Table 4 Activities of the partnership as manifested in its major projects.

1.

'Bijlmer Social Care Centre*

To establish a community-based, decentralized, integrated social care institution to prevent fragmented and compartmentalized social care delivery.

The centre was established in the South-eastern Amsterdam district. Community intelligence was used to plan the volume and capacity of the centre.

Residents actively participated in the development of the project.

At the strategic level, the partnership influenced local policy-making processes by promoting the establishment of the centre.

The centre was realized in 1972.

2.

Primary care centres

To establish decentralized and multifunctional primary care centres.

All centres were established in the South-eastern Amsterdam district. Community intelligence was collected and used to plan the centres.

Residents actively participated in the development of the centres.

At the strategic level, the partnership influenced local policy-making processes by promoting the establishment of the primary care centres.

At the operational level, the executive office supported the primary care professionals who had the lead in setting up the centres.

Five primary care centres have successfully been established between 1975 and 1981 and still exist today. In 2001, the centres merged into the GAZO.

3.

Outpost outpatient clinic Ganzenhoef

To establish an outpost for medical specialist care and to develop innovative relationships with primary care.

Residents living in South-eastern Amsterdam who needed medical specialist care could use the outpost.

At the strategic level, the partnership discussed and developed proposals to continue the outpost and to use it as a vehicle for innovation.

The outpost outpatient clinic was closed in 1983 because support from the AMC fell away.

4.

Regional ambulatory mental care institution South-east (RIAGG)

To establish one decentralized institution for ambulatory mental health care.

The RIAGG was established in the South-eastern Amsterdam district. Community intelligence was collected and used to plan the institution.

Residents actively participated in its development.

At the strategic level, the partnership influenced local policy-making processes by promoting the establishment of one RIAGG.

At the operational level, the executive office supported the working group that had to develop and implement the plan.

The RIAGG has been operational since 1980, though more centrally organized than originally planned. In 1997 the RIAGG merged with the AMC and the Frederik van Eeden Stichting to form AMC/de Meren.

5.

Intensive home care/respite care beds

To organize health care as close as possible to the living environment of patients by optimizing the use of available expertise. This implied intensifying home care and establishing respite care beds in residential homes.

All residents living in South-eastern Amsterdam could make use of intensive home care and/or respite care beds.

Community intelligence on production data (e.g. waiting lists, bed occupancy rates, needs assessments conducted) are continuously registered and regularly reported to manage the project.

At the strategic level, the partnership initiated, developed and realized the project.

In order to execute the project, the partnership set up the circuit management that had to develop, implement, monitor, coordinate, control the budget and manage the project.

Since 1990, intensive home care and respite care beds have been developed and are operational.

6.

Shared care of psychogeriatric patients

To optimize the diagnosis, treatment and care for psychogeriatric patients by strengthening primary care and improving the input of secondary and tertiary care professionals.

All psychogeriatric patients residing in South-eastern Amsterdam can use this shared care service.

Community intelligence on demographics and on the existing psychogeriatric care delivery was used to legitimize and manage the project.

At the strategic level, the partnership initiated, developed and realized the project.

At the operational level, the circuit management developed, implemented, monitored, coordinated, and managed the shared care arrangement.

In 1989, a working group started to develop a project proposal. In 1992, a pilot was started. Since 1995, the shared care arrangement for psychogeriatric patients has been operational.

7.

Integrated care needs assessments

To assess care needs of patients and to allocate and initiate appropriate care.

The partnership was responsible for assessing care needs of all patients residing in South-eastern Amsterdam.

Community intelligence on production data was registered and monitored and regularly reported to manage the project.

At the strategic level, the partnership the partnership initiated, developed and realized the project.

At the operational level, the circuit management was responsible for conducting, registering and monitoring the integrated care needs assessments.

The project was operational between 1993 and 1997.

8.

Stroke service

To establish a complete, reliable and standardized supply of diagnosis, treatment, care, nursing and rehabilitation for stroke patients.

All stroke patients residing in South-eastern Amsterdam are eligible for admission.

Community intelligence on the prevalence of stroke was used to estimate the number of patients a year and production data are continuously collected to monitor and manage the service.

At the strategic level, the partnership developed and realized the project, which was initiated and developed primarily by the AMC.

At the operational level, the circuit management coordinates, controls, monitors and registers all individual patients in the stroke service according to standardized criteria and procedures.

The project has been operational since 1996. In April 1998, the stroke service became a structural, integrated care arrangement in the region.

9.

Professional knowledge centre for care of the elderly

To develop a regional knowledge centre aimed at developing integrated care arrangements and care coordination for the frail elderly.

The project is targeted at all frail elderly residing in South-eastern Amsterdam.

At the strategic level, the partnership was involved in the initiation, development and realization of the knowledge centre.

The professional knowledge centre has been operational since November 2002.

10.

Emergency psychogeriatric care unit

To retain four nursing home beds for temporal and emergency admissions of psychogeriatric patients.

Only patients residing in South-eastern Amsterdam are eligible for admission.

The unit was legitimized on the basis of monitoring data that showed inappropriate care for 10 to 15 patients a year in the community.

At the strategic level, the partnership was involved in the initiation, development and realization of the unit.

At the operational level, the circuit management collects, assesses and registers applications according to standardized criteria and procedures.

The unit has been operational since January 2004 and four beds are available.

11.

Coordination of complex patients at home

To coordinate, align and supervise multidisciplinary care for complex patients by one assigned professional.

All patients with multidimensional health problems and living in the South-eastern Amsterdam are eligible for care coordination

At the strategic level, the partnership initiated and developed the service.

At the operational level, the circuit management initiated and developed the service; it also supports the service on a day-to-day basis.

The one-year pilot has been evaluated. The service has now become structural.

12.

Community care service points

To support elderly residents living at home to find an appropriate mix of health care, social care and housing that meet their needs and wishes.

Nine service points are planned in the elderly care institutions located in South-eastern Amsterdam.

Community intelligence on demographics and the local health system was used to legitimize the service points.

At the strategic level, the partnership got involved to approve, support, align activities and monitor the development of the service points.

The first three community service points became operational on 1 May 2005. The other six will be implemented at a later stage.