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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