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Table 1 Basic information on the 17 selected integrated care programmes for persons with complex needs

From: The patient at the centre: evidence from 17 European integrated care programmes for persons with complex needs

  Programme name Location Programme type Target group Aim
P01 Health Network Tennengau Tennengau region, Salzburg, Austria Bottom-up network of social and health service providers and voluntary organisations Entire population of the Tennengau region, but particular focus on elderly persons in need of social care Improving coordination of care across sectors and providers; improving patient experience
P02 Sociomedical Centre Liebenau Liebenau and Jakomini districts in the city of Graz, Styria, Austria Multi-disciplinary group practice collaborating with association for practical social medicine Persons with complex needs in multiple life domains (e.g. physical/mental health problems, social problems) Providing holistic health and psychosocial care to vulnerable groups according to an emancipatory approach
P03 GeroS Croatia (covers several counties) Information system for health and social care records All insurees aged 65 and over, in particular geriatric patients Centralising of health and social care data; monitoring and evaluating health needs and functional abilities of the elderly population
P04 Palliative Care System Croatia (covers several counties) Coordination programme for palliative care Persons in need of palliative care Improving quality and adequacy of palliative care; implementing systematic care approach on a national level
P05 Casaplus Germany (covers entire country) Case management programme contracted by sickness funds Persons aged 55 and over with multiple chronic conditions and at high risk for hospitalisation Reducing avoidable hospitalisations through preventive case management and enhanced self-management skills
P06 Gesundes Kinzigtal Kinzigtal region, Baden-Württemberg, Germany Population-based integrated care initiative Entire population of the Kinzigtal region Improving health of the population and patient experience; reducing per-capita costs of care
P07 OnkoNetwork Somogy county, Hungary Coordination programme in an oncology centre Persons with (suspected) diagnosis of a solid tumor Improving clinical outcomes for oncology patients via timely access to care and patient pathway management tools
P08 Palliative Care Consult Service Baranya county, Hungary Consultation programme for palliative care Persons in need of palliative care Providing high-quality palliative care to patients as well as support to families and professionals
P09 Proactive Primary Care Approach for Frail Elderly (U-PROFIT) Utrecht and North-West Veluwe regions, Netherlands Nurse-led elderly care intervention Frail elderly persons aged 60 years and over living at home Transitioning from reactive to proactive elderly care; preserving daily functioning; improving quality of care; reducing costs of care
P10 Care Chain Frail Elderly South-East Brabant region, Netherlands Multi-disciplinary care chain Elderly persons with complex care needs living at home Improving functional ability, health status and well-being; preventing/postponing nursing home admission
P11 Better Together in Amsterdam North (BSiN) Amsterdam North district in the city of Amsterdam, Netherlands Alliance of organisations from healthcare, social care, welfare, social security and youth care Persons with complex needs in multiple life domains (e.g. physical/mental health problems, social problems) Improving health and self-sufficiency of target population; improving quality of care; reducing costs of care
P12 Medically Assisted Rehabilitation Bergen City of Bergen, Norway Multi-disciplinary specialised treatment programme for opioid addiction Persons with opioid addiction Providing low-threshold integrated care beyond addiction treatment; improving quality-adjusted life expectancy
P13 Learning Networks Municipalities across Norway Multi-disciplinary integrated care teams in municipalities Elderly persons using home nursing services or with short-term stays in nursing homes Developing coordinated and safe patient pathways and health promotion services; improving functional ability
P14 Badalona Serveis Assistencials Badalona region, Spain Integrated care organisation of health and social service providers Frail elderly persons with complex care needs Promoting independent living by offering support to prevent hospitalisation and nursing home admission
P15 Área Integral de Salut, Barcelona Esquerra (Ais-Be) Barcelona-Esquerra, city of Barcelona, Catalonia, Spain Programme for community-based collaborative care by a university hospital Persons with complex care needs Bridging between hospital-based specialised care and community-based services
P16 Salford Integrated Care / Salford Together City of Salford, Greater Manchester, United Kingdom Community-based integrated chronic care programme Adults with chronic conditions Improving coordination of care; supporting patients in self-management; reducing hospitalisations and nursing home admissions
P17 South Somerset Symphony South Somerset district, United Kingdom Health coaching programme in hospital-based complex care hubs and GP practices Persons with 3 or more chronic conditions Supporting patients in self-management and thereby empowering them; improving coordination of care