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Bert Vrijhoef

2008-09 Harkness Fellow Director of Research Department of Integrated Care University Medical Hospital Maastrich Associate Professor Department of Health Care and Nursing Science Maastricht University

Harkness Project Title: Responding to the Burden of Chronic Disease: Development of a Framework to Minimize Unwanted Fragmentation of Chronic Care

Mentor: Edward Wagner, M.D.

Placement: Group Health Cooperative of Puget Sound

Biography at time of Harkness Fellowship: Bert Vrijhoef, Ph.D., a 2008–09 Commonwealth Fund Harkness Fellow in Health Care Policy and Practice, is director of research at the University Medical Hospital Maastricht's Department of Integrated Care, as well as associate professor at Maastricht University's Department of Health Care and Nursing Science. In addition, he is leading a new research program, "Redesigning Health Care," at the Maastricht Care and Public Health Research Institute, and is a board member of the International Disease Management Association. Vrijhoef has previously worked as program director of Master Health Care Studies and is program director of Master Health Services Innovation at Maastricht University. Vrijhoef's research focus is on innovations in health services for long-term conditions as part of care-coordination interventions, and he has authored over 50 peer-reviewed journal articles, with publications in the International Journal of Health Care Quality, British Medical Journal, International Journal of Technology Assessment in Health Care, Diabetic Medicine, and Journal of Clinical Epidemiology. In 2007, he was awarded Leading Researcher in Faculty of Health Sciences, and he has previously received awards from the Federation of Patients and Consumer Organizations in the Netherlands and the Dutch National Organization for Health Research and Development. Vrijhoef holds a Ph.D. from Maastricht University, and a M.Sc. from Erasmus University Rotterdam.


Project: Bert Vrijoef aimed to clarify the consequences and drivers of fragmentation of chronic care, to identify strategies to minimize unwanted fragmentation, and to identify measures to assess the impact of such strategies.  The study consisted of two phases. In phase I, he conducted semi-structured interviews with an international group of experts on chronic care fragmentation.  In phase II, he used a Delphi technique among experts to analyze a conceptual set of measures of fragmentation.

Career Activity Since Fellowship

  • Professor, Health Systems and Policy, National University of Singapore, 2012
  • Member, Advisory Commission on Bundled Payment System for Chronic Care, Ministry of Health, Welfare, and Sport, Netherlands, 2010
  • Professor in Chronic Care, Tilburg University, 2009
  • Visiting Professor, National University of Singapore, 2009

Current Position: (updated 01/2017)

  • Chief Innovation Officer, PANAXEA 
  • Principal Investigator, Maastricht University Medical Center and Tillburg University 
  • Honorary Visiting Professor, Vrije Universiteit Brussels 
  • Editor-in-Chief of the International Journal of Care Coordination

E-mail: [email protected]

Selected Publications

Garschagen A, Steegers MA, van Bergen AH, Jochijms JA, Skrabanja TL, Vrijhoef  HJ, Smeets RJ, Vissers KC. Is There a Need for Including Spiritual Care in Interdisciplinary Rehabilitation of Chronic Pain Patients? Investigating an Innovative Strategy. Pain Pract. 2014 Sep 17. 

Khoo HS, Lim YW, Vrijhoef HJ. Primary healthcare system and practice characteristics in Singapore. Asia Pac Fam Med. 2014 Jul 19;13(1):8

Wang P, Tai ES, Thumboo J, Vrijhoef HJ, Luo N. Does diabetes have an impact on health-state utility? a study of Asians in Singapore. Patient. 2014;7(3):329-37.  

Stijnen MM, Van Hoof MS, Wijnands-Hoekstra IY, Guldemond-Hecker Y, Duimel-Peeters IG, Vrijhoef HJ, Jansen MW. Detected health and well-being problems following comprehensive geriatric assessment during a home visit among community-dwelling older people: who benefits most? Fam Pract. 2014 Jun;31(3):333-40.

van Leijen-Zeelenberg JE, van Raak AJ, Duimel-Peeters IG, Kroese ME, Brink PR,Ruwaard D, Vrijhoef HJ. Barriers to implementation of a redesign of information transfer and feedback in acute care: results from a multiple case study. BMC Health Serv Res. 2014 Apr 3;14:149.

De Bruijn-Geraets DP, Van Eijk-Hustings YJ, Vrijhoef HJ. Evaluating newly acquired authority of nurse practitioners and physician assistants for reserved medical procedures in the Netherlands: a study protocol. J Adv Nurs. 2014 Mar 31.

Peek ST, Wouters EJ, van Hoof J, Luijkx KG, Boeije HR, Vrijhoef HJ. Factors influencing acceptance of technology for aging in place: A systematic review. Int J Med Inform. 2014 Apr;83(4):235-248.


Luo N, Wang P, Thumboo J, Lim YW, Vrijhoef HJ. Valuation of EQ-5D-3L Health States in Singapore: Modeling of Time Trade-Off Values for 80 Empirically Observed Health States. Pharmacoeconomics. 2014 Feb 12.

Grustam AS, Severens JL, van Nijnatten J, Koymans R, Vrijhoef HJ. COST-EFFECTIVENESS OF TELEHEALTH INTERVENTIONS FOR CHRONIC HEART FAILURE PATIENTS: A LITERATURE REVIEW. Int J Technol Assess Health Care. 2014 Feb 4:1-10.

Boyne JJ, Van Asselt AD, Gorgels AP, Steuten LM, De Weerd G, Kragten J, Vrijhoef HJ. Cost-effectiveness analysis of telemonitoring versus usual care in patients with heart failure: the TEHAF-study. J Telemed Telecare. 2013 Jul;19(5):242-8.

Hendriks JM, Vrijhoef HJ, Crijns HJ, Brunner-La Rocca HP. The effect of a nurse-led integrated chronic care approach on quality of life in patients with  atrial fibrillation. Europace. 2013 Sep 20.

Boyne JJ, Vrijhoef HJ. Implementing telemonitoring in heart failure care: barriers from the perspectives of patients, healthcare professionals and healthcare organizations. Curr Heart Fail Rep. 2013 Sep;10(3):254-61.

Boyne JJ, Vrijhoef HJ, Spreeuwenberg M, De Weerd G, Kragten J, Gorgels AP; on  behalf of the TEHAF investigators. Effects of tailored telemonitoring on heart failure patients' knowledge, self-care, self-efficacy and adherence: A randomized controlled trial. Eur J Cardiovasc Nurs. 2013 Apr 29.

Elissen AM, Adams JL, Spreeuwenberg M, Duimel-Peeters IG, Spreeuwenberg C, Linden A, Vrijhoef HJ. Advancing current approaches to disease management evaluation: capitalizing on heterogeneity to understand what works and for whom.  BMC Med Res Methodol. 2013 Mar 14;13:40.

Stijnen MM, Duimel-Peeters IG, Jansen MW, Vrijhoef HJ. Early detection of health problems in potentially frail community-dwelling older people by general practices--project [G]OLD: design of a longitudinal, quasi-experimental study. BMC Geriatr. 2013 Jan 18;13:7.

Dukers-Muijrers NH, Somers C, Hoebe CJ, Lowe SH, Niekamp AM, Oude Lashof A, Bruggeman CA, Vrijhoef HJ. Improving sexual health for HIV patients by providing  a combination of integrated public health and hospital care services; a one-group pre- and post test intervention comparison. BMC Public Health. 2012 Dec 27;12:1118.

Hendriks JM, Crijns HJ, Tieleman RG, Vrijhoef HJ. The atrial fibrillation knowledge scale: development, validation and results. Int J Cardiol. 2013 Sep 30;168(2):1422-8.

Elissen AM, Duimel-Peeters IG, Spreeuwenberg C, Spreeuwenberg M, Vrijhoef HJ. Toward tailored disease management for type 2 diabetes. Am J Manag Care. 2012 Oct;18(10):619-30.

Hendriks JM, de Wit R, Crijns HJ, Vrijhoef HJ, Prins MH, Pisters R, Pison LA, Blaauw Y, Tieleman RG. Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation. Eur Heart J. 2012 Nov;33(21):2692-9.

Drewes HW, Steuten LM, Lemmens LC, Baan CA, Boshuizen HC, Elissen AM, Lemmens KM, Meeuwissen JA, Vrijhoef HJ. “The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes.” Health Serv Res. 2012 Oct;47(5):1926-59.

Wijers N, Schoonhoven L, Giesen PH, Vrijhoef HJ, van der Burgt R, Mintjes J, Wensing MJ, Laurant MG. “The effectiveness of Nurse Practitioners working at a GP cooperative: a study protocol.” BMC Fam Pract. 2012 Aug 7;13(1):75.

Boyne JJ, Vrijhoef HJ, Crijns HJ, De Weerd G, Kragten J, Gorgels AP; TEHAF investigators. “Tailored telemonitoring in patients with heart failure: results of a multicentre randomized controlled trial.” Eur J Heart Fail. 2012 Jul;14(7):791-801.

Voogdt-Pruis HR, Vrijhoef HJ, Beusmans GH, Gorgels AP. “Quality improvement of nurse-led aftercare to outpatients with coronary heart disease: report of a case study.” Int J Qual Health Care. 2012 Jun;24(3):286-92.

Hendriks JM, de Wit R, Crijns HJ, Vrijhoef HJ, Prins MH, Pisters R, Pison LA, Blaauw Y, Tieleman RG. “Nurse-led care vs. usual care for patients with atrial fibrillation: results of a randomized trial of integrated chronic care vs. routine clinical care in ambulatory patients with atrial fibrillation.” Eur Heart  J. 2012 Mar 27.

Elissen AM, Steuten LM, Lemmens LC, Drewes HW, Lemmens KM, Meeuwissen JA, Baan CA, Vrijhoef HJ. “Meta-analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes.” J Eval Clin Pract. 2012 Feb 29.

De Bakker DH, Struijs JN, Baan CB, Raams J, de Wildt JE, Vrijhoef HJM, Schut FT. “Early Results from Adoption of Bundled Payment for Diabetes Care in the Netherlands Show Improvement in Care Coordination.” Health Affairs. February 2012.

Nolte E, Knai C, Hofmarcher M, Conklin A, Erler A, Elissen A, Flamm M, Fullerton B, Sönnichsen A, Vrijhoef HJ. “Overcoming fragmentation in health care: chronic care in Austria, Germany and The Netherlands.” Health Econ Policy Law. 2012 Jan;7(1):125-46.

Erler A, Bodenheimer T, Baker R, Goodwin N, Spreeuwenberg C, Vrijhoef B, Nolte E, Gerlach FM. “Preparing primary care for the future – perspectives from the Netherlands, England, and USA.” Z Evid Fortbild Qual Gesundh. Wesen (German Journal for Evidence and Quality in Health Care). 2011.

Gress S, Baan CA, Calnan M, Dedeu T, Groenewegen P, Howson H, Maroy L, Nolte E, Redaèlli M, Saarelma O, Schmacke N, Schumacher K, van Lente EJ, Vrijhoef B. “Co-ordination and management of chronic conditions in Europe: the role of primary care--position paper of the European Forum for Primary Care.” Qual Prim Care. 2009;17(1):75-86.