HOW IT WORKS
The BSiN model relies on a coordinating case manager to integrate health care and social services. A referral may be made after administration of a validated, structured needs assessment using the Self-Sufficiency Matrix (SSM). Eleven factors are evaluated, including finances, housing, personal relationships, social network, mental and physical health, and addictions. Individuals with high SSM scores are triaged by a team of health and social services providers to determine the types of support needed, from home care and supportive housing to social and financial support. Case managers meet with each client to craft an individual care plan, informed by needs identified by the triage team, and contacts all relevant service providers. They also coach clients and caregivers on self-sufficiency and self-management. The SSM assessment is repeated after three months and again after six months, the latter assessment determining whether the patient is self-sufficient or needs additional support. A web-based information system supports enrollment and care delivery.
Launched as a pilot in 2013, the program has been scaled up across north Amsterdam over the last few years. BSiN is being evaluated by an external organization. The program will be evaluated along with other European programs using standardized metrics and a common research design as part of SELFIE (Sustainable Integrated Care Models for Multi-morbidity: Delivery, Financing and Performance) a Horizon2020 EU project.
The structured web-based enrollment system allows both health and social care providers to refer potential clients and affords access to managed, needs-based, coordinated, and integrated health and social care. The referring provider can follow progress through the system portal. However, this information and communication technology (ICT) system was not developed to exchange information between the referring provider and clients. Providers work closely with the case manager, who works directly with the patient and all relevant providers on the individualized health and social care plan.
Rather than trying to coordinate services themselves, the patient and caregiver work closely with a case manager on an individualized health and social care plan. This detailed planning process takes place over the program’s first four weeks and sets clear patient-centered goals.
The program is run by an alliance of 12 primary care providers (general practitioners), secondary health care (hospitals), mental health, welfare (debt services case managers and social workers) and social security (municipality “return-to-work” coordinators, home care and youth care). In addition to care providers, three other entities involved with BSiN provide advice and financial support: the health insurer Zilveren Kruis Achmea, the municipality of Amsterdam and the Netherlands research organization TNO.
At the outset, structural financing was arranged through the predominant health insurer in the region, Zilveren Kruis Achmea, and through the municipality of Amsterdam. As the project has matured, the financing partners are working on long-term contracts.