>> „From pilot project to showcase model: IGiB-StimMT in Templin sets a precedent for outpatient and inpatient care,“ the Brandenburg Ministry of Social Affairs, Health, Integration and Consumer Protection proudly announced in a press release (1) following the positive G-BA decision. „Templin is setting the course for future-proof outpatient and inpatient healthcare,“ added Health Minister Ursula Nonnemacher at the opening ceremony of the ASZ (Association of Statutory Health Insurance Physicians).
The Templin structural migration project received a total of approximately €14.5 million in funding from the Innovation Committee over four years. An additional €10 million in funding from the Hospital Structure Fund was provided for the necessary renovations to the recently opened outpatient-inpatient center (ASZ) at the Sana Hospital Templin. Of this amount, €501,000 each came from state funds and the liquidity reserve of the Health Fund. Nonnemacher continued: "IGiB-StimMT is now known throughout Germany and officially serves as a blueprint for sustainable medical care in rural regions – we are very proud of this." She explained that demographic changes, particularly in rural areas, pose significant challenges for hospitals and general practitioners, requiring new approaches. "Cooperation with outpatient care is playing an increasingly important role in this. Templin demonstrates how it can be done," the Brandenburg Minister of Health stated (see also MVF 06/20 (2)).
Since the Innovation Committee has passed a positive resolution on the IGiB-StimMT project, the "success and nationwide model character for a lighthouse project made in Brandenburg" has been confirmed.
„Based on the decision reached, all key players in the German healthcare system are called upon to examine how the approaches developed and implemented in Templin can be used to improve medical care in rural, structurally weak regions,“ the minister added.
This makes it clear that there will be neither a general 1:1 implementation of the positively evaluated project, nor a simple and rapid transfer of the findings into standard care, however positive they may be. This becomes more than clear when one reads the introductory passages in the resolution (3) of the Innovation Committee of the Federal Joint Committee pursuant to Section 92b Paragraph 3 of the German Social Code, Book V (SGB V), concerning the completed IGiB-StimMT project (01NVF16001), which, while recommending the transfer of approaches from the new form of care into standard care based on the results, also explains:
a) The findings obtained in the project will be forwarded to the self-governing bodies in the healthcare sector – the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband), the German Hospital Federation (Dt. Krankenhausgesellschaft), the National Association of Statutory Health Insurance Dentists (KZBV), and the National Association of Statutory Health Insurance Physicians (KBV) (the body responsible for the Federal Joint Committee (G-BA)). These institutions and/or their members will be asked to examine to what extent approaches from the new model of care can contribute to the further development of needs-based care in rural and/or structurally weak regions.
The project will examine how these resources can be used and to what extent this can be done within a uniform framework across Germany. Additionally, the findings of the project will be forwarded to the state ministries of health and social affairs, as well as the Federal Association of Local Authorities.
b) The findings obtained in the project will be forwarded to the Federal Ministry of Health (BMG). The BMG will be asked to examine whether legal adjustments can be proposed within the framework of legislative procedures to facilitate the implementation of needs-based, locally accessible, and cross-sectoral care approaches in rural and/or structurally weak regions.
In its resolution, the Innovation Committee also explains why it is imposing this limitation. Overall, the project demonstrated that adapting healthcare structures to meet demand is possible with the involvement of all relevant stakeholders. However, the diversity of challenges involved in complex healthcare reforms also became evident. The resolution states: „Implementation experience showed that an iterative approach is necessary and that solutions can only be implemented by adapting them to specific regional circumstances. During the course of the project, several approaches and care modules had to be adapted or even discarded. Other approaches proved to be unfeasible within the project scope.“
Therefore, the clause under point a), which states that "findings are to be forwarded to the state ministries of health and social affairs as well as the Federal Association of Local Authorities," is likely to be of particular importance in this resolution. While it may well be argued, at least to some extent (from a regulatory policy perspective), that health/healthcare is a local/regional good, one could equally assume that the "changes suggested" by the project, in the view of the Innovation Committee and consequently also the G-BA (Federal Joint Committee), should inherently have a "municipal" aspect. In any case, this encourages the project results to be made known to the Association of Cities and Towns, and thus ultimately to all district administrators and mayors facing similar challenges.
It should also be noted that the new care model evaluated in Templin consisted of five sub-projects, four of which were successfully integrated into the existing care structure. The central focus was the restructuring of the Sana Hospital Templin into an outpatient-inpatient center (ASZ) with a broad range of services that were more closely aligned with the regional needs of patients.
Within this framework – the resolution continues – a medical on-call practice (ÄBP), a Decision Unit (DU), and a Coordination and Advisory Center (KBZ) have been established, all located at the Sana Hospital Templin. In addition, cross-sectoral treatment pathways for heart failure, back pain, and obesity, as well as structured urinary incontinence care, have been implemented.
According to the resolution, the evaluation positively assessed the counselling services at the KBZ (Cultural and Social Services Center) and the case management, as well as the ÄBP (Medical and Social Care Program) and the DU (Disability Support Unit). Furthermore, the low-threshold, inter-agency counselling services at the KBZ and the case management for care coordination were consistently rated positively by all stakeholders surveyed and, particularly in light of demographic trends, were seen as a sensible addition to and further development of basic care in the Templin area.
Ultimately, the resolution states, the project succeeded in implementing a new form of care with selected care modules, the approaches of which could make a meaningful contribution to shaping needs-based care. Accordingly, the project results were forwarded to the self-governing bodies in the healthcare sector and the state ministries of health and social affairs, who now have the power to decide how to proceed with the results. However, they are not obligated to do so, since – as Dr. Thomas Ruppel and Prof. Dr. Neeltje van den Berg explained in a scientific article in the MVF – „the transition of research projects into standard care is currently not subject to effective legal protection“ (4).

This is likely one reason why the Federal Ministry of Health (BMG) is asked in the resolution to create a "secure, nationwide, uniform legal basis" for the implementation of similar needs-based, locally based, and cross-sectoral care approaches in rural and/or structurally weak regions that cannot be provided within the usual structures of standard care and, if applicable, not through existing selective contracting arrangements. The BMG is also to examine whether legal adjustments can be proposed within the framework of legislative procedures to facilitate the implementation of needs-based, locally based, and cross-sectoral care approaches in rural and/or structurally weak regions.
So far, only one federal state plans to do this – as of today. According to the revised Lower Saxony Hospital Act, „Regional Health Centers“ (5) are to be established, which are intended to serve as „central regional points of contact for patients as an alternative form of care to ensure local medical care for the population, in which various service providers can pursue their activities in an interdisciplinary and interprofessional manner“ – thus closely following the Templin model.

This state policy declaration closely follows the conclusions of the evaluator of the structural migration project in the Templin region, Berlin-based inav GmbH. In their nearly 300-page report (6), excluding appendices, the authors write that ensuring comprehensive healthcare coverage in rural areas must increasingly be seen as a challenge. For example, for several years now, vacant physician positions have sometimes been impossible to fill, or only possible with great difficulty, and local hospitals are frequently operating at a loss. According to the evaluators, this presents "various stakeholders – from municipalities and districts to health insurance funds and associations of statutory health insurance physicians – with the task of developing and testing new concepts." A particular focus is on the challenge of better integrating outpatient and inpatient care services and promoting interprofessional collaboration among the various professional groups involved in care, based on their qualifications, strengths, and potential. This was precisely the goal of the Innovation Fund project IGiB-StimMT, which developed and implemented diverse solution strategies for these complex challenges.
According to the authors, this is "a prototype of a complex intervention" with the corresponding evaluative challenges and limitations of being able to attribute causes and effects. Against this backdrop, a mixed-methods approach with quantitative and qualitative research is indispensable, and the interpretation of results—in every direction—requires thorough further examination and evaluation. Furthermore, it is "more of an experiment" from which "no simple, monocausal conclusions can be drawn." Moreover, "a simple evaluation of individual modules would not do justice to the complexity of the overall project." In particular, the evaluators believe that the concept of the ABP (Agency for Health Promotion) is "excellently suited as a blueprint" for other regions facing similar structural challenges. Transferring it to other healthcare settings also appears plausible. For example, on-call medical practices in urban districts with a high proportion of residents with a migration background could also lead to more efficient care, since the use of emergency rooms is particularly high in these districts due to cultural factors.
The concept of the DU (Departmental Unit) could also serve as a blueprint for implementation at other locations. This applies particularly – but not exclusively – to underserved regions with long travel distances to the nearest hospital. Furthermore, in the current pandemic situation, DUs could make a significant contribution to relieving the burden on staffing levels in hospitals.
Overall, the Innovation Fund project IGiB-StimMT is praised for having highlighted the potential and challenges of complex structural migration and for having been able to point to a multitude of concrete positive effects on healthcare provision, which are presented in detail in the evaluation report (6). Likewise, based on the findings obtained from both quantitative and, in particular, qualitative research, some initial recommendations for action – both for Templin and for other regions with comparable healthcare challenges – could be presented as examples:
• The evaluation shows that structural migrations require a very high degree of persuasion and coordination between different stakeholders. Against this background, sufficient time should definitely be allocated for preparation and implementation.
• In general, a modular approach is recommended, such as starting with a smaller range of services, which can then be gradually expanded to include further services or indications.
• The governance structure is of central importance in projects of this size.
Order/complexity of IGiB-StimMT. Building and managing such complex network structures is extremely demanding.

The evaluation also highlights that the newly created structures in the Templin region are very well suited to effectively guide patients and ensure they receive care at the appropriate level. According to the evaluators, several of the care modules implemented in the IGiB-StimMT project even serve as models that could be transferred to other regions and other care settings. In this respect, the project fulfills the Innovation Fund's objective of testing approaches that go beyond standard care, generate insights for improving care, and have the potential to be integrated into standard care.

„The initial situation and the challenges ahead are comparable in many respects to the Templin region in other rural areas,“ write Steffen Bohm, Lutz O. Freiberg, and Alicia Prinz in their final report (7). In more general terms, the authors state that the project's goal was to „contribute to the further development/improvement of care by providing answers and practical solutions“ for how comparable regional „care landscapes“ can be restructured to address current and future challenges through a future-proof, needs-based, and intersectoral care structure. In addition to the question of need, the question of what can be achieved locally, with quality assurance and economic viability, using the available resources, also plays a role – including support from telemedicine.
In rural regions like the Templin area, hospitals have a mandate to provide local medical care to the population, particularly in acute and emergency care. However, to avoid hospital admissions, outpatient care should ideally be structured in such a way that inpatient admissions are not necessary in the first place; for example, by supporting patients in receiving treatment at the appropriate level of care based on their specific illness. Therefore, according to the authors of the report, outpatient service structures must be designed to "proactively address existing care needs that were previously met through inpatient care due to a lack of alternatives" and to meet these needs through outpatient care or an expanded outpatient service with improved infrastructure, staffing, and technology.
However, this does not mean that a duplicate structure should be established alongside the capacities available in the hospital. Rather, it means that the capacities available locally should be used as needed for inpatient, day-patient, or outpatient care. Any necessary adjustments must also take into account, and ideally anticipate, the fact that the population size and demographic structure, and with them the demands on healthcare provision, will continue to change significantly in the coming decades. Finally, digitalization creates new opportunities to support healthcare, which must be considered in the necessary adjustments and structural migration.
from:
MVF editor-in-chief Peter Stegmaier

1: https://msgiv.brandenburg.de/msgiv/de/presse/pressemitteilungen/detail/~01-04-2022-positiver-beschluss-zum-pilotprojekt-igib-stimmt-in-templin
2: https://www.monitor-versorgungsforschung.de/Abstracts/Abstract2020/mvf-0620/Online-Fachtagung-IGiB-StimMT
3: https://innovationsfonds.g-ba.de/downloads/beschluss-dokumente/154/2022-04-01_IGIB-StimMT.pdf
4: https://www.monitor-versorgungsforschung.de/Abstracts/Kurzfassungen_2022/MVF_01-22/MVF01_22_Ruppel_van-den-Berg_Regelversorgung
5: https://www.landtag-niedersachsen.de/drucksachen/drucksachen_18_12500/10501-11000/18-10578.pdf
6: https://innovationsfonds.g-ba.de/downloads/beschluss-dokumente/156/2022-04-01_IGiBStimMT_Evaluationsbericht.pdf
7: https://innovationsfonds.g-ba.de/downloads/beschluss-dokumente/155/2022-04-01_IGiBStimMT_Ergebnisbericht.pdf