zorgteams

Zorgteams are multidisciplinary care teams used in Dutch-speaking health and social care settings to coordinate and deliver comprehensive, patient-centered services. They bring together professionals from different disciplines to manage complex or chronic health and social needs, aiming to ensure seamless care across settings and reduce fragmentation.

A typical zorgteam includes professionals such as nurses or nurse practitioners, physicians or general practitioners, social workers, physiotherapists or occupational therapists, pharmacists, and sometimes psychologists or mental health workers. Roles and responsibilities are usually defined in a shared care plan that states goals, tasks, and communication procedures. Teams often operate with access to a common electronic health record and participate in regular case conferences or rounds to review progress and adjust plans.

Operations and methods commonly involve coordinated care planning, regular meetings, home visits, and close collaboration with patients and family members. The emphasis is on patient-centered goals, self-management support, and proactive problem solving. In many systems, zorgteams operate across settings—primary care, hospitals, community or home-based care, and long-term or palliative care—to ensure continuity of care.

Benefits frequently cited include improved care coordination, better alignment of services, higher patient satisfaction, and reduced hospital admissions or readmissions. Challenges can include funding and reimbursement structures, data sharing and privacy concerns, role clarity, workload management, and the need for ongoing interprofessional training.

Zorgteams reflect broader movements toward integrated care and coordinated service delivery in Europe, where similar concepts are described as multidisciplinary or integrated care teams in various local contexts.