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