The Rheumatism Route: integrated care and support for people with rheumatism

People with rheumatism may, in addition to their medical treatment, need support with mobility, fatigue, mental health, lifestyle and day-to-day functioning. This support is often spread across different healthcare providers, meaning that patients have to find their own way and ensure everything is coordinated. Patient interviews and working sessions revealed a need for a single point of contact, an overview of available support and a focus on learning to live with rheumatism. That is why we are developing the Rheumatism Pathway, in which care and support are organised around the patient’s personal goals and needs. Our aim is to strengthen patients’ autonomy and quality of life, reduce unnecessary or duplicated care, and improve collaboration between healthcare providers.

We are developing the Rheumatism Route based on a review of the literature, patient interviews, advisory groups and joint design sessions with patients and healthcare professionals. The Route begins with a comprehensive assessment, during which symptoms, daily functioning, personal goals and participation in work and society are examined together. An occupational therapist with additional training fulfils the role of rheumatism case manager: the designated point of contact who, together with the patient, determines what support is appropriate and ensures continuity of care. Depending on the patient’s needs, physiotherapy, occupational therapy, podiatry, psychological support and/or lifestyle coaching are utilised, with the support being adapted as needs change. Digital support and regular review meetings help to facilitate self-management and monitor progress. To implement this, we are working on clear agreements regarding referrals, the exchange of information and feedback between Rondom, GP care and rheumatology, whilst diagnostics and medication management remain the responsibility of the GP and rheumatologist.

The substantive framework of the Rheumatism Route has been developed, including the patient journey, the integrated intake, the case manager role and collaboration between different disciplines. We are now preparing for the move towards practical implementation and sustainable collaboration with other healthcare organisations. As part of this, we are working on the necessary work processes, digital infrastructure, training, collaboration agreements and evaluation. As part of the planned implementation process, a regional pilot is being prepared in which we will investigate how the Route works in practice and what patients and professionals make of it, with a focus on performance, patient autonomy, collaboration, healthcare utilisation and staffing levels. The lessons learnt should result in a practical implementation guide, training materials and tools that will enable other healthcare organisations and regional networks to adopt the approach as well.

Rheumatism, appropriate care, network-based care, interprofessional collaboration, case management, self-management, self-direction, daily functioning

Development: Rondom, together with patients, people with lived experience and healthcare professionals from the relevant disciplines.

Intended implementation partnership: Rondom, the Regional Rheumatology Centre at Máxima MC, Fontys, Saxion, the National Association for Rheumatology Care in the Netherlands (ReumaZorg Nederland) and the Dutch Health Professionals in Rheumatology (NHPR). Within this partnership, clinical expertise, research, patient participation and knowledge-sharing are brought together.

GPs from our own network are involved in co-creation, working sessions and focus groups, without being formal co-applicants.

Public publications, reports and presentations on the development, implementation and evaluation will be added here as soon as they become available.