Interview with the management of De Voordeur

40,000 patients, 4000 employees, 70 locations and yet: only one Front Door. Eight years ago, mental health institution Arkin decided to arrange the registration of new clients centrally from now on, instead of per specialism. Since then, Arkin's De Voordeur has fulfilled a broad bridging function from outside the mental health care to the inside, which meets the needs of (potential) patients, practitioners and general practitioners. At the time, this was radically innovative, but now it is a fixed agreement within the Integral Care Agreement. Directors Gertrude van Nederpelt and Jurgen Cornelis talk about 'their' Front Door and what goes on in front of and behind it.

From fax to front door

It was one of those statements that stays with you. Who just like that, in all its simplicity, painfully presses the finger on the sore spot. Eight years ago, registering new clients still worked by fax, Gertrude van Nederpelt recalls. Now she is director of operations at the Voordeur, when she worked as a policy advisor for the Board of Directors (BoD). "I received signals from both within and outside the organization that our registration process was outdated. GPs just had to know which specialism they wanted to register their client with, so that could only be arranged by fax. One of the GPs said to me: 'And then I'll send that fax, and then I'll pray.' It came in."

So let's get to work: find out how it could be improved. In the first place, a solution had to be found for the fragmentation, no longer through all those different counters. And ideally, mental health specialists would think along at the front end about which part could best help a client. This is how Arkin's Central Registration (CAA) was created, where a team of practitioners from all parts advise general practitioners, triage referrals and offer consultations.

"Moreover, the GPs indicated that they would like to remain involved with the client they had registered: when was the intake, what was the treatment plan, were medicines prescribed? Believe it or not, but that was a real eye-opener for us at the time." What was also centralized a little later: the distribution of clients over the various clinics. This is what the Central Bureau for Placement (CBP) came for, where it is checked which beds become available and by whom they can best be occupied again.

Across the border

To further strengthen the bond with the general practitioners, the third branch of De Voordeur was created: the mental health nurse practitioners (POH-GGZ) who assist general practitioners from all over Amsterdam from Arkin. They help and advise them on the care of psychiatric patients and offer support and treatments to people with various psychological or psychosocial complaints – such as burnout or relationship problems. The fourth and final part of the Front Door became Prevention. Think of lifestyle training, support groups or peer groups. After all, a front door has a double function: not only to allow people in, but also to keep people out if there is
is a better alternative for them outside mental health care.

"It is a wide range: from prevention to admission to a clinic," says Gertrude. "But I do see that we can achieve a lot by combining these four branches. We can be there for everyone: from people with minor complaints to clients who need specialist care, from their loved ones to general practitioners and practitioners."

And that broad view also translates into the help that the Front Door wants to offer, notes director of treatment affairs Jurgen Cornelis. "The mental health care system thinks very much from a medical perspective, but that is actually too limited. When I started in this position for six months of reading, I shadowed colleagues from the CAA and the CBP for a while. I was very impressed by what I found: people listened with so much attention and thought along so broadly. They look not only beyond the boundaries of their own specialism, but also beyond the boundaries of psychiatry. The CAA asks: what is going on besides your psychological problems? And what is most important to you? That broadening is already there. Stress about money or relationship problems cannot simply be seen separately from their mental complaints."

Better and more targeted

Ideally, both directors would like to further embed this working method within the Front Door. Gertrude: "That screening for social issues and lifestyle aspects becomes a permanent part of the route that a client goes through. That it is requested as standard and that help is then used as standard." But we are not there yet – anyone with any knowledge of mental health care knows how complicated it is to arrange money flows and responsibility. Moreover, there is also an ethical consideration: "Of course, the approach must also be client-friendly. In such a first, telephone conversation, can you immediately ask if someone often finds reminders on the mat or sometimes argues at work? Not everyone wants to share that just like that. So we have to find a good form for that."

Nevertheless, the desire for such a broad approach is as strong as ever. This has to do not only with offering better help, but also with more targeted help. Everyone who needs mental health care should be able to get it quickly and appropriately, and at the same time it is also good to focus on who really needs it. If successful, it will not only be beneficial for the clients involved, but it will also have a positive impact on the waiting lists and the workload for practitioners.

Top fit at the start

"Within Arkin, we are exploring how we can help clients who are waiting for treatment to prepare for it as well as possible," says Jurgen. "We know from research that a healthy lifestyle – with attention to better food, sufficient sleep and more exercise – can already have a lot of effect on your mental well-being. By involving a lifestyle coach in the intake and offering guidance for a few weeks, it appears that up to 30 percent of the applicants no longer need treatment: they have already recovered sufficiently."

Even those who do move on to mental health care benefit greatly from such a process. "That's just like with surgery, you want to start in top shape. This increases the chances of success and may shorten the treatment time." On the one hand, lifestyle coaching can relieve the pressure on the waiting lists a bit, on the other hand, clients who insist on it spend the waiting time usefully. But here too, the organization of offering this guidance as standard has quite a few snags. "Because who should initiate it, who should pay for it and who should organize it?"

Incidentally, Jurgen nuances, it is not certain that this 30 percent lighting would be achievable everywhere. "It has a lot of results especially in relatively milder mental health care. For Mentrum, for example, the results would probably be different again." And it is a harsh reality that not all problems can be solved with psychiatric treatment, lifestyle training or another form of social help. "Certainly not here in Amsterdam. It remains difficult to find a good home, there is always a lot of chaos and noise around you. We cannot just take away financial worries from everyone. And people also have to learn more to be able to tolerate dissatisfaction. Strengthening social cohesion - family, friends, neighbours - can help with this."

Out of the box thinking

Yet that does not detract from the will to continue to develop that broader view. "I sincerely think that a larger group of people can receive better care, more tailor-made. By looking at the problems as a whole, you also see people in their totality – and so someone becomes less of a mental health patient." In general, we should think less in boxes in mental health care, he believes. "Mental problems often go hand in hand with other problems. If someone becomes gloomy or has a constant restlessness in their head, should we always label it as a psychiatric illness and treat it as such? Or should we first investigate the underlying problems and provide appropriate guidance? You don't always have to label to come up with the best approach. It's about the quality of life that we can help our clients find, with a focus on what is possible, instead of a focus on the disease."

Involving loved ones is extremely important in this. "They have the know-how about who someone is outside of their complaints. What is someone's strength, and the power of their environment? That is very valuable knowledge for me. Moreover, as a practitioner, I only play a temporary role. They will soon have to continue together and then it is good to look together at how that can best be done and how they can best support each other."

The IZA for

In fact, everyone must stand together around the client: practitioners, relatives and the social domain. Such an integrated approach is also literally described in the Integral Care Agreement of 2022. "That felt like a confirmation to us that we are on the right track, yes," says Gertrude. "Everything we focused on eight years ago, what is there now and what we are still developing, is also in the IZA. It also felt very natural and logical when I read it. Or at least, in almost every way."

Because at the 'mental health center' that the IZA is focusing on, they have a few caveats at the Front Door. "It should be a building where people with mental health problems can easily step in. But that feels like an extra step in the process is being added between the general practitioners and the mental health care, and that doesn't help anyone. Actually, all structures are already in place, but they are not united in a physical building: broad screening, consultation, triage and good cooperation between general practitioner, POH GGZ, prevention, social domain and mental health care. But we still have to reinforce that together, the pieces of the puzzle have not yet been properly put in place in all places. We are working that. How that works best varies greatly from region to region. By wanting to wring it into a fixed form, you only make it more complicated."

Jurgen and Gertrude are very proud of what De Voordeur has to offer at the moment. Jurgen: "By pulling it all together and centralizing it, we can really help everyone better. Here we have the overview: what is possible to help people, where can they go if they need mental health care, and for existing clients: where can they be admitted if necessary? With our expertise, we can help clients and general practitioners find their way within and also outside our organization." "We actually want to offer all the advantages of a large organization, but with the feeling of a practice on the corner," Gertrude adds. "All the expertise, but also the proximity." The work of De Voordeur consists of four pillars:

• Prevention, where people with questions or mild symptoms can go for advice and low-threshold preventive programs.
• The central registration, where new clients of Arkin's various specialties are received.
• The central placement office, where clients who need a place within one of our clinics are helped.
• The POH-GGZ, where general practitioners can make use of our expertise with the deployment of a practice nurse.

Within Arkin, we work triadically where possible, that is, in the triangle between practitioner, client and their loved ones. It is known that mental health care is more effective if the client's environment is also involved in the treatment. In addition, we also offer direct help to the loved ones, to support them in their care and to prevent them from developing psychological problems themselves.