Integrative Rheumatology Care Program

The idea of integrative care programs isn’t new. Such programs should promote networks across sectors in health care (primary care physicians, specialists, hospitals) to improve the quality of patient care and to reduce health costs at the same time. It took decades until legislation formed the guiding laws to enable interested health care providers to build such programs and networks.

We’re in the 9th year with our Integrative Rheumatology Care Program. We are the Rheinisches Rheuma Zentrum, Inoges (Rehab facilities, physical and occupational therapy), the health insurance company BARMER/GEK, general practitioners of the region, and of course our patients. We developed a unique model of integrated care for all inflammatory rheumatic joint diseases. The result of our treatment are above average patient satisfaction and show excellent treatment results. We were one of the first clinics in Germany implementing such a program. Patients are treated the entire duration of illness in out-patient , day-clinic as well as in-patient or rehabilitation settings, always the one that is appropriate to disease activity and severity. So far about 700 patients have or still are being treated in our Integrative Rheumatology Care Program. Involved are also more than 230 practicing physicians as cooperation partners, who were all trained in the Rheinisches Rheuma Zentrum. The program already has offsprings at other locations.

A Case Manager (or Rheumatology Care Coordinator) is available on a hot-line for patients looking after quick first appointments and follow-ups, aids, rehab coordination and so on. Important is the involvement of GPs, who fax a screening questionnaire of patients and forwarding these patients to our out-patient clinic. It is only after verifying the diagnosis that patients enter the program.

The program has no restrictions as to drugs. Maybe it’s due to the fact that DAS28, HAQ, BASDAI, RADAI, and other tools are implemented to guide therapy decisions. Maybe the better care keeps the costs down; we hope to publish data on this together with the University of Duesseldorf.

All in all, we're happy with this program and hope that other insurance companies join us.

Typical screening questionnaire for GPs.

Flowchart on how patients enter the program  

Links: 
More on Integrated Care on Wikipedia: 
http://en.wikipedia.org/wiki/Integrated_care

The German text on Wikipedia is better, try to read it by machine translation: http://de.wikipedia.org/wiki/Integrierte_Versorgung

Rheinisches Rheuma Zentrum / Integrierte Versorgung (German text): http://www.rrz-meerbusch.de/de/kompetenzen/medizinische-kompetenzen/innere-medizinrheumatologie/integrierte-versorgung.html