出版社：Utrecht University, Maastricht University, Groningen University
摘要：Introduction : In an increasing number of EU countries, integrated care initiatives are being put in place as new models to support older people with complex problems living in the community. Evidence of the effectiveness of integrated care is, however, inconclusive. Also there is little knowledge of what is the best way to practice integrated care, how to successfully implement it and how to transfer successful initiatives to other regions and health systems. Aim : SUSTAIN is a European-wide project in which thirteen organizations from nine European countries collaborate to work towards the following aims: 1. improve established integrated care initiatives for older people living at home with multiple health and social care needs and 2. ensure that improvements to the integrated care initiatives are applicable and adaptable to other health systems and regions in Europe. Targeted population and stakeholders : The SUSTAIN project is currently 18 months underway. We have established working relationships with thirteen integrated care initiatives spread across seven European countries. These initiatives vary in terms of e.g. type of care services being offered, involved stakeholders and organizations, and targeted populations of older people (e.g. older people discharged from hospital, older people with cognitive impairment, frail older people in primary care). Practice change implemented : Despite their differences, these sites encounter quite similar bottlenecks to coordination and integration of care, and as such aim to improve in similar areas. Areas of improvement include clearer agreements on tasks and responsibilities of stakeholders involved, better collaboration between professionals from health and social care, better information exchange and more intense engagement of older people and their informal carers. Theory of change : SUSTAIN research partners are collaborating with local stakeholders (e.g. health and social care professionals, managers, older people, policy-makers) attached to the different sites to change the current way of working; all intended to move towards more person-centred, prevention-oriented, safe, and efficient care. Time line and highlights : Improvement projects will be rolled-out and outcome and progress will be monitored during an 18 month period (approx. October 2016-April 2018). This process is underpinned by the Evidence Integration Triangle, an approach targeted at effective implementation of scientific evidence in daily practice. Sustainability and transferability : Overarching analyses will be undertaken to compare and integrate data from the different integrated care initiatives to robustly identify what works for whom, in what context and with what outcome. As such, we will obtain EU evidence on the applicability and adaptability of integrated care initiatives for older people living at home with multiple health and social care needs in relation to different European health systems and regions. Equally importantly, we will identify the steps that are necessary to realise improvement of existing initiatives. Project results will be translated to a roadmap targeted at policy-makers and decision-makers in care systems tasked with designing, establishing and maintaining systems of integrated care that focus on older people with complex needs. Conclusion, discussion and lessons learned : During this workshop, we will share the lessons that we have learned so far during the SUSTAIN project. During the first presentation, we will provide a general overview of the project. The second presentation focusses on our overall methodological approach and the methodological challenges that we have encountered. During the third and fourth presentation, we will provide insights in the participating integrated care sites from the Netherlands and Catalonia respectively and their experiences with the roll-out of their improvement projects so far. The fifth presentation is dedicated to the development process of the roadmap. We will discuss with the audience what will be important elements of the roadmap and inform them how we aim to move forward.
