出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : Due to population ageing, health systems face the challenge to offer care and support to an increasing number of older people. Therefore, governments are encouraging older people to participate in society and to live at home for as long as possible, with support from formal and informal caregivers. Many people age in good health and remain active participants in society throughout their lives. However, the prevalence of frailty, (multi)morbidity and disability increases with age, eventually leading to multiple health and social care needs. These multiple needs often lead to restrictions in social participation, reduced self-reliance and care dependence, which in turn may lead to the utilisation of long-term care and support services. Sustainable health systems, addressing both health and social care needs, will be necessary to optimally support older people, while potentially restricting healthcare expenditures. Integrated care is widely acknowledged to be the way forward in care delivery to support this vision. Therefore, in an increasing number of EU Member States, integrated care initiatives are being put in place as new models for safe and efficient, prevention-oriented care to an increasing number of older people. Evidence of the effectiveness of integrated care is, however, inconclusive. Also there is little knowledge of how to practice integrated care, how to successfully implement it and how to transfer successful initiatives to other regions and health systems. In response to these challenges, a European multidisciplinary consortium has been assembled to work towards the following objectives: 1. to improve established integrated care initiatives for older people living at home with multiple health and social care needs, ensuring they are patient-centred, prevention-oriented, efficient, and safe; 2. to ensure that improvements to the integrated care initiatives are applicable and adaptable to other health systems and regions in Europe. The SUSTAIN project (i.e. Sustainable tailored integrated care for older people in Europe) is funded under Horizon 2020 – the Framework Programme for Research and Innovation (2014-2020), and carried out by thirteen partners from nine EU Member States. Methods : The SUSTAIN project will last 48 months and is divided into three interrelated phases. During the first phase (i.e. preparation phase), we will establish working relationships with two established integrated care initiatives in seven countries (Austria, Estonia, Germany, the Netherlands, Norway, Spain, United Kingdom) that have indicated to be motivated to improve current practice. To understand where improvements are necessary, baseline assessments will take place in each of the countries to understand experiences, strengths and weaknesses, barriers to successfully put integrated care into practice, and attitude to change of stakeholders involved. In the second phase (i.e. implementation research to improve existing integrated care initiatives) based on the outcomes of the baseline assessments, tailored sets of improvement will be designed and implemented together with stakeholders (i.e. policymakers, commissioners, health insurers, health and social care professionals, older people, informal carers). The implementation of improvements and the overall evaluation of the implementation processes and its outcomes will be guided by a multi-methodological approach, the Evidence Integration Triangle (EIT). Overarching analyses will be undertaken to compare and integrate data from the different sites to robustly identify what works for whom, in what context and with what outcome. Throughout the project, the applicability and adaptability of the improvements in different context are central, to ensure that different regions and countries use each other’s knowledge and learn from each other’s experiences. In the third phase, (i.e. translation to products and impacts) previous work will be translated to products and impacts for different user groups. Tailored dissemination strategies will be designed to increase uptake of SUSTAIN’s findings. SUSTAIN is now in its preparation phase. Results and discussion: Lessons learned in SUSTAIN and international evidence and theory in the context of integrated care will be brought together in one of SUSTAIN’s main deliverables, being an online roadmap. The roadmap will be a set of instructions, guidelines and proposed actions that will provide a step-by-step guide to support designing, establishing and maintaining systems of integrated care. As such, we aim to support policy-makers and decision-makers to improve care for older people with multiple health and social care needs now and in the future by working towards more patient-centred, prevention-oriented, safe and efficient integrated care provision.
关键词：complex needs ; european collaboration ; integrated care ; older people
