Mathematical Models To Improve The Current Practic

OR Spectrum (2020) 42:43–74
https://doi.org/10.1007/s00291-019-00565-w
REGULAR ARTICLE
Mathematical models to improve the current practice

in a Home Healthcare Unit
Sacramento Quintanilla1 · Francisco Ballestín1 · Ángeles Pérez1
Received: 18 June 2018 / Accepted: 5 October 2019 / Published online: 18 October 2019
© Springer-Verlag GmbH Germany, part of Springer Nature 2019
Abstract
This paper addresses a home healthcare routing problem in which doctors and nurses
visit patients at their homes to provide services. We consider a real-world home
healthcare service arising in a particular hospital in Spain. Doctors and nurses are
distributed in teams and travel by taxi; taxis transport a pre-defined set of workers
who travel together the whole route. The objective is to minimise the transportation
costs related to the total taxi journey time, including travelling and waiting costs.
The paper presents a mathematical model that considers these current policies and
permits the problem to be solved optimally. The paper also explores, after review-
ing the hospital’s current model, the benefits that can be obtained by changing some
of the current policies of the hospital. In this way, a new model is proposed based
on two sustainable strategies that can be extended to other home service fields: (1)
workers can walk between houses and (2) the workers transported by a taxi may
change during the route. A complex nonlinear mathematical model is presented, and
a metaheuristic is designed to provide quality solutions. Computational tests on a set
of instances based on real-world data estimate the gap between the solutions of both
models.
Keywords Home healthcare problem · Heuristics · Nonlinear integer programming ·

Linear integer programming
* Ángeles Pérez
angeles.perez@uv.es
Sacramento Quintanilla
maria.quintanilla@uv.es
Francisco Ballestín
francisco.ballestin@uv.es
1
Dept. de Matemáticas para la Economía y la Empresa, Universitat de València, 46022 Valencia,
Spain
13
Vol.:(0123456789)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

44 S. Quintanilla et al.
1 Introduction
The home care unit (HCU) (Fikar and Hirsch 2017) is a special unit inside some
hospitals. The HCU arises as a model of hospital management in a context in which
the demand for hospital care has grown considerably. Its expansion is due to fac-
tors such as the increase in life expectancy and the advances in medical techniques
and technologies that permit services outside the hospital. Moreover, social changes
have occurred in which patients have become more open to home care and their
families are more inclined to share responsibility for their well-being.
In short, the HCU is a healthcare alternative consisting of an organisational
model that allows doctors and nurses to carry out, at the patient’s home, diagnostic
and therapeutic procedures and provide care similar to that provided at the hospi-
tal to patients for whom their home is the “best therapeutic place”. Given that the
duration of home care is for a limited time, as in a conventional hospital, and that
the quality of life of patients generally improves, it is unsurprising that this alterna-
tive has proved to be popular among users. Many governments are now taking into
account (Genet et al. 2012) this emerging model because it appears to be part of
the solution to the problems of overcrowding and rising costs associated with con-
ventional hospitalisation, achieving the desired therapeutic targets in less time, with
fewer health complications and at lower economic and social costs.
The HCU does incur some costs that do not arise under the conventional hospital
model, among which are the costs for health workers to travel to the various homes
of patients. Our paper looks at the teams of doctors and nurses who provide home
care services and examines how to minimise their transportation costs. The costs
of healthcare workers are not considered because they have a permanent contract
with the hospital and they are available during the entire work day. This research is
inspired by a real case of a hospital in Valencia (Spain), which henceforth will be
referred to as the reference hospital.
Today’s society requires more and more that the processes applied by compa-
nies and public institutions are sustainable. Accordingly, our approach is not only
a method for cost optimisation, but it also takes into account these matters. It intro-
duces the possibility that healthcare workers walk between houses and looks for a
more rational use of transport (taxis in this case), obtaining high vehicle utilisation.
The benefits of the proposed set of changes are multiple. They reduce the total trans-
portation time and the lack of parking spaces. There is also an additional side ben-
efit for the healthcare workers, who enjoy increasing physical activity in a world in
which the sedentary lifestyle needs to be countered. When walking is introduced,
a trade-off should exist between the distance to be covered and the equipment to
be carried. In the reference hospital considered, no heavy equipment is carried by
doctors or nurses. However, if this were the case, the trade-off could be achieved by
adjusting the maximum distance a worker can walk.
The paper has two main contributions. First, we study the problem as it is cur-
rently considered by the reference hospital. Due to the problem’s complexity, the
hospital has established several simplifications and rules in order to be able to
calculate a daily feasible plan of visits. Doctors and nurses are divided in teams
13
Mathematical models to improve the current practice in a Home… 45
that travel from the hospital to the homes by taxi. Each taxi is assigned to one or
two healthcare workers from the same team: the taxi and the workers assigned
to it make the whole journey together. The journeys of the taxis start at the same
time from the hospital. The paper presents an integer linear programming model
that considers these current hospital strategies. The model is tested with a set of
instances based on real-world data. All of them have been optimally solved with
the commercial high-level modelling system GAMS. At the moment, the hospital
just builds a feasible solution through a manual time-consuming process; there-
fore, this first contribution represents an important advance for the hospital.
Second, after analysing, together with the hospital, the limitations of the cur-
rent model and establishing guidelines to improve its effectiveness, a more gen-
eral model has been proposed. The new model is based on two new strategies:
(1) healthcare personnel can walk between homes and (2) taxi plans are more
flexible, i.e. they are not pre-assigned to certain workers and can start the journey
at any place and time. The paper presents a nonlinear integer programming model
for the new problem and a metaheuristic algorithm to solve it, due to the fact that
GAMS fails to obtain optimal solutions. Another main objective of the paper is to
explore the possible gains if the hospital changes the way of calculating the solu-
tion. Computational results show that this second model significantly improves
the first one’s performance.
Some background is needed regarding the terms of use of the taxis performing
the routes as they heavily determine the models and the solutions. All the visits are
made during the day, and the taxi costs are the same. The cost of the taxi starts to
run when the taxi collects the first passenger(s). We do not consider Uber or simi-
lar; only traditional taxis whose costs are independent of the number of passengers
are considered. The hospital works with a specific taxi company. Two conditions
have been established for the use of the taxis: (1) there are a maximum number of
taxis the hospital can use in a day and (2) the work of a taxi must be continued
once it is requested. Therefore, it is not possible to order a taxi at any time of the
plan. This situation is common in Spain where public companies can normally only
work with certain pre-established private companies. These companies have usually
won a public tender to offer the services under certain established conditions. The
limitations in the availability of taxis and the terms of use established in this case
mean that, when routes are calculated, some waiting times do appear (for both work-
ers and taxis). These waiting times could have been avoided if more freedom had
existed in the terms of use of the taxis.
To the best of our knowledge, there is no published work that considers our pre-
cise problem. No study addresses taxis or considers a distribution by teams of doc-
tors and nurses as in our case. Furthermore, the use of: (1) various and combined
modes of transport and (2) vehicle sharing strategies (as explored in this paper)
are interesting new research directions not only from a cost optimisation point of
view, but also taking into account sustainability considerations (Fikar and Hirsch
2017). Moreover, the strategies examined in this paper are not only applicable to the
healthcare field. They can also be extended to any other area where workers need to
visit homes to provide services, such as the repair and maintenance of appliances or
equipment.
13
Although it is beyond the scope of the paper, we would like to point out that the
algorithms developed have been integrated into a web application designed to be
used by the HCU in order to minimise transportation costs. The application calls
the developed algorithms, automatically providing the data related to transfer times
between addresses and indicating the routes that the health personnel must follow.
The application also allows real-time management of routes and schedules. The
environment is user-friendly, with input and output screens and graphical informa-
tion of the solution routes. The web application is developed for iOS and Android,
allowing doctors and nurses to carry all the information on their mobile devices. The
design of a friendly tool seems to be a decisive factor in the integration of math-
ematical and complex resolution models in company processes. An example of a
friendly decision support system for the staff planning of home care can be found in
Eveborn et al. (2009). However, this type of tool is not normally described or men-
tioned in the literature, which usually focuses on the mathematical models.
The rest of the paper is organised as follows. In Sect. 2, we carry out a review of
the literature. Section 3 describes and models the current method used by the refer-
ence hospital to solve the problem and Sect. 4 the generalised model proposed. Sec-
tion 5 introduces the algorithms to solve the models defined in Sects. 3 and 4. Sec-
tion 6 compares the quality of the solutions attainable with the two models. Finally,
conclusions are presented in Sect. 7.
2 Literature review
The importance of optimising the use of resources in healthcare systems has led
to a growing body of the literature on the subject. Hulshof et al. (2012) carry out a
classification of the planning decisions in healthcare systems, compiling a total of
462 items. According to the authors, the literature dealing with home health care
(HHC) was not compared extensively with other services at that moment. However,
the number of items was growing owing to the competition between different Euro-
pean public and private companies offering their services. The majority of the arti-
cles address a group of nurses that move around with private vehicles and/or public
transport and try to minimise the cost and/or maximise patient satisfaction.
The home healthcare routing problem (HHCRP) has similarities with some
routing problems, such as the dial-a-ride problem (DARP), which designs vehicle
routes and schedules for a certain number of users who specify pickup and delivery
requests between origins and destinations. For an overview of DARPs, we refer to
Cordeau and Laporte (2007) and Ho et al. (2018). However, there are several aspects
that make HHCRPs and DARPs different. Fikar and Hirsch (2015), one of the pub-
lished works most related to ours, also point out several important differences with
DARPs. Some of these differences are: first, DARPs only assign homes to taxis and
schedule the pickups and deliveries; however, HHCRPs also have to assign skilled
workers. Second, transportation requests are not pre-defined in HHCRPs, but are
created at the same time the assignment of workers is executed, because the point
in time at which a worker has to be picked up from a home depends on when they
arrived there. Third, there are also differences regarding the routes considered. In
13
HHCRPs, doctor and nurses can travel in several different taxis during the planning
horizon or can even walk between them. They can arrive at a home with one taxi
and leave in a different one, making the number of vehicles that have to visit a home
a variable. Moreover, they can even arrive and/or leave on foot, which means that
the number of “arrivals” at a home may be different from the number of “depar-
tures”. There can even be homes not visited by taxis. These last factors make a great
difference with many routing problems.
Gutierrez et al. (2013) conduct a review of the literature on the subject; the
authors emphasise the need to develop and implement more integrated methodolo-
gies to support decisions at the tactical and strategic levels of planning and consider
key features of real systems. In a later work, Gutierrez et al. (2014) identify, through
a survey of service providers in Valle del Cauca, Colombia, the need for a more inte-
grated management of logistics decisions.
Maya Duque et al. (2015) provide an up-to-date bibliographic overview on plan-
ning for home care services and discuss the different objective functions, constraints
and methodologies used in the articles published. Among the objectives, they high-
light the optimisation of time, cost, workload balance, patient preferences, staff pref-
erences, number of admitted patients and uncovered visits. Among the restrictions
noted are time windows, skill matching, staff/patient preferences, repetition of daily
sequences, synchronisation among several specialists who come to the same address
and precedence in the visits. With regard to methodologies, they consider hybrid
and heuristic algorithms to be accurate.
Fikar and Hirsch (2017) review the literature on HHC with a focus on the related
routing and scheduling problems, noting the increasing attention that this problem
has been receiving in recent years. The paper analyses single-period and multi-
period planning problems and, within each one, compares objectives, constraints
and solution methods. The authors highlight the heterogeneity of the papers due to
the national and regulatory settings. The paper finishes with a discussion of future
research directions, among which we can highlight: robust settings, multi-stage
multi-period methods, implementation of various and combined modes of trans-
port, development of sustainable solutions and the means of acceptance of HHC
optimisation.
Marcon et al. (2017) use the term hospital-at-home service and present a litera-
ture review of problems related to two areas, assigning patients to caregivers and
planning the caregivers’ routes. They highlight operations research approaches and
multi-agent methods, and propose defining an integrated architecture using both
techniques to solve these types of problems.
Bertels and Fahle (2006) published one of the first articles that considered the
HHC problem to find an assignment of work for nurses and then sequence the visits
of each element of the assignment. In their problem, all health workers are nurses,
the households have certain preferences defined as soft and hard constraints, and
the journey can be made in private or public transport. The attempt is made to mini-
mise the cost while maximising patient satisfaction. To solve the problem, they use
a combination of three techniques, obtaining good heuristic solutions: linear pro-
gramming, constraint programing and metaheuristics. Eveborn et al. (2006) propose
a decision support system for planning HHC routes that considers time windows
13
and different worker skills, areas assigned to each person, group visits that must be
made by the same person and patient preferences. They solve the problem heuris-
tically, repeatedly using a matching approach. Rasmussen et al. (2012) model the
problem as a set partitioning problem with side constraints and develop a Branch
and Price algorithm. The authors consider several objectives that are weighted to
unify them into one goal, and as a novelty, they introduce generalised precedence
relations that restrict the differences between the starting moments of different vis-
its. Allaoua et al. (2013) minimise the number of workers needed in the HHC prob-
lem when patients require services of different complexity that must be addressed
within a time window and the workers have different skills and available time. The
authors model the problem as an integer linear problem, and for large applications,
they propose a heuristic that breaks the original problem into two subproblems. The
first subproblem finds a partition of the patients, and the second creates a route con-
sistent with the time windows. If a possible solution is not found, a new resource is
added. Trautsamwieser et al. (2011), Trautsamwieser and Hirsch (2011, 2014) and
Fikar and Hirsch (2015) work with real problems of the Austrian Red Cross, consid-
ering a workforce with different skills, time windows, mandatory working times and
break regulations. Trautsamwieser et al. (2011) model the problem of minimising
the sum of the driving times and waiting times and solve it by a variable neighbour-
hood search metaheuristic. Trautsamwieser and Hirsch (2011) minimise the total
daily transportation time and the level of customer dissatisfaction through a variable
neighbourhood search-based metaheuristic. Trautsamwieser and Hirsch (2014) pre-
sent a mathematical model formulation for the medium-term HHC planning prob-
lem and introduce a branch-price-and-cut solution approach and a metaheuristic
based on a variable neighbourhood search.
Fikar and Hirsch (2015) study a related problem in which they examine a trans-
port service to pick up and deliver nurses combined with the option of walking. The
necessity of considering sustainability aspects and combining modes of transport
is noted. The authors solve a complex HCU problem, where routes need to satisfy
several real-world requirements, with a two-stage metaheuristic. Their paper consid-
ers characteristics such as: nurses’ qualification levels, earliest and latest start times
for jobs, maximum nurse’s working time, maximum nurse’s working time without a
break, maximum nurse’s cumulative walking and waiting between each delivery and
pickup.
The problems studied in their paper and in this present work, although related,
are different. The objective function, the guidelines to assign workers to homes and
especially the constraints imposed on the routes are different. Among those differ-
ences we find the following elements in our problem, but not in the paper of Fikar
and Hirsch (2015):
(1) Workers are distributed in teams of doctors and nurses.

(2) Two workers must, in some cases, visit a home (a doctor and a nurse).
(3) Some visits must be made first thing in the morning.
(4) Workers in our problem travel by taxi. This aspect has cost implications.
(5) Taxis can wait for the healthcare workers at any home.
(6) In our more general model, a taxi can start or finish its route at any home.
13
As none of these features appear in the paper of Fikar and Hirsch (2015), we can-
not use their procedure to solve our problem. Furthermore, our paper puts emphasis
on developing mathematical models, which in one of the models leads to the obten-
tion of an optimal solution.
Koeleman et al. (2012) address the problem of finding the minimum amount of
resources required such that no patients are rejected by means of a stochastic model
that considers whether there are patient waiting lists, representing the system as a
Markov chain. Carello and Lanzarone (2014) work with uncertainty in patient
demand, proposing a model in which overtime and the costs of redeployment are
minimised. They solve it with a cardinality-constrained approach.
Guericke and Suhl (2017) introduce new and adapted working regulations to the
HHC problem. They propose a heuristic approach based on an adaptive large neigh-
bourhood search to cope with the complexity of the problem. They also show that
neglecting regulations in the modelling can lead to a larger number of violations.
Carello et al. (2018a) solve a problem of assigning nurses to patients taking into
account the different stakeholders involved: patients, operators, service provider
managers and the contracting authority. The first three stakeholders’ perspectives are
modelled as alternative objective functions of an integer linear programming model,
and a threshold method to include all of them is proposed. The last stakeholder
pays for the service and fixes the requirements in terms of costs, quality of service
and working conditions. Carello et al. (2018b) propose a robust model that assigns
nurses to patients taking into account time dependency of the demands. The model
is based on the “implementor–adversarial” framework.
Several published works perform tests on actual data (Eveborn et al. 2006; Ras-
mussen et al. 2012; Carello and Lanzarone 2014; Fikar and Hirsch 2014; Maya
Duque et al. 2015; Gutierrez et al. 2014; Trautsamwieser et al. 2011; Trautsam-
wieser and Hirsch 2011, 2014). Thus, the HHCRP is attracting growing interest (cf.
Hulshof et al. 2012; Fikar and Hirsch 2017). However, none of these studies have
considered the main characteristics of our model.
3 Current model at the reference hospital: description and modelling
3.1 Description of the problem
In this section, we model the HHC problem that minimises the transportation costs
following the indications currently established by the hospital. The transportation
costs include the travelling and waiting costs of the employed taxis. In the HCU, a
set of doctors and nurses travel to n homes h1, h2,…., hn, in which there are patients
to visit. We will use the words home and house interchangeably. A fictitious home
h0 representing the hospital is added. The ndoc doctors and nnur nurses are dis-
tributed in nteam teams t1, t2,…., tnteam. Each team is composed of one doctor and
one or two nurses; therefore, nteam = ndoc. The number of teams and the composi-
tion of each team are fixed and pre-established by the hospital. Each patient requires
the daily visit of a doctor or a nurse or both a doctor and a nurse, always from the
same team. In teams with two nurses, it is not necessary that the nurse assigned
13
to a patient be the same every day. We will denote team(i) as the team assigned to
home hi. The visits made to a house have a known duration. We will call tdoc(i) and
tnur(i) the required time for the visit of the doctor and nurse at home hi, respectively.
If the patient has to be visited by both the doctor and the nurse, the required time
for the visit is max(tnur(j),tdoc(j)), because both visits occur simultaneously. If the
patient does not need to be visited by either the doctor or the nurse, then tdoc(i) or
tnur(i) are 0, respectively.
Some visits must be made first thing in the morning, for example, because the
patient must be treated on an empty stomach. We will call this type of visit a first-
hour visit. The other patients can be visited at any time within the planning period. A
doctor or a nurse cannot visit a patient who does not have a first-hour visit assigned
before a patient requiring this type of visit.
Transportation of healthcare workers in the reference hospital is facilitated using
as many taxis as nurses. Therefore, in this model, the number of taxis ntax will be
equal to nnur. Doctors always share a taxi with a nurse from their team. In teams
with two nurses, homes that require both a nurse and a doctor are assigned to the
nurse sharing a taxi. The rest of the homes should be distributed between the two
nurses such that the number of homes assigned to each is balanced. All taxis leave
the hospital at the same time (first thing in the morning) and end the route at the
hospital. In a shared taxi, when a patient requires the visit of only one member of
the team, doctor or nurse, the other person waits in the taxi during the visit.
The transportation cost is proportional to the time employed by the taxis through-
out the day, from the start at the hospital to the end at the hospital. These costs
include travelling and waiting costs. The travelling times between two houses are
known beforehand. Let us call d(i,j,1) the time needed to go from home hi to home
hj if a taxi is employed. The number 1 indicates that the journey is made by taxi.
We assume that all times are deterministic. Therefore, we do not consider delays or
longer travel times than assumed. Table 1 summarises the notation of the paper.
3.2 Mathematical model
To model the problem, it suffices to decompose the problem into as many subprob-
lems as teams. If the team has one doctor and only one nurse, the subproblem is
equivalent to the asymmetric TSP with some additional constraints. If the team has
one doctor and two nurses, the problem is equivalent to solving the 2-TSP (TSP with
two vehicles), also with additional constraints. The minimum total cost will be the
sum of the optimal costs of the subproblems. Below, we define the subproblem cor-
responding to a team.
For each team t, we consider a directed graph Gt = (Vt,At) with as many vertices
as homes the team has assigned, with one more fictitious vertex (0) representing
the hospital and with an arc between each pair (i,j) of vertices. We assign to arc (i,j)
with j ≠ 0 the cost cij = d(i,j,1) + max(tnur(j),tdoc(j)). To each arc (i,0) we assign the
cost ci0 = d(i,0,1). In addition, to each arc (i,j) we assign the constant first(i,j), which
will be 1 if vertex j corresponds to a home that has a first-hour visit associated and
13
Table 1 Notation
Notation Definition
n #Homes
hi Home i
ndoc #Doctors
nnur #Nurses
nw #Healthcare workers; it includes nurses and doctors (nw = ndoc + nnur)
wi Worker i
ntax #Taxis
taxk Taxi k
capacity_max The maximum number of people a taxi can carry at the same time
nteam #Teams
ti Team i
team(i) Team assigned to home hi
tdoc(i) Service time of the doctor at hi
tnur(i) Service time of the nurse at hi
d(i,j,1) Travel time from hi to hj by taxi
d(i,j,2) Travel time from hi to hj on foot
Vt The set of vertices assigned to team t and a fictitious vertex representing the hospital
(vertex 0)
Gt = (Vt,At) Complete graph where the set of vertices is Vt. At is the set of arcs in Gt
cij Cost of an arc in Gt; it sums up the time from hi to hj and the visit time at hj
V A set of vertices with as many vertices as homes and two fictitious vertex: one for the
hospital and another for the start/finish of taxi routes not starting/ending at the hospital
G = (V,A) Complete graph where the set of vertices is V. A is the set of arcs in G
S Any subset of Vt\{0}, used to eliminate subtours
first(i,j) Constant assigned to an arc in Gt or in G; equal to 1 if hi and hj are assigned to the same
team, home hj is a first-hour visit, and home hi is not; 0 otherwise
wait_max Maximum time a worker should wait for a taxi at a home
walk_max Maximum time a worker can walk between two houses
twork(i,l) Service time of worker l at hi
candidate(i,l) 1, if worker l can be assigned to hi; 0 otherwise
Variables Definition
xijk 1, if taxk travels along arc (i,j), 0 otherwise

zil 1, if hi is visited by worker wl; 0 otherwise
ykijl 1, if taxk travels through arc (i,j) with wl; 0 otherwise
y0ijl 1, if wl walks through arc (i,j); 0 otherwise
inki Arrival time of a taxi (worker) to hi, if the taxi visits hi (if the worker visits hi as a
pedestrian); 0 otherwise
outik Leaving time of a taxi (worker) of hi, if the taxi visits hi (if the worker visits hi as a
pedestrian); 0 otherwise
13
i does not, and 0 otherwise. The graph Gt is used if the team has either one or two
nurses.
To solve the problem, we must find in Gt as many routes as nurses (or taxis) in the
team. All vertices must be visited by exactly one taxi and all routes must start and
end at the hospital. Additionally, the requirements of the first-hour visits must be
satisfied.
In the following part, we model the case in which the team is composed of one
doctor and two nurses. The other case is a simplification. For the case considered,
two routes must be found; the first is associated with the doctor and a nurse and the
second with the other nurse. Each route is performed by a different taxi denoted as
taxk with k = 1,2. Without loss of generality, we will assume that the doctor and a
nurse travel in tax1.
The maximum number of homes that each taxi must visit is known a priori
(workload is balanced), but not the particular houses each one has to visit. This last
point is calculated by the model.
The model and its variables are as follows:
{
1, if taxi taxk travels along arc (i, j)
xijk = k = 1, 2; i, j = 0, … , n; i ≠ j
0, otherwise
∑∑ ∑∑
Minimise cij xij1 + cij xij2
(1)
i∈V t j∈V t i∈V t j∈V t
Subject to:
∑( )
xji1 + xji2 = 1 ∀j ∈ V t �{0} (2)
i∈V t
∑
1
x0i =1 (3)
i∈V t
∑
2
x0i =1 (4)
i∈V t
∑ ∑
xij1 = xji1 ∀j ∈ V t (5)
i∈V t i∈V t
∑ ∑
xij2 = xji2 ∀j ∈ V t (6)
i∈V t i∈V t
∑( )
xij1 + xij2 ≤ |S| − 1 ∀S ⊆ V t �{0} (7)
i≠j∈S
13
(⌊ t ⌋ )
∑ |V |
xij1 ≤ max , #homes with visit of the doctor + 1 (8)
i≠j∈V t
2
⌊ ⌋
∑ |V t |
xij2 ≤ +1 (9)
i≠j∈V t
2
(tdoc(i) + tdoc(j)) ∗ xij2 = 0 ∀i, j ∈ V t (10)
( )
first(i, j) ∗ xij1 + xij2 = 0 ∀i, j ∈ V t �{0} (11)
xijk ∈ {0, 1} ∀i, j ∈ V t ; k = 1, 2 (12)
The objective function corresponds to the total time spent by the two taxis.
Restriction (2) ensures that the number of taxis that leaves a home is exactly one.
Restrictions (3–4) ensure that each taxi leaves the hospital exactly once. Restrictions
(5) and (6) ensure that the arrival at and departure from each vertex is accomplished
with the same taxi. Restrictions (2), (5) and (6) together ensure that each home is
visited exactly once. Restriction (7) eliminates any subroutes in the taxis. Restric-
tions (8) and (9) balance the number of homes assigned to each taxi. Restriction (10)
prevents a doctor from using the second taxi. Restriction (11) ensures that homes
with an associated first-hour visit are in a route always before homes without an
associated first-hour visit. Lastly, restriction (12) makes the variables binary.
If the team has only one nurse, the two members of the team, doctor and nurse,
should share a vehicle that will perform the shortest route coinciding with the solu-
tion of the TSP in the graph associated with the team and considering the first-hour
restrictions. The modelling
( of this problem ) is analogous to the previous modelling,
using only variables xij xij = 0 ∀i, j ∈ V and deleting restrictions (4), (6), (8), (9)
1 2 t
and (10).
3.3 Illustrative example
Let us consider the following example with two teams: t1 and t2. The first team t1 is
formed by a doctor w1 and two nurses, w3, w4, and the second team, t2, has a doc-
tor w2 and a nurse w5. Nine homes {h1,….,h9} must be visited. The assignment of
homes to teams and the times of the visits are shown in Table 2. The travelling times
by taxi between homes are shown in Table 3. Homes 1 and 2 are associated with a
first-hour visit.
Because there are three nurses, the hospital needs three taxis. There are two
taxis assigned to team 1 (the first taxi to the doctor and one of the nurses and the
second taxi to the other nurse), and there is one taxi assigned to team 2. There
13
Table 2 Assignment of homes hi team(i) tdoc(i) tnur(i) First-hour visit

to teams and times of visits by
doctors and nurses 1 t1 20 15 Yes
2 t2 45 20 Yes
3 t1 20 No
4 t1 20 25 No
5 t2 60 No
6 t1 15 No
7 t2 50 No
8 t1 30 No
9 t1 10 60 No
Table 3 Travelling times by taxi 0 1 2 3 4 5 6 7 8 9
0 – 20 30 39 30 25 32 30 30 30
1 25 – 20 24 10 23 22 20 20 20
2 30 22 – 20 15 10 22 20 24 24
3 40 22 20 – 20 22 25 26 10 28
4 28 15 20 20 – 23 32 10 15 15
5 23 23 9 24 26 – 15 25 23 22
6 35 25 24 30 28 10 – 25 15 12
7 30 22 15 24 12 30 30 – 15 20
8 28 20 24 10 14 24 12 20 – 20
9 35 15 24 28 20 23 12 25 20 –
Table 4 Initial distribution of taxi Description Workers Homes

taxis
1 Team 1, doctor + nurse w1, w3 1, 4, 9
2 Team 1, nurse w4
3 Team 2, doctor + nurse w2, w5 2, 5, 7
are six homes assigned to team 1 and three to team 2. The assignment of homes
to teams is not a decision of the model; the hospital establishes this assigna-
tion. Related to the six homes assigned to team 1: three of them require a doc-
tor and a nurse, and the other three require only a nurse. Therefore, following
the rule of the hospital, homes that require a doctor and nurse (homes 1, 4 and
9) will be assigned to taxi 1 and the other houses should be distributed by the
model between both taxis balancing the number of houses assigned. (In this case,
the only possibility for the model will be to assign homes 3, 6 and 8 to taxi 2.)
Table 4 shows the initial distribution of taxis. Note that nurses in team 1 (w3 and
w4) are interchangeable.
13
4}
{w
20-40 30-75 69-99
1 w1: 20-40
} 2 w2: 30-75 8 w4: 69-99
w3: 20-35 , w5 w5: 30-50
{ w2
{w {w4}
1 ,w }
3
} {w 4
185-0 w 1,w
3} 39-59
{ 50-75
{w4}
111-126 3 w4: 39-59
4
{w 2
161-0 0 w1: 50-70
6 w4: 111-126
,w 5
250-0 {w w3: 50-75
}
1 ,w
3}
{w
{w1,w3}
2,
w5
170-220 90-150
7 w5: 170-220 9 w1: 90-100
{w2,w } w3: 90-150
5 85-145
5 w2: 85-145
― : arrival-leaving time of taxi k {workers who travel through the arc by taxi 1}
i wj: start - final time of the visit of worker wj at home hi
{workers who travel through the arc by taxi 2}
Fig. 1 Optimal solution following the model currently used by the hospital
Figure 1 shows the optimal solution for this problem. The route of taxi 1 is
depicted with a continuous line (in red), the route of taxi 2 with a discontinuous
line with dots and dashes (in blue) and the route of taxi 3 in a discontinuous line
only with dots (in green). The costs associated with the taxis are 185, 161 and
250, respectively. The total optimal cost is 596. The figure also shows the starting
and finishing times of the visits of each worker and the arrival and leaving times
of the corresponding taxi to each home, denoted by inki and outik , and defined as:
{
arrival time of taxi taxk to home hi , if taxk visits hi
inki =
0, otherwise
{
leaving time of taxi taxk from home hi , if taxk visits hi
outik =
0, otherwise
k = 1, … , ntax; i = 0, … , n
Routes have been calculated using two independent graphs and models (one for each
team) as explained in Sect. 3.2.
13
4 Extended model: description and modelling
4.1 Description of the problem
After reviewing the unnecessary limitations of the current model with the hospi-
tal and the guidelines that can be changed to diminish the transportation costs, we
arrived at the following possible changes regarding the original model: (1) Taxis are
not assigned to any specific team. Taxis can transport any group of workers. The set
of workers that a taxi transports may change during the route according to the needs.
(2) If a patient must be visited by a doctor and a nurse, they can arrive at the house
at different times. (3) Short distances can be travelled on foot. (4) The route of a taxi
can start and/or finish either at the hospital or at a home. The healthcare workers
continue to start and finish their routes at the hospital. (5) As in the original model,
the assignation of houses to teams is pre-established by the hospital; the number of
houses each nurse must visit is balanced as in the current model at the hospital.
With the new guidelines, the route of a taxi will consist of a set of consecutive
trips. The start and/or end of the route can be the hospital or a house. Each of
the trips that compose the route is defined by a start, an end and the set of work-
ers (can be empty) transported by the taxi during the trip. The start of the route
has a place and a time associated with it, where the place can be a home or the
hospital, and this applies analogously for the end. Taxis can transport more than
one healthcare worker, even from different teams. We denote capacity_max as the
maximum number of people a taxi can carry at the same time.
All the healthcare workers must leave the hospital in the morning at the same
time in taxis (when the service starts). More taxis can be incorporated to the ser-
vice during the morning, if necessary. Once a taxi is incorporated to the service,
all the time until it abandons the service counts towards the transportation cost,
even if it is waiting. The taxi company only makes available to the hospital a
certain number of taxis for all these services, ntax. We assume this value cor-
responds to the number of taxis used in the model of Sect. 3. Therefore, in the
model presented in this section, the solutions do not use more taxis than the solu-
tions following the model in the previous section.
In the original model, as workers are assigned to only one taxi, the route of a
worker is the same as the one from the taxi he/she is assigned to. However, in the
extended model, as workers can use different taxis and can travel on foot, the route
of a worker is not defined by the route of any taxi. The routes of the workers are also
a set of consecutive trips where the start and end of the route is always the hospital.
Each of the worker trips that compose the route is defined by a start, an end and
the means of transportation (taxi or on foot). The start of each trip has a place and
a time associated with it, where the place can be a home or the hospital, and this
applies analogously for the end. A worker can use different taxis on his/her route.
There can be waiting times. However, the time that a worker has to wait for a taxi
at a home once the work has been finished should not exceed a quantity denoted as
wait_max. We define this value as 10 min. This value corresponds to the approxima-
tion of the average waiting time for a doctor or nurse who shares a taxi with another
worker in the model currently followed by the reference hospital.
13
The times needed to perform the route between two houses on foot are also
known beforehand. We call d(i,j,2) the time needed to travel from home hi to hj on
foot. Obviously, d(i,j,2) = d(j,i,2). There is an upper bound walk_max for the time a
worker can walk from one house to the next. Therefore, some routes cannot be made
on foot. Table 1 summarises the notation of this model as well.
4.2 Mathematical model
The new problem is modelled as a nonlinear integer optimisation problem. We con-

sider a directed graph G = (V, A) in which the vertices V correspond to the homes
and the arcs (i,j) join each pair of homes hi, hj. The vertices include two fictitious
homes: one for the hospital (vertex h0) and another (vertex hn+1) representing the
start of the route of the taxis that go directly to a house or the end of the route of
the taxis that finish their route at a home. Each arc (i,j) has two weights d(i,j,1) and
d(i,j,2) associated with it, being d(i,n + 1,1) = d(n + 1,i,1) = 0 ∀ i = 0,…,n.
To solve the problem, we must find in G a route (cycle) for each worker, starting
and ending at the hospital, in such a way that all homes are visited exactly once by
the established workers. The trips that make up the tour of the workers can be per-
formed on foot or by taxi. Each worker will visit a house no more than once. The
routes of the taxis can start and/or end at the hospital or at a house. Each taxi will
visit a house no more than once, but different taxis can visit the same house. Addi-
tionally, the requirements of the first-hour visits should be satisfied. The objective is
to minimise the transportation cost associated with the taxis.
The route of a taxi k is also represented by a cycle in G. The cycle of taxi k will
visit a set of vertices representing the route followed, and at each vertex i, the instant
of arriving and departing from the vertex will be calculated (variables inki , outik ). Let
us detail the relationship between the cycles in the model and the taxi routes:
(1) If the route of taxi k starts at the hospital, the start and the end of the cycle are
the hospital, independent of whether the route finishes at the hospital or at a
home. The start (out0k ) will be instant 0, and the arrival (ink0 ) will coincide with
the total time employed by the taxi to travel along the route. If the route finishes
at a home j, the cycle goes from the home j to the fictitious home and from there
to the hospital. (The cost of these two last trips is zero.) In this case,
outjk = inkn+1 = outn+1
k
= ink0.
(2) If a taxi k starts the route at a home and not at the hospital, the start of the cycle
is the fictitious home. In this case, the departure (outn+1k
) will be different from
0. The route of the taxi can end at a home or at the hospital. In the model, the
route goes from the house or the hospital to the fictitious home to close the cycle.
The total time employed by the taxi in the route will be equal to the arrival at the
fictitious home minus the departure from the fictitious home.
We consider all healthcare workers (doctors and nurses) in the same ordered set
of workers. The first ones will be the doctors and the last ones the nurses, w1,w2,…,
wndoc,…,wnw. We call nw the total number of workers (nw = ndoc + ndur).
13
We can define the required time for the visit of a worker l to a home i, twork(i,l),
without distinguishing whether the worker is a doctor or a nurse, as:
⎧ tdoc(i), if l ≤ ndoc, w ∈ team(i)

⎪ l
twork(i, l) = ⎨ tnur(i), if l > ndoc, wl ∈ team(i), i = 1, … , n; l = 1, … , nw
⎪ 0, otherwise
⎩
Given a specific instance, we define the matrix candidate of order n × nw such as:
{
1, if twork(i, l) > 0
candidate(i, l) = i = 1, … , n; l = 1, … , nw
0, otherwise
A doctor or a nurse will not be allowed to visit a patient with a first-hour visit after
a patient who does not have a first-hour visit. The characteristic of first-hour visit is
applied to both the doctor and the nurse in the event that both have to visit the patient.
To solve this, we calculate first(i,j) as constants that will be 0 or 1 and will be used in
the model. The constant first(i,j) will be 1 if homes hi and hj are assigned to the same
team, home hj is a first-hour visit, and home hi is not; it will be 0 otherwise.
Is important to remark that for any instance a feasible solution of the first model is
obviously also a feasible solution for the extended model.
The variables in the extended model are:
{
1, if home hi is visited by worker wl
zil = i = 1, … , n; l = 1, … , nw
0, otherwise
⎧ 1, if taxi tax travels through

⎪ k
ykijl = ⎨ arc(i, j) with worker wl k = 1, … , ntax; i, j = 0, … , n; i ≠ j; l = 1, … , nw
⎪ 0, otherwise
⎩
{
1, if worker wl walks through arc (i, j)
y0ijl = i, j = 0, … , n; i ≠ j; l = 1, … , nw
0, otherwise
{
1, if taxi taxk travels through arc (i, j)
xijk = k = 1, … , ntax; i, j = 0, … , n + 1i ≠ j
0, otherwise
⎧ arrival time of taxi tax to home h ,

⎪ k i
inki = ⎨ if taxk visitshi k = 1, … , ntax; i = 0, … , n + 1
⎪ 0, otherwise
⎩
⎧ leaving time of taxi tax from home h ,

⎪ k i
outik = ⎨ if taxi taxk visits hi k = 1, … , ntax; i = 0, … , n + 1
⎪0 otherwise
⎩
13
⎧ arrival time of worker (k − ntax)to home h ,

⎪ i
inki = ⎨ if worker (k − ntax) visits hi as a pedestrian
⎪ 0, otherwise
⎩
k = ntax + 1, … , ntax + nw; i = 0, … , n
⎧ leaving time of worker (k − ntax) from home h ,

⎪ i
outik = ⎨ if worker (k − ntax) visits hi as a pedestrian
⎪ 0, otherwise
⎩
k = ntax + 1, … , ntax + nw;i = 0, … , n
The extended model can be modelled as follows:
∑
ntax
( k )
(13)
k
Minimise inn+1 − outn+1 + ink0 − out0k
k=1
Subject to:
⎛ ⎞ ⎛ ⎞
⎜ n ⎟ ntax ⎜ n ⎟
�⎜ �
ntax
�⎜ �
k ⎟ k ⎟ (14)
⎜ yjil ⎟ = ⎜ yijl ⎟ i = 0, … , n; l = 1, … , nw
k=0 ⎜ ⎟ k=0 ⎜
j=0 j=0 ⎟
⎜ ⎟ ⎜ ⎟
⎝j≠i ⎠ ⎝j≠i ⎠
∑
n+1
∑
n+1
xjik = xijk i = 0, … , n + 1; k = 1, … , ntax
(15)
j=0 j=0
j≠i j≠i
zil ≤ candidate(i, l) i = 1, … , n; l = 1, … , nw (16)
∑
ndoc
zil twork(i, l) = tdoc(i) i = 1, … , n (17)
l=1
∑
nw
zil twork(i, l) = tnur(i) i = 1, … , n (18)
l=ndoc+1
∑
nw
ykijl ≤ capacity_max k = 1, … , ntax; i, j = 0, … , n; i ≠ j (19)
l=1
13
ykijl ≤ xijk i, j = 0, … , n; i ≠ j; k = 1, … , ntax; l = 1, … , nw (20)
y0ijl d(i, j, 2) ≤ walk_max i, j = 0, … , n; i ≠ j; l = 1, … , nw (21)
( )
xijk outik + d(i, j, 1) ≤ inkj i, j = 0, … , n + 1; i ≠ j; k = 1, … , ntax (22)
( )
y0ijl outintax+l + d(i, j, 2) ≤ inntax+l
j
i, j = 0, … , n; i ≠ j; l = 1, … , nw (23)
∑
n
out0k ∗ k
x0j =0 k = 1, … , ntax (24)
j=1
∑
n
out0k ∗ y00jk−ntax = 0 k = ntax + 1, … ., ntax + nw (25)
j=1
inki ≤ outik i = 1, … ., n;k = 1, … , ntax + nw (26)
ink0 ≥ out0k k = 1, … , ntax + nw (27)
inkn+1 ≥ outn+1 (28)

k
k = 1, … , ntax
⎡⎛ ⎞ ⎤
⎢⎜ n ⎟ ⎥
� ⎢⎜ �
ntax
� k �⎥ �
n
� �
k ⎟
⎢⎜ yjil ⎟ in i
+ zil twork(i, l) ⎥ + y0jil ∗ inntax+l
i
+ zil twork(i, l)
k=1 ⎢⎜
j=0 ⎟ ⎥ j=0
⎢⎜ ⎟ ⎥
⎣⎝ i ≠ j ⎠ ⎦ j≠i
⎡⎛ ⎞ ⎤
⎢⎜ n ⎟ ⎥
� ⎢⎜ �
ntax
�
n � �
k ⎟ k⎥
≤ ⎢⎜ yijl ⎟ ∗ outi ⎥ + y0ijl ∗ outintax+l i = 1, … , n;l = 1, … , nw
k=1 ⎢⎜
j=0 ⎟ ⎥ j=0
⎢⎜ ⎟ ⎥
⎣⎝ i ≠ j ⎠ ⎦ i≠j
(29)
13
⎛ ⎞
⎜ n ⎟
�⎜ �
ntax
k ⎟
zil ∗ ⎜ yjil ⎟ = zil i = 1, … , n; l = 1, … , nw (30)
k=0 ⎜
j=0 ⎟
⎜ ⎟
⎝i≠j ⎠
( n )
∑
ntax
∑
yk0jl =1 l = 1, … , nw (31)
k=0 j=1
( n )
∑
ntax
∑
ykj0l =1 l = 1, … , nw (32)
k=0 j=1
⎛ ⎞
⎜ ⎟
�
ntax
⎜ � k⎟
n
⎜ yijl ⎟ ≤ 1 i = 0, … , n; l = 1, … , nw (33)
k=0 ⎜
j=1 ⎟
⎜ ⎟
⎝j≠i ⎠
⎛ ⎞
⎜ n ⎟
�⎜ �
ntax
k ⎟
⎜ yjil ⎟ ≤ 1 i = 0, … , n; l = 1, … , nw (34)
k=0 ⎜
j=1 ⎟
⎜ ⎟
⎝j≠i ⎠
∑
n
(35)
k
xin+1 ≤1 k = 1, … , ntax
i=0
∑
n
(36)
k
xn+1i ≤1 k = 1, … , ntax
i=0
∑
n
( k ) ∑n
( k )
(37)
k k
xin+1 + xn+1i + x0i + xi0 ≤3 k = 1, … , ntax
i=0 i=1
13
(38)
k
x0n+1 ∗ out0k = x0n+1
k
∗ ink0 k = 1, … , ntax
∑
ntax
first(i, j) ykijl zil = 0 l = 1, … , nw; i, j = 1, … , n; i ≠ j (39)
k=0
⎡⎛ ⎞ ⎤ ⎡⎛ ⎞ ⎤
ntax ⎢⎜ n ⎟ ⎥
� � ntax ⎢⎜ n ⎟ ⎥
� ⎢⎜ � �
n
� � � k �⎥
k ⎟ k⎥ 0 ntax+l ⎢⎜ k ⎟
⎢⎜ y ijl ⎟ ∗ out i⎥ + yijl
∗ out i
− ⎢⎜ yjil ⎟ in i
+ zil twork(i, l) ⎥
k=1 ⎢⎜
j=0 ⎟ ⎥ j=0 k=1 ⎢⎜
j=0 ⎟ ⎥
⎢⎜ ⎟ ⎥ ⎢⎜ ⎟ ⎥
⎣⎝ i ≠ j ⎠ ⎦ i≠j ⎣⎝ i ≠ j ⎠ ⎦
�
n
� �
− y0jil ∗ inntax+l
i
+ zil twork(i, l) ≤ wait_max i = 1, … , n; l = 1, … , nw
j=0
j≠i
(40)
zil ∈ {0, 1} i = 0, … , n; l = 1, … , nw (41)
ykijl ∈ {0, 1} k = 0, … , ntax;i, j = 0, … , n; i ≠ j; l = 1, … , nw (42)
xijk ∈ {0, 1} k = 1, … , ntax; i, j = 0, … , n + 1; i ≠ j (43)
inki , outik ∈ ℤ+ k = 1, … , ntax; i = 0, … , n + 1 (44)
inki , outik ∈ ℤ+ (45)

k = ntax + 1, … , ntax + nw; i = 0, … , n
The objective function corresponds to the total time invested by the taxis from
the moment at which they start until they finish the routes. Restrictions (14) and
(15) ensure that at every node, if a worker (taxi) enters that node, that worker
(taxi) leaves the node. Restrictions (16), (17) and (18) establish the times of visits
by each worker at each home, assigning only one nurse when there are two possi-
ble candidates. Restriction (19) ensures that the travellers in a taxi do not exceed
its capacity. Restriction (20) ensures that if a worker travels with a taxi along an
arc, the taxi will use that arc. Restriction (21) prevents a worker from walking
more than the established limit. Restrictions (22) and (23) ensure that if a taxi or
a pedestrian travels between two houses, the arrival time at the second home will
be greater than or equal to the departure time plus the necessary time to cover the
distance. Restrictions (24) and (25) ensure that every taxi and pedestrian with
the start of the route at the hospital begin their route at instant 0. Restriction (26)
ensures that for the homes inside a route, the exit time is greater than or equal to
the entrance time. Restrictions (27) and (28) ensure that the exit time at homes
13
that are the beginning of routes (hospital or fictitious home) are less than or equal
to the entrance time. Restriction (29) does not allow a worker to leave a home in
a taxi if all workers who must leave in the same taxi have not finished their work.
If a worker leaves a house on foot, it is only necessary that s/he has finished his
or her work. Restriction (30) forces all workers to arrive at each home they have
to visit. Restrictions (31) and (32) force all workers leaving the hospital to travel
to a non-fictitious home and return to the hospital from a non-fictitious home.
Restrictions (33) and (34) ensure that if a worker leaves (arrives at) a home, s/
he does so on foot or in a single taxi. Restrictions (35), (36) and (37) ensure that
taxis arrive at the fictitious home and leave it no more than once and that it will
never be in the middle of a route. If a taxi starts a route at a home and ends the
route at the hospital, in the model, the taxi will start and end the route at the fic-
titious home. Equation (38) forces the time at which the taxi leaves the hospital
to coincide with the arrival time at the hospital in the arc that closes the cycle
when the taxi route starts in the fictitious vertex n + 1 and finishes at the hospital.
Restriction (39) ensures that a doctor or nurse will always first visit a home with a
first-hour visit before visiting one that does not have this requirement. Restriction
(40) prevents the waiting time at a home once the work has been finished to be
greater than the allowed limit. Equations (41–45) define the variables as binary or
non-negative integers.
4.3 Illustrative example
Following the example proposed in Sect. 3.3, let us suppose that the viable walk-
ing times between houses are five minutes between homes 2 and 5, 3 and 8, 4 and
7, and 6 and 9. The values of twork(i,l) are the ones shown in Table 5.
Figure 2 shows a feasible solution for this problem using three taxis. The
routes represented correspond to taxis. The route of taxi 1 is depicted with a con-
tinuous line (in red), the route of taxi 2 with a discontinuous line with dots and
dashes (in blue), and the route of taxi 3 in a discontinuous line only with dots (in
green). On each line the workers travelling in the taxi during that part of the route
Table 5 Values of twork(i,l)

hi w1 w2 w3 w4 w5
(doctor/team 1) (doctor/team 2) (nurse/team 1) (nurse/team 1) (nurse/team 2)
1 20 15 15
2 45 20
3 20 20
4 20 25 25
5 60
6 15 15
7 50
8 30 30
9 10 60 60
13
20-40 30-50 145-145

1 w1: 20-40 5} 2 w2: 30-75 3 w3: 125-145
,w
{w
2
w3: 20-35 w5: 30-50 3}
{w {w
1 ,w
}
4 3 ,w {w3}
,w
2}
4}
{w
3
140-0 ,w
1 {w5} 65-65
{w 170-170 50-75 90-90
185-0
0 {w 6 w4: 145-160 4 w1: 50-70 {w1, w3} 8 w3: 90-120
203-203 1 ,w
5}
w3: 50-75
4}
w
{w 2
3,
{w1}
{w
{w4} {w5}
,w 3
{w4}
,w 4
80-150
}
180-180 140-140 110-120

5 w2: 80-140 {w1, w5} 7 w5: 70-120
9 w1: 140-150
w4: 80-140
10
203-145
― : arrival-leaving time of taxi k´

― : arrival-leaving time of taxi k
i wj: start - finish time of the visit of worker wj at home hi
{workers who travel through the arc on foot}
Fig. 2 Feasible solution following the new model
Table 6 Assignment of homes Worker Homes

to workers
w1 (team 1-doctor) 1, 4, 9
w2 (team 2-doctor) 2, 5
w3 (team 1-nurse) 1, 4, 8, 3
w4 (team 1-nurse) 9, 6
w5 (team 2-nurse) 2, 7
Table 7 Route for w

1
Home Arrival time at Departure time Working time at Waiting time at Transport
the home from the home the home the home to the next
home
0 – 0 – – Taxi 1
1 20 40 20 0 Taxi 1
4 50 75 20 5 Taxi 1
8 90 90 0 0 Taxi 1
7 110 120 0 10 Taxi 1
9 140 150 10 0 Taxi 2
0 185 – – – –
13
are shown. The figure also shows the trips made on foot by a worker, depicted
with a black line with dashes. Furthermore, the start and finish times of the visits
of each worker and the arrival and leaving times of the taxis to each home (inki
and outik ) are shown.
Table 6 shows the assignment of homes to workers according the solution of
Fig. 2. We have: z11 = z13 = z22 = z25 = z33 = z41 = z43 = z52 = z64 = z75 = z83 = z91 = z94
= 1. The rest of the variables zil are 0.
Taxi 2 starts and finishes the route at the hospital. Taxi 1 starts at the hospital
and finishes at home 9. Therefore, in the model, to close the cycle, this taxi goes
from home 9 to the fictitious home and from there to the hospital. Finally, taxi
3 starts at home 3 and finishes at the hospital. The total cost associated with the
solution is (140 − 0) + (185 − 0) + (203 − 145) = 383.
Regarding the routes of the workers, worker 1 makes the entire route with taxi
1 except the return to the hospital, which is made in taxi 2 from home 9. Workers
2, 3, 4 and 5 walk between two houses; for instance, worker 2 walks from home 2
to home 5. As an example, Table 7 shows in detail the route for worker 1.
In the solution, the workers in some cases spent time just travelling because
the model does not limit these aspects and a solution with only three taxis, as in
the hospital model, has been sought. These waiting times already appear in the
first model, although in the extended one restriction limiting these aspects could
be added if necessary.
5 Solution approach for the extended model
The model presented in Sect. 4 is a nonlinear integer problem whose resolution is

difficult when the number of doctors, nurses and homes is not small, as is the case
in our hospital. Therefore, heuristic algorithms are needed to find good solutions
in a reasonable time. One of the main objectives of this paper is to study whether
there is a significant gap between the two models presented. To accomplish this,
we have developed a metaheuristic algorithm capable of finding a good feasible
solution for the general model. Specifically, we have defined a constructive method
for the first model that can be used to obtain different solutions and a GRASP that
uses that method for the second model. Section 5.1 describes the constructive pro-
cedure, whereas the GRASP is presented in Sect. 5.2. We want to remark that the
first model that follows the current guidelines of the hospital can be solved optimally
(see Sect. 6). The constructive method designed in this chapter for this model also
provides a quick method to obtain solutions and is employed at the resolution of the
second model.
5.1 Constructive procedure
This constructive procedure offers solutions for the model explained in Sect. 3;
hence, it follows the solution scheme currently used by the hospital. To build a solu-
tion, the method introduces randomness in the distribution of houses among the
13
teams of two nurses and in the routes of the taxis. This randomness allows us to use
the method to obtain many different solutions.
The following algorithm describes the constructive method CM for one team with
two nurses. The first nurse accompanies the doctor, and the second nurse goes alone.
Let us call the number of houses the team has to visit m, the houses that must be
visited by a doctor f and the houses the first nurse visits m1. The idea is that houses
are distributed randomly between the two nurses so that the number is balanced if
possible and we apply a randomised greedy algorithm to calculate the routes. In the
case of a team with just one nurse, it suffices to apply step 3.
Constructive method
1. Assignment of houses to nurses:
1.1. Homes that should be visited by a doctor are assigned to the 1st nurse:
m1 = f.
1.2. If f < m/2, assign houses randomly to the 1st nurse until m1 ≥ m/2.
1.3. Assign the remaining homes to the 2nd nurse.
2. A taxi is assigned to the 1st nurse (and doctor) and another to the 2nd nurse.
3. Calculation of the route for a taxi (the other one is done analogously):
3.1. Start the route at the hospital.

3.2. Calculate the candidate set L = homes with a first-hour visit.
3.3. While L ≠ ∅:
3.3.1. Select a home from L according to some probabilities. The probability
of a candidate is inversely proportional to the distance between the
last home selected and the candidate.
3.3.2. Eliminate the selected home from L.
3.4. Calculate L = unassigned homes. If L ≠ ∅, go to 3.3. Else go to 3.5.
3.5. End the route at the hospital.
5.2 Grasp
As we can see in the review of Fikar and Hirsch (2017), many metaheuristic algo-
rithms applied to this kind of problem are based on constructive methods and local
searches, such as Tabu Search and GRASP. We have decided to use a GRASP
algorithm because of its adaptability to many different problems and its ease in
the implementation, in particular the fact that few parameters need to be set and
tuned (Feo and Resende 1995). GRASP is a multi-start or iterative process (Feo and
Resende 1995; Feo et al. 1994). It calculates many different solutions and the best
one is kept as the result. There are two phases in each iteration. In the first phase,
a feasible solution is calculated. This construction is made one element at a time,
where the inclusion of the element includes knowledge of the problem and random-
ness. An important feature of the inclusion of the element is that it is adaptive, i.e.
13
the probability of including an element changes through the process according to the
information available. Step 3.3.1 of our CM satisfies this characteristic. In the origi-
nal version of GRASP, a restricted candidate list is built in each iteration of the con-
struction of the solution. Only the best candidates are included on the list, and then,
a random candidate from the list is chosen. The number of candidates to include on
the list, nRCL, is a parameter of the algorithm. In our case, we include on the list the
nearest nRCL homes to the one studied. We have also included a version without
this parameter that includes all candidates on the list. In this version, the next home
to be included has more probability to be chosen the closer it is to the current home.
We will call this version nRCL = ∞.
In the second phase of each iteration of the GRASP, a local search is applied to
the solution obtained in the first phase. The local search starts from any feasible
solution and attempts to improve it in the following way: (1) changing arcs travelled
by taxi to arcs travelled on foot, (2) taking advantage of the idle times of the taxis
to transport passengers and (3) using the maximum capacity of taxis in the jour-
neys from (to) the hospital, if this is advisable. To accomplish these tasks, we have
defined four procedures that are applied consecutively, as long as the objective func-
tion is not increased. Let us consider them in detail.
FromTaxiToWalk It changes every journey by taxi to a journey on foot as long as
the distance between homes is not greater than walk_max.
TaxiShareOut If two different taxis leave the hospital to travel to two homes (A
and B), the sum of the passengers in both taxis does not exceed capacity_max, and
the distance from A to the hospital is less than the distance from B to the hospital.
This function puts the passengers of both taxis in the taxi that travels to B. This taxi
now leaves the passengers, previously in the other taxi, at home A and continues to
house B to leave the rest of the passengers there. The other taxi now starts its route
at home A, once the visit there finishes.
TaxiShareArrival If two different taxis arrive at the hospital from two homes A
and B and the sum of the passengers in both taxis does not exceed capacity_max,
this function applies changes such that a taxi leaves home A to pick up the passen-
gers from home B, and all of them will travel to the hospital. The taxi that carried
the passengers from home B to the hospital is free to travel to the fictitious home
once it has left the passengers at home B. To accept the change, the waiting time at
home B when the workers finish their work should not exceed wait_max. In a second
step, the function interchanges the roles of A and B, and the best option with regard
to the objective function is chosen.
AllocateIdleTimesTaxiTour This function attempts to take advantage of the idle
times of the taxis at the homes. If during the idle time a taxi can perform one of the
other journeys and come back to the same home, the function performs the changes
such that the taxi can do so.
At the end of the process, there may be some incoherencies in the solution that
must be fixed: consecutive arcs walked by a worker without performing a visit to the
home in between, consecutive arcs of a taxi without carrying any worker, or that the
first (last) arc of a taxi has as its origin (destination) the hospital and does not carry
any worker. In the case of two consecutive arcs, they will be replaced by a single
arc, extending from the origin of the first arc to the end home of the second arc. If
13
the first (last) arc of a taxi route leaves (arrives at) the hospital and does not carry
any worker, we change the origin (destination) of the arc to the fictitious home.
Once this process is finished, the times must be recalculated. Owing to the different
changes, some journeys made on foot exceed the established limit (walk_max); in
that case, we look for the taxi that can perform that route and that leads to the mini-
mum impact on the objective function.
6 Computational results
To analyse the solutions of the two proposed models, 300 random instances have
been generated, replicating the characteristics of the HCU hospital with which
we have worked. The number of teams varies randomly between ten and twenty.
80% of the teams are made up of one doctor and two nurses, and the remaining
20% have one doctor and one nurse. The number of patients assigned to each team
with two nurses varies randomly between 11 and 14. If there is only one nurse, this
number varies between 5 and 7 patients. The number of houses corresponds to the
total number of patients generated in the process. There is a 50% probability that a
house will require a doctor. If the patient does not need a doctor, a nurse will always
be required. If a doctor is needed, there is an 80% probability that a nurse will be
required. The consultation times considered, for both doctors and nurses, are 20, 25,
30 or 45 min, with probabilities of 50%, 20%, 15% and 15%, respectively. A consul-
tation will be first thing in the morning with a probability of 10%.
Households are generated in the urban area assigned to the hospital, covering
2070 m × 1665 m, by drawing a grid with horizontal and vertical parallel lines at a
distance of 10 m. Households may correspond to any intersection of the grid lines,
considering that the reference hospital is near the sea and some points of this grid
fall into the water and are eliminated. The hospital is found at point (1550,800) on
the grid.
Each home is represented by a randomly generated point, i.e. a pair of x and y
values. All grid points share the same probability of being selected. Once calculated,
the households are numbered consecutively, and a procedure is followed to assign
the distance between each pair of points on foot and by taxi. A speed of 4.68 km/h
walking and 34.98 km/h in a taxi is set (speed values correspond to the average speed
provided by Google in our geographical zone considering several journeys). We use
these speeds and the previously calculated distances to allocate the times between
each pair of points on foot and by taxi. To calculate the distance between two points
on foot, the Euclidean distance between each pair of points is calculated, and these
distances are altered randomly between 0 and 20%. Then, if necessary, it is altered
to satisfy the triangular inequality. To accomplish this, if the distance between two
points d(i,j) is greater than the distance between those two points through an inter-
mediate point (d(i,j) > d(i,k) + d(k,j)), the distance d(i,j) = d(i,k) + d(k,j) is updated.
The process is repeated with some of the distances updated. Obviously, the distance
between two points i and j coincides with the distance between j and i; therefore, it
is necessary to calculate only half the distances. We assume symmetric durations for
13
Table 8 Results of the Dev. to optimal sol Average cost

algorithms for the first model (%)
Optimal GAMS 24.4 – 6724.64

CM(1) 9.7 7375.91
CM(1000) 0.92 6786.89
25
20
Improvement
15
10
5
100 120 140 160 180 200 220 240
Number of houses
Fig. 3 Relationship between number of houses and improvement
walking because the reference hospital is placed in a completely flat region. In any
case, the model can be easily generalised.
The procedure for calculating the distances by car is similar except that the altera-
tion considered is carried out between 0 and 100%. Moreover, in this case, the dis-
tance is not symmetric and thus must be computed between any two pairs of points
in both directions (d(i,j) may be different from d(j,i)). The value of capacity_max
has been set at 3.
As stated above, this method has been used to generate 300 random instances.
The instances have been solved with two solvers included in the modelling system
GAMS 24.4. The model proposed in Sect. 4 has been solved using the BARON
solver (Tawarmalani and Sahinidis 2005), whereas the model proposed in Sect. 3
has been solved with the CPLEX solver.
In the case of the model following the scheme of the hospital (Sect. 3), all the
instances have been optimally solved with an average computational time of 12 s
and with an average optimal cost of 6724.64. In the case of the more general model,
none of the instances has been solved exactly. In fact, the solver solves instances
with a maximum of five homes and a team consisting of a doctor and two nurses,
sometimes with a computational time of several days. For example, the example pre-
sented in this article has not been solved due to a lack of memory.
To analyse the quality of the GRASP presented in Sect. 5, we are first going
to analyse the quality of the constructive method it uses (Sect. 5.1) comparing its
results with the optimal solutions that have been obtained for each instance using
CPLEX.
13
We have run the constructive method for every instance. First, we have applied
it with just one run: CM(1). Since the procedure includes randomness, it can be
applied several times and obtain different solutions. We have then run it 1000 times:
CM(1000). Table 8 shows the results of both procedures. As we can see, the devia-
tion to the optimal solution of CM(1000) is very good, not reaching 1%.
We also want to analyse whether the second model can offer better solutions than
the first model. For the first tests, we have considered walk_max = 0. This value
requires that no journey is made on foot, as in the current model of the hospital.
We have run GRASP(1) and GRASP(1000), in the version nRCL = ∞, where the
procedure is applied to 1 or 1000 solutions. The local search is repeated iteratively
on each solution until no further improvement in the objective function is achieved
after 100 iterations.
The average total cost of GRASP(1) and GRASP(1000) is 6702.89 and 5718.99,
respectively. The average computational time of GRASP(1000) is 2.3 min. The algo-
rithm GRASP(1) already obtains a better Average Cost than the optimal solution
of the first model. The comparison of the total cost obtained by GRASP(1000) in
the second model and the optimal total cost of the first model offers an estimation
of the improvement attainable if the hospital changes its method of working with-
out including journeys on foot. The average improvement in the second model is
close to 15% (14.61%), with a minimum of 6.47% and a maximum of 21.80%. In
96% of the instances, the improvement is more than 10%. The average improvement
here, as well as the ones that appear below, is calculated as the average over the 300
instances.
To analyse the behaviour of the heuristic algorithm, we have studied the correla-
tion between the number of houses in the 300 instances and the improvement obtained.
Figure 3 shows the relationship between the values, with the linear regression line
depicted. The x-axis corresponds to the number of houses (approximately between 100
and 230) and the y-axis to the improvement percentage (approximately between 6.5 and
22%). The variable [number of houses] does not completely explain the improvement,
since the coefficient R2 is equal to 0.31. However, there is a positive and statistically
significant correlation between the variables: the larger the number of houses, the larger
the improvement. The slope of the line is very small, 0.0448. Nevertheless, as com-
mented, a statistical hypothesis test confirms that the slope is bigger than 0. The cor-
relation between the number of teams and the improvement is very similar to the one
studied. It is interesting to note that, as expected, both the cost of the optimal solution
in the first model and the cost of the heuristic solution for the second model grow as the
number of houses grows (the R2 here is almost one, 0.973–0.989). However, even with
a higher cost, the improvement for a larger number of houses is in proportion greater
than for a smaller number of houses.
Table 9 Role of nRCL in the nRCL = 2 nRCL = 3 nRCL = 3 nRCL = ∞

GRASP
Average cost 5751.15 5768.56 5839.27 5718.99
13
Furthermore, we have analysed the role of the parameter nRCL in the GRASP.
Table 9 shows the average cost of GRASP(1000) with different values for the parame-
ter, together with the version without parameter. As we can observe, there are not many
differences among them, but the versions with a parameter do not improve the ver-
sion without it. Therefore, we work with this version to make comparisons with other
algorithms.
Although the objective of the paper is to lower the transportation cost of the taxis,
we include here an analysis of the travelling and waiting costs of the taxis, as well as
the staff costs and the number of taxis employed. Note that in our case we are assum-
ing that the healthcare workers have a permanent contract and are available during the
entire work day.
The algorithm GRASP(1000) improves the waiting costs of the taxis of the optimal
solution for the first model in = 43.56%. However, the driving costs
opt 1st model−GRASP
opt 1st model
of the optimal solution for the first model improves those of GRASP(1000) in
= 29.55%. That is, the improvement we obtain comes from the
GRASP−opt 1st model
GRASP
improvement in the waiting costs, at the expense of larger driving costs. Regarding staff
cost, we have calculated it as the total time spent by the staff, as we do with taxis. The
time spent by the healthcare workers is = 4.14% better in the optimal
GRASP−opt 1st model
GRASP
solution of the first model than in the GRASP(1000). Therefore, part from the improve-
ment in the transportation cost is obtained at the expense of increasing the total time
spent by healthcare workers. Since the second model includes the constraint of working
with the same number of taxis as the first model, the number of taxis used in
GRASP(1000) is the same as in the first model, except for the 13% of the cases where
GRASP(1000) uses one less taxi. Summing up, even considering staff costs and the
number of taxis employed the second model provides a solid improvement over the first
one.
Finally, we have analysed whether the possibility of walking can even further
reduce the total transportation costs. We have tested GRASP(1000) with walk_
max = 5 and walk_max = 10 min, obtaining the results of Table 10. Hence, depend-
ing on the instance, allowing for the possibility of walking may reduce the cost by
more than 5%.
To summarise, computational results show that the mathematical model that
reflects the current practice of the hospital is an efficient tool that can be used by the
hospital for obtaining the solution for such a complex problem in a short computa-
tional time. However, computational results with the generalised model also indi-
cate that there is room for improvement. The relaxing of some requirements and the
inclusion of more sustainable policies, like the options of walking or sharing taxis,
considerably reduce the transportation cost.
Table 10 Results of the inclusion of walking in the second model

Average improvement with respect to Maximum improvement with
GRASP(1000) (%) respect to GRASP(1000) (%)
walk_max = 5 min 0.58 5.76

walk_max = 10 min 1.32 6.74
13
7 Conclusions and future work
In this paper, we have considered the possibility of reducing the transportation costs
of healthcare staff in a home hospitalisation unit. To accomplish this, we have math-
ematically modelled the problem as the reference hospital solves it each day. The
model presented can be optimally solved with the use of a commercial modelling
system, thereby simplifying the time-consuming process currently followed at the
hospital.
The paper has also explored changes in the current strategies of the hospital that
can achieve an improvement in the quality of the solution. The changes to explore
have been agreed on with the hospital. In this way, a new model focused on costs
that includes only the restrictions considered necessary by the hospital and adds new
policies has been presented. The complexity of the new model has meant that only
very small instances (much smaller than the ones at the hospital) can be optimally
solved. Therefore, it has been necessary to develop a metaheuristic for its resolution.
Computational results find a gap between the two models of at least 15% on average.
If we consider the monthly cost of the taxis in the home hospitalisation unit to be
approximately €20,000, this 15% would translate into an annual saving of €36,000
without major changes to the initial solution. The evidence shows, therefore, that the
introduction of new models can improve the solutions found each day based solely
on experience.
Both the current model in use at the hospital and the new one proposed in Sect. 4
are only focused on transportation costs. This single-objective function leads to a
worsening in the staff times. To lessen the effect of this fact, another objective func-
tion considering this cost could be added to the generalised model. We would thus
obtain a multi-objective model taking into account transportation and staff costs. It
would then be necessary to develop specific local searches which could reduce staff
costs while increasing transportation costs as little as possible. We could either cre-
ate a joint objective function with both costs following the guidelines of each hos-
pital or create an algorithm which would obtain a set of alternatives with different
combinations of transportation and staff costs—a Pareto front of the two objective
functions. Each hospital would then select the most appropriate solution. In both
cases, other important features could be added to the model: maximum total wait-
ing time for workers, maximum ride time, maximum total walking time, different
capacities for the taxis, etc.
The new strategies proposed to the hospital also provide more sustainable solu-
tions. Mathematical models that balance the economic quality of the solution with
sustainability aspects are going to be an interesting new research field in the future
(Gunasekarana and Subramanian 2018). The ideas we propose in this paper are eas-
ily extended to other areas in the home service industry.
Given the marked superiority of the more general model, there are several areas
for further research. The development of more complex heuristic and metaheuris-
tic algorithms will allow for further reductions in the transportation costs. In this
paper, we have worked with deterministic times. However, variability is an impor-
tant issue, especially since the travel time between homes depends on the traffic
13
and thus may vary significantly. More complex algorithms could be developed to
provide sufficiently robust solutions such that this variability does not substantially
affect the quality of the solutions. A simulation study which considers real-world
settings would be worthwhile to affirm the robustness of the solutions. Furthermore,
mechanisms that could check the solution in real time and react to any unforeseen
circumstance would obviously improve the implementation of the scheme.
Acknowledgements This research has been partially supported by the Ministerio de Ciencia e Inno-
vación (Ministry of Science and Innovation), MTM2011-23546. We would like to thank La Fe Hospital
for introducing the problem to us and for offering real data of the routes, especially Dr. Bernardo Val-
divieso and nurse Amparo Bahamontes.
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Mathematical Models To Improve The Current Practic

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OR Spectrum (2020) 42:43–74

Mathematical models to improve the current practice

Sacramento Quintanilla1 · Francisco Ballestín1 · Ángeles Pérez1

Keywords Home healthcare problem · Heuristics · Nonlinear integer programming ·

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

(1) Workers are distributed in teams of doctors and nurses.

3 Current model at the reference hospital: description and modelling

3.1 Description of the problem

xijk 1, if taxk travels along arc (i,j), 0 otherwise

(tdoc(i) + tdoc(j)) ∗ xij2 = 0 ∀i, j ∈ V t (10)

xijk ∈ {0, 1} ∀i, j ∈ V t ; k = 1, 2 (12)

Table 2 Assignment of homes hi team(i) tdoc(i) tnur(i) First-hour visit

Table 3 Travelling times by taxi 0 1 2 3 4 5 6 7 8 9

Table 4 Initial distribution of taxi Description Workers Homes

{workers who travel through the arc by taxi 3}

4 Extended model: description and modelling

4.1 Description of the problem

The new problem is modelled as a nonlinear integer optimisation problem. We con-

⎧ tdoc(i), if l ≤ ndoc, w ∈ team(i)

⎧ 1, if taxi tax travels through

⎧ arrival time of taxi tax to home h ,

⎧ leaving time of taxi tax from home h ,

⎧ arrival time of worker (k − ntax)to home h ,

⎧ leaving time of worker (k − ntax) from home h ,

zil ≤ candidate(i, l) i = 1, … , n; l = 1, … , nw (16)

ykijl ≤ xijk i, j = 0, … , n; i ≠ j; k = 1, … , ntax; l = 1, … , nw (20)

y0ijl d(i, j, 2) ≤ walk_max i, j = 0, … , n; i ≠ j; l = 1, … , nw (21)

inki ≤ outik i = 1, … ., n;k = 1, … , ntax + nw (26)

ink0 ≥ out0k k = 1, … , ntax + nw (27)

inkn+1 ≥ outn+1 (28)

zil ∈ {0, 1} i = 0, … , n; l = 1, … , nw (41)

ykijl ∈ {0, 1} k = 0, … , ntax;i, j = 0, … , n; i ≠ j; l = 1, … , nw (42)

xijk ∈ {0, 1} k = 1, … , ntax; i, j = 0, … , n + 1; i ≠ j (43)

inki , outik ∈ ℤ+ k = 1, … , ntax; i = 0, … , n + 1 (44)

inki , outik ∈ ℤ+ (45)

Table 5 Values of twork(i,l)

20-40 30-50 145-145

180-180 140-140 110-120

― : arrival-leaving time of taxi k´

{workers who travel through the arc by taxi 3}

{workers who travel through the arc on foot}

Fig. 2 Feasible solution following the new model

Table 6 Assignment of homes Worker Homes

Table 7 Route for w

5 Solution approach for the extended model

The model presented in Sect. 4 is a nonlinear integer problem whose resolution is

1. Assignment of houses to nurses:

3.1. Start the route at the hospital.

Table 8 Results of the Dev. to optimal sol Average cost

Optimal GAMS 24.4 – 6724.64

Fig. 3 Relationship between number of houses and improvement

Table 9 Role of nRCL in the nRCL = 2 nRCL = 3 nRCL = 3 nRCL = ∞

Table 10 Results of the inclusion of walking in the second model

walk_max = 5 min 0.58 5.76

7 Conclusions and future work

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3 Current model at the reference hospital: description and modelling

3.1 Description of the problem

4 Extended model: description and modelling

4.1 Description of the problem

5 Solution approach for the extended model

7 Conclusions and future work