Integrated Care for Older People and the Implementation in the INSPIRE Care Cohort

Proposal based on the Integrated Care Manual for the Elderly (ICOPE),  has been developed by the World Health Organization (WHO) to meet the health needs and demands of rapidly aging populations around the world. The Manual helps to set person-centered goals and integrate approaches at the system, service, and clinical levels. The care plan can include multiple interventions to manage declining capacity, provide social and support, develop self-management skills, and support caregivers.

The main objective of the INSPIRE study is to build a Bio-resource Research Platform for Healthy Ageing gathering biological, clinical and digital resources in order to identify markers ...

Empowering Better End-of-Life Dementia Care (EMBED-Care): A mixed methods protocol to achieve integrated person-centred care across settings

It is known that the number of people with dementia continues to increase in the world. We also know that people with dementia live to advanced stages of the disease, so they will require comprehensive palliative care. The aim objetive of this work, is to promote a “step change” in care for people with dementia and their carers to enable delivery of timely person-centred care, to identify unmet needs and improve outcomes, including comfort and qualitive of life, towards end of life. Each of six-interdependent work streams (WSs) will deliver new knowledge and sequentially build a complex intervention to improve ...

Understanding integrated care at the frontline using organisational learning theory: A participatory evaluation of multi-professional teams in East London

Integrated care has been proposed as an organising principle to address the challenges of the rising demand for care services and limited resources. There is limited understanding of the role of learning in integrated care systems. Organisational Learning (OL) theory in the guise of ‘Learning Practice’ can offer a lens to study service integration and reflect on some of the challenges faced by multi-professional teams in developing a learning culture.

The study presents findings from two qualitative evaluations of integrated care initiatives in three East London boroughs, England, undertaken between 2017 and 2018.

Different Contexts, Similar Challenges. SUSTAIN’s Experiences with Improving Integrated Care in Europe

SUSTAIN stands for ‘Sustainable Tailored Integrated Care for Older People in Europe’ (www.sustain-eu.org). The SUSTAIN-project was carried out between 2015 and 2019 by thirteen partners from eight European countries: Austria, Belgium, Estonia, Germany, Norway, Spain, the Netherlands, and the United Kingdom.

The SUSTAIN project was designed to support the development of integrated care for older people living at home with health and social care needs. Its objectives were twofold: 1. To support and monitor improvements to established integrated care initiatives and 2. To contribute to the adoption and application of such improvements to other health ...

The Over 75 Service: Continuity of Integrated Care for Older People in a United Kingdom Primary Care Setting

Continuity of care is concerned with quality of care over a period of time. It describes a process by which service users and their families are co-operatively involved with health and social care professionals in managing their care needs. Continuity of care can be divided into informational, managerial and relational and has been associated with improved user- and service-related outcomes. To date, there have been few studies which examine how continuity of care is developed and maintained in integrated primary care systems. 

Integrated Care for Older Adults: A Struggle for Sustained Implementation in Northern Netherlands

Integrated care has been suggested as a promising solution to the disparities in access and sustained high quality long-term care emerging in Europe’s ageing population. The Dutch integrated person-centred health service for older adults was based on two evidence-based models (the Chronic Care Model and the Kaiser Permanente Triangle). In this case study we assess the impact of the programme based on past evaluations, reflect on why it ended, lessons learned and ideas to take forward.

Supporting older people in remote areas in a post COVID-19 time

The COVID-19 pandemic, like other disasters, undermines older people´s capacity and chances of survival as a result especially of emergency induced mental health and psychological problems, and the breakdown in services for preventing and treating chronic conditions and for providing social support. Furthermore, maintaining relationships is often identified by older people as central to their wellbeing, but social distancing has transformed the lives of everyone in society and has changed relationships and personal contact as well. Here, we set out how the COVID-19 pandemic affects older people in remote areas specifically.

Impact of the CareWell integrated care model for older patients with multimorbidity: a quasi-experimental controlled study in the Basque Country

Older patients with multimorbidity have complex health and social care needs, associated with elevated use of health care resources. The CareWell program for older patients with multimorbidity, is based on the coordination between health providers, home-based care and patient empowerment, supported by information and communication technology tools. The implementation of CareWell integrated care model changed the profile of health resource utilization, strengthening the key role of primary care and reducing the number of emergency visits and hospitalizations

Measuring the benefits of the integration of health and social care: qualitative interviews with professional stakeholders and patient representatives

Integrated care has the potential to ease the increasing pressures faced by health and social care systems, however, challenges around measuring the benefits for providers, patients, and service users remain. This paper explores stakeholders’ views on the benefits of integrated care and approaches to measuring the integration of health and social care.

Improving Person-Centredness in Integrated Care for Older People: Experiences from Thirteen Integrated Care Sites in Europe

Although person-centredness is a key principle of integrated care, successfully embedding and improving person-centred care for older people remains a challenge. In the context of a cross-European project on integrated care for older people living at home, the objective of this paper is to provide insight at an overarching level, into activities aimed at improving person-centredness within the participating integrated care sites. The paper describes experiences with these activities from the service providers’ and service users’ perspectives.