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 |