsidiaryofahospitalsystem.Accordingtotheorganizations
director,MichelleMichels,effortstobuildawarenessthroughoutreachtochurchesandsocialservices
organizationsarebeginningtopayoff.MichelsisoptimisticthatBuurtzorgUSAcanattractpatientsandbuild
aworkforceofnursestoprovidethefullrangeofinhomeservices.
Themajorchallengetheorganizationfacesistheneedtodealwithmultiplepayers,eachwithitsown
paymentrulesandprocedures.ThiswillmakeitdifficultfornursestofollowtheapproachoftheDutch
Buurtzorgnurses,whodotheirownbilling.IttooktheDutchBuurtzorgseveralyearstonegotiateaflatper
hourpaymentmethodforitsservicesdoingsointheU.S.wouldrequirebothMedicaidandMedicare
waivers.
SurmountingsuchchallengesmayhavebeenlessdauntingifBuurtzorgUSAwerepartofanother
organization,suchasahealthsystemorvisitingnurseservice.ButDeBlokchosetocreatehisorganization
fromthegroundup,ratherthantryingtochangethecultureofanexistingorganization.Hesays,however,
thatspreadingBuurtzorgthroughafranchisingapproachmayalsobefeasible.
BUURTZORGSFUTURE
BuurtzorgNederlandachievedsuccesswithinaparticularpolicyenvironmentandmarketplace.Itwill
certainlyfacenewcompetitivechallengesasotherprovidersadoptelementsofitsmodel.Thepayment
environmentmayalsobecomemoredifficult:in2015,costcontainmentpressuresledtheDutch
governmenttochangethepaymentsystemforhomecare,puttingtheinsurancecompaniesthroughwhich
governmentfundsflowatfinancialriskforthecostsofhomecare.Buurtzorgwouldbedisadvantaged,for
example,ifinsurancecompaniesweretobasetheircontractsonperhourratherthanpercasecosts.
Buurtzorgsabilitytoadapttosuchchangeswillbeanimportanttestofthemodelsresilience.Growthitself
mayalsoprovidechallenges,ifthenumberofBuurtzorgteamscontinuestoincreaseatamuchfasterrate
thantheheadquartersofficethatprovidesadministrativesupport.Andorganizationscreatedbya
charismaticleadereventuallyfacedifficultquestionsofsustainabilityandtransition.

BeyonditsgrowthinhomecareintheNetherlandsandabroad,theBuurtzorgselfmanagementmodelis
beingtriedindifferentkindsoforganizations,particularlythoseinwhichstaffmoraleisachronicissue,such
aslongtermcarefacilities.Ultimately,theimportanceofBuurtzorgmaylienotjustinthewholesalespread
ofthismodelbutintherecognitionofthevalueofitskeycomponents.Theseincludethecolocationofhealth
professionalsinneighborhoodsettingsandtheprovisionofcomprehensiveandcoordinatedcare.Perhaps
mostimportant,however,istheuseofselfmanagedteams.Withtheirpotentialtobringjoytowork,
autonomousworkteamsmayofferanantidotetothegrowingproblemofburnoutamonghealth
professionals.27
AppendixA.ListofInterviewees
JosdeBlok,GertjevanRoessel,ArentJanZwart
BuurtzorgNederland
OliviervanNoort
Menzies(Dutchinsurer)
DavidIkkersheim
KPMGPlexus
InekevanderVoort
DutchHealthCareInstitute
AnnoPomp
MinistryofHealth,Welfare,andSport
PetraSchout
DutchPatientandConsumerFederation
IrmaHarmelink
ZorgAccent(competinghomecareorganization)
RobDijkstra
DutchCollegeofGeneralPractitioners
GuusvanMontfortandHillieBeumer
ActiZ(tradeassociation)
MarjetvanBaggumandSanderKoopman
DutchHealthcareAuthority
MariekeJ.Schuurmans
UniversityMedicalCenterUtrecht
AbKlink
FormerMinisterofHealth,Welfare,andSport

AppendixB.PatientandNurseSatisfactionwiththeNetherlands'BuurtzorgHomeCareModel
Patientsatisfaction

Nursesatisfaction

Ina2015study,Buurtzorgpatientratingson
measurespertainingtophysicalcare,staff
quality,information,andparticipationwerein
thetop10of370homehealthagencies.1
Ina2015study,Buurtzorgranked7thof360
homehealthagenciesonwhetherpatients
saidtheywouldrecommendtheirproviderto
familyandfriends.1

BuurtzorgNederlandwasnamedthebestemployer

In2012,Buurtzorgranked1stamongall

intheNetherlandsin2010,2011,and2012by

homecareorganizationsinpatient

Effectory,aDutchcompanythatcollects,analyses,

satisfactioninthenationalqualityofcare

andusesfeedbackfromemployeesandcustomers.3

assessment.2
Patientsatisfactionwasmeasuredat9.1out
of10inastudyconductedfrom2008to
2010.3
In2009,Buurtzorghadthehighest
satisfactionratesamongpatientsanywhere
inthecountry.4

Sources:1KPMG,TheAddedValueofBuurtzorgRelativetoOtherProvidersofHomeCare:AQuantitative
AnalysisofHomeCareintheNetherlandsin2013[inDutch],Jan.20152K.Leichsenring,IntegratedCare
forOlderPeopleinEuropeLatestTrendsandPerceptions,InternationalJournalofIntegratedCare,Jan.
March201212:e73K.MonsenandJ.deBlok,BuurtzorgNederland,AmericanJournalofNursing,Aug.
2013113(8):5559and4A.J.E.deVeeretal.,ErvaringenvanBuurtzorgeclienteninlandelijkperspectief
(NIVEL,2009).
Notes
1InterviewwithJosdeBlok,February18,2015.Heprovidedadditionalinformationviaemail.
2S.S.Nandram,OrganizationalInnovationbyIntegratingSimplification:LearningfromBuurtzorgNederland

(Cham,Switzerland:Springer,2014).
3TheemployeesurveysareconductedbyEffectory,aninternationalorganizationthatconductsemployee

surveystohelporganizationsuseemployeeengagementtoimproveorganizationalperformance.
4BothtermswereusedbypeopleinterviewedinFebruary2015byauthorBradfordH.Gray.
5KPMG,TheAddedValueofBuurtzorgRelativetoOtherProvidersofHomeCare:AQuantitativeAnalysisof

HomeCareintheNetherlandsin2013[inDutch],Jan.2015.
6AsexplainedbyOliviervanNoortoftheinsurerMenzies,therearethreelevels(basic,extra,andspecial)

ofthreefunctionsnursing,personalcare,andcounselingandAIV(advice,information,andeducationfor
peoplewithdiseaseslikediabetesorCOPDwhodontneedlongtermcarebutwhodoneedafewhoursof
educationforsecondarypreventionpurposes).Basiccaretakesplaceaccordingtoaplan(e.g.,fivehoursa
weekforassistanceinbathinganddressing).Extraisforunscheduled24/7care.Specialisforcomplex
patientsthatrequiremorethanordinaryservices(e.g.,activecasemanagement).
7DuringtheyearsofBuurtzorgsgrowth,determinationsofpatientseligibilityforhomecareserviceswere

madebyindependentorganizationsrelatedtotheinsurancecompanies.Theservicesprovidedbyhome
careorganizationsoperatedwithintheconstraintsofindicationsofneede.g.,forhowmanyhoursofwhat
sortofcareoverwhatperiodoftime.
8Thelistofservicesprovidedincludespreparationofsimplemealsbutnothousekeepingsupport.SeeK.

MonsenandJ.deBlok,BuurtzorgNederland,AmericanJournalofNursing,Aug.2013113(8):5559.
9DeBloksaidinearly2015that70percentofBuurtzorgsnurseshavetheequivalentofabachelors

degreeandmostoftheothershaveatleasttwotothreeyearsoftraining.Theorganizationsemphasisona
highlytrainedworkforcedistinguishesitfromprevailingpracticesinDutchhomecare.
10TheOmahaSystemisanelectronicstandardizedtaxonomyusedforplanning,documenting,and

analyzingclientcare.Itincludesaproblemclassificationsystem(42environmental,psychosocial,
physiological,andhealthrelatedbehavioralproblems),aninterventionschemethatcoversdifferent
services,andanoutcomeratingscaleforknowledge,behavior,andhealthstatus.ItisusedbyBuurtzorg
notonlyforplanninganddocumentingcarebutalsoforbillingandanalysesofpatternsofservices.
11Coachesrelyonexperience.Therichelectronicdatatrovecreatedbynursesisnotyetbeingusedto

createalearninghealthcaresysteminwhichdataaboutservicesareanalyzedforlessonsforhealthcare
improvement.
12AccordingtoZwart,suchproblemsincludecopingwithabsencesbecauseofillness,poorperformanceof

acolleague,disagreementswithinteamsaboutsomepatientcareissue,andissuesregardingmanagement
ofteamsfinancialperformance.
13Nurseswhofallbelowthetargetof60percentoftheirtimeinayearspentonbilledforservicesare

notified.
14EmailcorrespondencewithJosdeBlok,February27,2015.
15MonsenanddeBlok,BuurtzorgNederland,2013,p.57.
16Alargestackoftransmittallettersconveyingemploymentcontractstonewnurseemployeeswasonthe

tableawaitingdeBlokssignatureonthedayGrayvisitedBuurtzorgsofficesinAlmeloinFebruary2015.De
Bloksaidthatonaveragetheorganizationhiredabout150newnursespermonth.
17ThissummarycomesfromMonsenanddeBlok,BuurtzorgNederland,2013.
18Buurtzorgwasabletomeetpatientsneedsinfarfewerhoursthanhadbeenauthorized.Seenote7.
19OneoftheseinvolvedadisputewithinsurerswhenBuurtzorg,becauseofitsrapidgrowth,exceededthe

numberofpatientcarehoursforwhichithadcontracted.Thedisputewaseventuallysettled,largelyin
Buurtzorgsfavor.
20WeweretoldthattherehadalsobeenclaimsthatBuurtzorgsrelativelylowercostsmightbebecauseof

selectionofpatientswithlightcareneeds.
21DavidIkkersheim,directoroftheKPMGstudy,alsonotedinapersonalcommunicationthatthestudys

casemixadjustment(whichincludedpatientszipcodes)accountsfordifferencesintraveltime.
22A.J.E.deVeeretal.,ErvaringenvanBuurtzorgeclienteninlandelijkperspectief(NIVEL,2009).
23TheseweretheConsumerQualityIndexbasedonasurveyconductedbienniallyforthegovernmentand

theNetPromoterScore(thepercentagewhowouldrecommendtheorganizationtoafriendminusthe
percentagewhowouldnotdoso).
24Variablesinthecasemixadjustmentincludedpatientsage,sex,zipcode,socioeconomicstatus,and

pharmaceuticalcostgroupasaproxyforhighcostconditionsincludingCOPD/severeasthma,depression,
diabetes(IandII),cardiacdisorders,HIV/AIDS,cancer,kidneydisorders,Parkinson,psychosis/Alzheimers,
addiction,rheumatism,andtransplants.
25TheMinnesotalocationgrewfromdeBloksattendanceataUniversityofMinnesotaconferenceabout

theOmahacaredocumentationsystemandthesubsequentvisittoBuurtzorgbyMinnesotaAARPsMichele

Kimball(whobecametheinitialleaderofBuurtzorgUSA)andseveralMinnesotanurses.
26InformationabouttheAmericanBuurtzorgcomesprimarilyfromtwoofthefounders,MicheleKimballand

MichelleMichels,thefirstnursehiredwhoisnowdirectoroftheorganization.
27WearegratefultoMaureenBisognanooftheInstituteforHealthcareImprovementfordiscussionofthese

points.