The Regional Platform is a collaborative network of care providers in North Holland North and Zaanstreek-Waterland. Together, they sought a solution to the fragmented care surrounding COPD patients.
COPD is one of the most common chronic lung conditions among older adults. It requires intensive and often long-term support. General practitioners, hospitals and elderly care organisations each deliver part of the care, but coordination is often lacking. As a result, patients face duplicate appointments, confusion and poor handovers between professionals.
Improved prevention through collaboration
COPD patients offer a clear opportunity to reduce hospital admissions. With timely detection and effective information sharing, early intervention can prevent exacerbations. This eases pressure on scarce staff and avoids unnecessary costs from unplanned hospital stays and inefficient care processes.
The central question posed by the Regional Platform was: how can we organise COPD care so that patients gain more control, care providers collaborate more efficiently, and costly, burdensome hospital admissions are minimised?
The Solution
In collaboration with Conclusion (delivery was led by Morgens Conclusion), Luscii and care service centre Altide, the Regional Platform developed a digital, transmural COPD care pathway. The aim of the project was to demonstrate that a digital pathway, supported by a care service centre, leads to more efficient care. It also sought to establish a model for transmural collaboration and use this pathway as a springboard for transforming other care pathways.
The most significant change introduced by the COPD pathway is that patients now carry out measurements at home, enabling care providers to intervene early and prevent hospital admissions. The care service centre plays a coordinating role in this process.
Results
The project delivered three tangible outcomes:
Strengthened collaboration Care organisations in the region joined forces to shape the pathway. People, processes and technology came together during the design phase. Joint design sessions fostered trust and led to agreements on collaboration at all levels.
Successful proof of concept The pathway proved technically and functionally feasible. This enabled implementation to begin, and the first patients have now been enrolled.
Future-proof foundation The COPD pathway now serves as a blueprint for other conditions. Programmes for hypertension and type 2 diabetes are already underway.
The Regional Platform does not view this project as a standalone initiative, but as part of a broader, sustainable movement towards structural transformation of care pathways and deeper collaboration.
The project demonstrates that digital care pathways contribute to better cooperation, greater patient autonomy and more efficient use of scarce healthcare professionals. It directly addresses key challenges in healthcare: affordability, efficient deployment of staff, and regional collaboration.
Care partner
Regional Platform
The Regional Platform is a collaborative network of hospitals, general practitioners organisations and elderly care providers (ECP) in the regions of North Holland North and Zaanstreek-Waterland. It comprises three hospitals, four general practitioners organisations and five ECP organisations, working together to future-proof healthcare in these areas. Through joint projects and knowledge sharing, the platform aims to build a sustainable and accessible care infrastructure for the approximately 40,000 vulnerable older adults in its catchment area.
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