Integrated care sites

Consortium members established working relationships with two integrated care initiatives per country in order to improve current practice.

The initiatives have been identified using the following inclusion criteria, which have been constructed from previous research:

  • Focus of the integrated care initiatives should be on people at least aged 65 years who live in their own homes and who have multiple health and social care needs;
  • Integrated care initiatives should address older people’s multiple needs, in other words, they should not be single disease oriented;
  • Integrated care initiatives should aim at keeping people at their own home (or environment) for as long as possible;
  • Professionals from multiple disciplines (health and social care, e.g. nurses, social workers, pharmacists, dieticians, General Practitioners) in multidisciplinary teams should be involved;
  • Integrated care initiatives should be established, i.e. operational for at least two years;
  • Integrated care initiatives must be willing to improve towards more patient-centred, prevention-oriented, safe and efficient care;
  • Integrated care initiatives should cover one geographical area or local site;
  • Involvement of the integrated care initiative must be mandated by one organisation that represents the initiative (to facilitate partnering).


Coordinated Palliative Care in Graz

Graz (Styria)
Target group:
Clients with chronic and terminal illnesses living at home

The aim of this organisation is to coordinate the establishment and further development of hospices and palliative services in residential and community care, in particular by means of multi-professional mobile palliative care teams, in the region of Styria (our main focus will be on the area of Graz). This includes the improvement of quality, cooperation between relevant facilities specialised in palliative care and general health and social care services, as well as education and training in this field. The organisation has succeeded to receive mainstream-funding for currently nine mobile palliative care teams that offer services free of charge and cover the whole of Styria. The teams are involving volunteers in a coordinated manner and cooperate with a wide range of partners from hospitals to primary care, including home care and residential facilities.

Geropsychiatric Centre (GPZ) Vienna

Target group:
Clients living at home and suffering from (acute episodes of) depression, dementia, disorientation, acute stress disorders, forms of addiction, etc. - and their carers

The GPZ is affiliated to the ‘Psycho-Social Services’ (PSD) in Vienna. It is a unique centre for community-based geropsychiatric consultancy (clinical-psychiatry and neurology), and for anamnesis, thus functioning as a ‘clearing’ centre. It also includes a ‘Memory Clinic’ and offers counselling (by phone and face-to-face) to GPs, health and social care services as well as to hospitals and family carers. The multi-professional team (7.5 FTE) consists of psychiatrists, psychologists, nurses and a social worker. All services are free of charge. The integrated team is networking with a wide range of stakeholders in the area of health and social care.

Catalonia (Spain)

PCC/MACA /Geriatrics (Severe chronic patients/Advanced chronic disease/Geriatrics)

Target group:
Severe chronic patients, advanced chronic patients and people > 85 years old

This is a hospital-based integrated care programme at the population level in which different care levels are coordinated (primary care, acute care, intermediate and long-term care). The specialized care including the acute care (Vic Hospital Consortium), the intermediate care and long-term care (Santa Creu Foundation) have redesigned and reorganised their service delivery model under common agreements. Social care is provided from the different care levels and it is well articulated with social services at the City Council level, which manages more legal aspects (dependence law). All patients have a comprehensive assessment resulting in an individualized intervention care plan agreed with the patient and the family.

Social and health care integration in Sabadell, Catalonia

Vallès Occidental
Target group:
People with multiple social and health care needs. Eligibility criteria were jointly defined by social and health care professionals and they help to identify the target population. (e.g., chronic diseases, complex pharmacological treatments, lack of main caregiver, unskilled caregiver, among others)

This is a primary care based integrated care initiative in coordination with social services. This initiative is carried out in three Primary Care Centres (PCC Nord, PPC Ca N’Oriac and PPC Concòrdia) from which both health and social care are provided to the population living at the northern area of the city. Integration results from health and social care professionals sharing an agenda in which eligible cases are signed up to be discussed on a monthly basis meetings. Care plans are designed in these meetings and agreed with patients and family.


Alutaguse Hoolekeskus (Foundation)

Ida-Viru County, Mäetaguse
Target group:
Senior and disabled citizens

The objective of the Foundation Alutaguse Hoolekeskus is to facilitate living in dignity and safety for older and disabled citizens by supporting, promoting and maintaining their quality of life. The nursing and health care services of the Care Centre are mainly intended for older people from the Mäetaguse rural municipality and southern region of the Ida-Viru County. The Alutaguse Care Centre is based on a holistic approach recognizing clients’ physical, mental, social and spiritual needs and considering these to be of equal importance. The services have been planned with consideration of the real needs of senior citizens.

Services for older people include integrated nursing care proceeding from the needs determined by an assessment of the patient’s state of health; the services are offered in conformity to the objectives established and based on the (nursing) care plan. All activities are documented; the need for services is re-evaluated periodically to adapt individual (nursing) care plans.


Tallinn and nearby areas of Tallinn
Target group:
Clients discharged to home after the surgery, disabled clients and clients who for some other reason need follow-up care and treatment

Home nursing services are designed to assist older people and patients who are discharged to home after surgery, as well as disabled people and patients who for some other reason need follow-up care and treatment. In collaboration with the patient’s family and a specialist doctor, the best solution is found and the nurse’s role is to help patients stay at home. Medendi provides services that include consulting, drug distribution, blood pressure measurement, pulse reading, measurement of blood glucose with a glucometer, preventing pressure ulcers, treatment and care etc. Also rehabilitation in household activities is provided. Therapy of household activities includes: assessment of the client’s operational capability in his/her home environment; mapping of obstacles in the home environment and recommendations for readjustments; identifying the optimal personal assistance; setting the goal of activities; giving advice regarding personal assistance.


KV RegioMed Zentrum Templin

Templin – Uckermark - Brandenburg
Target group:
Multimorbid patients aged 65+ and their informal carers

In response to massive demographic change in rural Brandenburg, in 2014 an innovative care concept for older patients has been put in place in the Uckermark district, situated in the Northeast of Brandenburg. Housed at a local hospital in the town of Templin (16,000 inhabitants (2011), 23% of whom are 65+), the innovative programme offers intensive outpatient geriatric coaching for older patients with complex needs. With its Complex Therapy programme, KV RegioMed Zentrum Templin follows a preventive and rehabilitative approach aimed at strengthening the patient’s own coping capabilities. For three weeks, patients visit the practice spezialized on elderly people

on a daily basis. While receiving care and supportive therapy, programme participants learn about their medication plan, fall prevention, and a healthy diet and lifestyle. For each patient a personal, tailored care plan is developed, and guidance to professional and voluntary services in the community is also provided. During their time in the programme,  patients are supported by the “Agnes two” Case Manager (a specially trained practice assistant). However, a lot of patients do not get any support after having completed this 3 week programme.

The improvement project is a newly set-up Coordination and Consulting Centre (“Service Center”), which will be the central contact point regarding care issues for patients in the region. These services will not be exclusively for patients from the KV RegioMed Zentrum in Templin but are open and accessible to patients from other medical services in the region.


Pflegewerk (Careworks Berlin)

Berlin Marzahn-Hellersdorf
Target group:
Older, chronically ill people with long-term care needs as well as those affected by social isolation that comes with living alone

Careworks Berlin is aimed at improving the care of older people with complex health and long-term care needs. Careworks Berlin is already highly innovative and integrated in that it combines long-term condition (LTC) case management, discharge management, and palliative care under one roof.

The purpose of the SUSTAIN improvement project (“Therapy Pilots”) is to enhance inter-professional case management, creating synergies between therapists, nurses and informal carers, while putting healthcare therapists (i.e. physical therapists / speech therapists / occupational therapists  etc.) into the driver’s seat. This is an explicit transfer of prescribing practice to health care therapists according to the Social Code Book for Health (SGB V); § 63 SGB V, para 3b. This new role of health care therapists is aimed at improving multidisciplinary collaboration between medical doctors and health care therapists, allowing greater therapeutic involvement of  non-medical staff.



Integrated primary health and social care in Surnadal municipality

Møre and Romsdal county
Target group:
Frail, multimorbid patients age 65+ are among the key user groups

In Norway, municipalities are responsible for primary health and care services. Surnadal is a small municipality in central Norway. It has been innovative in developing home services with the aim of keeping users out of institutions.

Integrated rehabilitation at home, Søndre Nordstrand borough in Oslo municipality

Oslo County
Target group:
Frail, multimorbid patients age 65+ are among the key user groups

Everyday rehabilitation at patients’ homes. The objective is to train patients to regain functioning and live independently with good mastery over activities of daily living. Nurses, physiotherapists, occupational therapists and other health professionals deliver a variety of rehabilitative health services to patients at home. The service users are over 18 years old and include persons age 65+ who have multiple health problems. Average service hours per week is 5 hours.

The Netherlands

Good in one go, Arnhem

Arnhem, the Netherlands
Target group:
Frail older people living at home in the area

“Good in one go” is the name of a project executed by an existing network of health and social care organizations in the Arnhem region. The project aims to clarify and align the choices, scenarios and implications of a sudden need for more intensive care in the home (e.g. in the case of dementia or brain injury), for older people, their carers and professionals. In order to ultimately achieve the right care in the right place at the right time.

When a crisis (e.g. a fall or increased caregiver burden) in the home situation of a frail, older person occurs, often a temporary bed in a nursing home is requested. However, a temporary bed is not always the best solution for the older person since it may lead todisruption in the life of the older person . Additionally, it is not financially sustainable, because unnecessary admissions to temporary care or hospitals leads to higher costs. To make good decisions in a crisis situation, it is important that GPs, health care professionals and social care professionals take an holistic approach to the older person, taking into account their specific situation and needs. This means that not only a medical perspective is required, but a social perspective and the perspective of the family of the older person are just as important in making the best decision. This could be, for instance, more intensive care at home, hospital admission or a temporary bed in a nursing home, depending on the situation and the needs of the older person. To achieve this, collaboration between the involved professionals and organizations has to be improved.



Integrated Care Central and North Zeeland, Care for older people programme

Walcheren, Zeeland
Target group:
Frail older people living at home in the Walcheren region

The SUSTAIN project originally cooperated with the Walcheren Integrated Care Model (WICM) in the Netherlands. Unfortunately, the WICM had to withdraw from SUSTAIN due to prioritization reasons.

Integrated health and social care in the Geriatric Care Model, West-Friesland

West-Friesland, Noord Holland
Target group:
Frail older people living at home at risk for health and social problems

In the region of West-Friesland, health and social care professionals have been working in innovative ways to improve care and support for older people living at home. For instance, the municipality of Medemblik started working together with community nurses and social workers in a community social care team, in order to meet health and social needs in the community. Case-management to support people with dementia and their carers was introduced in the region, and general practitioners (GP’s) started working according to the Geriatric Care Model. In this model, a geriatric practice nurse is trained to carry out a multidimensional assessment of the patients’ functional health as well as their care and social needs using the Resident Assessment Instrument (RAI). This enables immediate identification of problem areas and provides guidance for individualised care plans. In complex situations, the assessment outcomes are discussed in  a multidisciplinary consultation team including a geriatric practice nurse, GP and/or nursing home physician and, if necessary, other involved health and social care providers.

In the SUSTAIN project, professionals aim to improve collaboration between these different activities, in order to better meet the needs of the frail, older person living at home.


Discharge to Assess: Swale

Target group:
Patients which would be triaged from hospital as needing category 2 health rehabilitation and which would then have transferred to community hospitals

65+ patients at Medway Maritime Hospital are currently assessed by the “Integrated Discharge Team” following the “own home is best” principle. The aim of the service is to reduce the number of patients transferring from acute hospitals to community hospitals or into care homes. The Team currently conduct triages and safety screens in the Hospital and, if clinically appropriate, patients are then discharged for a full care needs assessment in their own homes within four hours of the initial triage. Once home, patients receive the enablement and rehabilitative care as stipulated by the home assessment. In March 2016, “Discharge to Assess: Swale” will expand its service offer to patients who are discharged back home. The interventions will be delivered by the “Active Recovery Team” which will be made up of health and social care assessment practitioners like occupational therapists, physiotherapists, nurses, a Community Mental Health Practitioner Nurse, a Kent County Council Case Manager and Occupational Therapist. They will provide (more health & social care integrated) complex and high level support where required (including night care).

“Over 75 Service” – Sandgate Road Surgery

Kent, UK
Target group:
75+ with long-term care needs

Sandgate Road Surgery has developed an “Over 75 Service” which aims to establish clear multidisciplinary care pathways. The service identifies frail, older people and provides them with care that is person-centred and integrated in order to improve their health and wellbeing and maintain independence.

The initiative introduces a single assessment tool – the Dalhousie Frailty Screening Tool. A range of services can be offered such as befriending or regular telephone contact for those who are socially isolated, access to health training and care navigation as well as more complex care management involving multiple agencies. Anticipatory care planning is carried out for those nearing end of life. Carers’ needs are also assessed and supported. Through the Over 75 Service, care is individualised and preventative with a focus on patient safety.  Information sharing is enabled by monthly multidisciplinary meetings for those patients considered most at risk of unplanned admissions.