Quality of care for patients with chronic disease

Patients with a chronic medical condition often need care from several care providers. These care providers often work in partnership. This is called multidisciplinary care. This gives patients a single point of contact and also saves costs. Care standards have been developed for multidisciplinary care.

Chronic disease care standards

Care standards describe what good disease management means for patients with chronic disease, like diabetes, asthma or cardiovascular disease. Patient organisations and care providers develop the care standards together.

There are two versions of every care standard: one for patients and one for care professionals. The content is the same, but the patient version is written in language that is easy to understand.

Care standards and care plans

Individual care plans are based on the care standard. The individual care plan is made by the patient’s primary point of contact (often their family doctor) together with the patient. The plan outlines the patient’s care needs and the things they can do themselves. It covers things like diet, exercise and the use of medication.

Healthcare groups: multidisciplinary care for patients with chronic disease

Care standards do not say who should do what, or where care should take place. That makes it easier for care providers in a region to arrange multidisciplinary care together. That's why care providers are forming regional healthcare groups. They make agreements with insurance companies on the way they will look after chronic patients in their region. For example, doctors work together with dietitians and physiotherapists to manage patients with diabetes.

Benefits of multidisciplinary care for patients with chronic disease


The number of people with chronic disease is growing faster than the number of care professionals. That is why self-management and good communication between patients and care providers is becoming ever more important. Multidisciplinary care for patients with chronic disease has several benefits:

  • Patients get an individual care plan that is tailored to their needs.
  • Patients have a single point of contact.
  • Patients know what forms of care they will be getting.
  • Care is provided close to home, or at home.
  • Care providers consult with each other and with patients.
  • There is a lower risk of complications.
  • It drives down healthcare costs.

Funding multidisciplinary care for patients with chronic disease

Where possible, the costs of a patient's care should be bundled. This is called integrated funding. The healthcare group charges one price for the total chronic care package provided to an individual patient. This is only possible if there is a care standard for that disease.

If you are a care provider and you have a question about this method of funding, please contact the Dutch Healthcare Authority (NZA) (in Dutch).