Time to Care : Reimagining the homecare model

Context: In a context of persistent challenges facing the homecare sector which include staff shortages, poor working conditions and undervaluation of care work, a French association inspired by the Dutch Buurtzorg model has implemented a new homecare approach for nurses. Buurtzorg-France homecare nurses working in self-managed teams have experimented an hourly payment scheme, replacing the current fee-for-service (FFS). Using Joan Tronto's care ethics framework, this study investigates how this innovative organizational model reshapes nursing practices and patient outcomes. The study focuses on the interplay between organizational values, payment reform and nurses' professional autonomy to assess how structural incentives facilitate the practice of holistic care. We explore how the model supports and encourages holistic care by cultivating a favourable working environment that recognizes the value of caregiving. Methods: A longitudinal qualitative study was conducted between 2017 and 2023 to examine the French adaptation of the Buurtzorg model. 63 semi-structured interviews and 185 hours of shadowing and observation of homecare nurses were conducted capturing caregiving activities, team dynamics and patient interactions. Interviews were transcribed and analysed using thematic analysis in NVivo, followed by a secondary analysis based on Tronto's framework to identify caregiving phases and alignments with ethical values. Data triangulation ensured reliability and a comprehensive understanding. We obtained informed verbal consent, maintained anonymity and assigned pseudonyms. Results: The results reveal a "virtuous cycle of caring," driven by incentives resonating with nurses' ethical values and enabled by the hourly payment scheme. Previously constrained by the fee for service payment limitations, nurses were now empowered to provide relational, preventative and holistic care. Observations demonstrated enhanced patient autonomy, improved continuity of care and meaningful rapport-building. Nurses reported increased job satisfaction due to reduced time pressure and an alignment with their professional ethics. Organizational support including an assigned coach, continuing education, a performant IT system and teamwork facilitation further contributed to improving their work-life quality. As the hourly payment scheme is generalized, we raise attention to the fact that the success of this payment reform depends on its integration within the Buurtzorg organizational model. Our results underscore the importance of nurturing a values-driven care ecosystem to sustain improvements in care quality and workforce retention. Discussion: This study highlights the role of an organizational structure focused on work-life quality and an hourly payment scheme to improve nurse job satisfaction and address the undervaluation of care work. By aligning the payment model with nurses' ethical values, Buurtzorg-France fosters relational caregiving, accountability and patient-centred practices. Placing the spotlight on autonomy, teamwork and holistic care allows nurses to practice with integrity while enhancing patient outcomes and reducing systemic inefficiencies. However, scaling this model nationally will necessitate safeguarding its foundational principles because financial incentives alone will be insufficient. The payment scheme must be accompanied by a supportive organizational model and ecosystem that legitimizes caregiving as an essential societal contribution. This study therefore seeks to contribute to a broader discourse on the societal value of caring, urging policymakers to embed care ethics in healthcare reforms.