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
