**3. Three exemplary projects on integrated care**

#### **3.1. Integrated Neighbourhood Approach (***Even Buurten* **in Dutch)**

This project aimed to develop integrated support for vulnerable elderly people, using both informal and formal networks [12–14].

A central coordinator, or pivot, worked with key figures to provide appropriate support for elderly people. At first she inventorised on one hand the needs and wants of frail elderly and on the other hand the offer of the volunteers. And then she matched the needs and the offer to organize tailor made support for the elderly. This improves the self-reliance and quality of life of elderly people aged 70 and over who are living at home.

stable and their well-being increased. Participants also experienced a greater sense of security and more control over their lives. Thanks to Embrace, older adults were less affected by the

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Participants also experienced improved quality of care, while case managers reported that they were better able to proactively match the needs of participants due to having developed

Embrace is an effective way to provide care for the elderly, in other words, more quality at the same cost. Currently, this new integrated care service has been implemented in several communities and is being financed by healthcare insurance companies and municipalities.

The 'Transitional Care Bridge' project focuses on the interface between primary care and hospital care [18–19]. Today, elderly people are discharged from hospitals sooner than they would have been in the past. After discharge from hospital, many older people experience physical decline. A quarter die within the first 3 months after being discharged from hospital, and about a third suffer further deterioration in their ability to perform basic activities such as walking, eating or dressing. The transitional care bridge aims to provide better care and support at home after elderly patients leave hospital with a so-called warm transfer. This begins with a visit from the home-care nurse while the patient is still in hospital, allowing the home-care nurse to become acquainted with the patient and to obtain information from the geriatric nurse. Within 2 days after leaving the hospital, the elderly person is visited at home again by the home-care

Research: Using a randomized controlled trial, the Transitional Care Bridge was investigated with 674 elderly people (337 in the intervention group and 337 in the control group) from 350 GPs, in three hospitals and home-care organisations. Care was comparable across the three hospitals and determined by screening on admission and a comprehensive geriatric

Results: 30 days after discharge, there were 37% fewer deaths among the elderly people in the intervention group than among those in the control group. The decrease in mortality was mainly a result of the 'warm' transfer from hospital, the prompt home visit after discharge and a better transfer of medication. Eighty percent of elderly people leave hospital with new medication; about half of these do not cope well with the new medication by themselves. The home-care

Implementation: The transitional care bridge has already been implemented in half of the hospitals in the Netherlands. It is one of the criteria for becoming a 'senior-friendly hospital',

As home-care nurses are already familiar with 80% of elderly people in their area, a visit to the hospital is not always necessary, provided that the transfer of data and the follow-up visit are conducted within 2 days of discharge. Tools and activities important for successful delivery of the project include a patient letter with information concerning medication and

effects of ageing and were confident they could live at home longer.

**3.3. Transitional Care Bridge (***Transmurale Zorgbrug* **in Dutch)**

nurse helped with the proper administration of new medication.

a quality hallmark created to improve hospital care for the elderly.

nurse. Another four visits follow.

assessment.

long-term relationships with these older adults. The costs remained the same.

Research: The project was investigated with a mixed method design. The participants were 372 vulnerable elderly people (and their caregivers), half of whom were in the intervention group and the other half in the control group.

Results**:** This project led to a great deal of new knowledge, experience and insights. After 1 year, there was no change in self-reliance (health-related), quality of life and well-being among the elderly, and there were no effects on outcomes for caregivers. However, the elderly, the pivots and the volunteers reported that they were very satisfied with their work. The cooperation of the pivots with informal caregivers was better than it was with other professionals. It also became apparent that conducting the project for different neighbourhoods requires a specific approach that fits with the 'culture' of each neighbourhood.

Implementation: The 'Integrated Neighbourhood Approach' has already been implemented in other neighbourhoods of Rotterdam and in other regions such as Groningen and Zeeland.

### **3.2. Embrace service for person-centred and integrated primary care (***SamenOud* **in Dutch)**

Embrace is based on the Chronic Care Model and the Kaiser Permanente Triangle [15–17]. It provides person-centred and integrated care and support to older adults living in communities. People, 75 years and older, are invited by their GP to participate. Participants receive an annual questionnaire and based on their answers are classified into one of three risk profiles: robust, frail and complex care needs. A multidisciplinary elderly care team provides care and support, with a suitable care intensity level, to each risk profile. Each team consists of a GP, a nursing home physician and two case managers: a district nurse and a social worker.

The programme includes regular Embrace community meetings in which self-management abilities are encouraged. Local healthcare and welfare organisations provide information on health maintenance, physical and social activities and dietary recommendations. In addition, frail people and those with complex care needs receive individual support from a case manager. They jointly develop an individual care and support plan targeting all health-related problems. Before being implemented, the plan is agreed upon by the elderly care team. The case managers monitor changes in medical, psychosocial or living conditions and navigate the plan's delivery.

A web-based personal electronic record system supports the elderly care team and provides data for monitoring and evaluation.

Research: The original project was evaluated with a randomized controlled trial with about 1500 participating older adults and with several qualitative and longitudinal studies.

Results: The prevalence and severity of health-related problems were significantly decreased among older adults who received case management, while their general health remained stable and their well-being increased. Participants also experienced a greater sense of security and more control over their lives. Thanks to Embrace, older adults were less affected by the effects of ageing and were confident they could live at home longer.

Participants also experienced improved quality of care, while case managers reported that they were better able to proactively match the needs of participants due to having developed long-term relationships with these older adults. The costs remained the same.

Embrace is an effective way to provide care for the elderly, in other words, more quality at the same cost. Currently, this new integrated care service has been implemented in several communities and is being financed by healthcare insurance companies and municipalities.

#### **3.3. Transitional Care Bridge (***Transmurale Zorgbrug* **in Dutch)**

A central coordinator, or pivot, worked with key figures to provide appropriate support for elderly people. At first she inventorised on one hand the needs and wants of frail elderly and on the other hand the offer of the volunteers. And then she matched the needs and the offer to organize tailor made support for the elderly. This improves the self-reliance and quality of

Research: The project was investigated with a mixed method design. The participants were 372 vulnerable elderly people (and their caregivers), half of whom were in the intervention group

Results**:** This project led to a great deal of new knowledge, experience and insights. After 1 year, there was no change in self-reliance (health-related), quality of life and well-being among the elderly, and there were no effects on outcomes for caregivers. However, the elderly, the pivots and the volunteers reported that they were very satisfied with their work. The cooperation of the pivots with informal caregivers was better than it was with other professionals. It also became apparent that conducting the project for different neighbourhoods requires a specific

Implementation: The 'Integrated Neighbourhood Approach' has already been implemented in other neighbourhoods of Rotterdam and in other regions such as Groningen and Zeeland.

Embrace is based on the Chronic Care Model and the Kaiser Permanente Triangle [15–17]. It provides person-centred and integrated care and support to older adults living in communities. People, 75 years and older, are invited by their GP to participate. Participants receive an annual questionnaire and based on their answers are classified into one of three risk profiles: robust, frail and complex care needs. A multidisciplinary elderly care team provides care and support, with a suitable care intensity level, to each risk profile. Each team consists of a GP, a

The programme includes regular Embrace community meetings in which self-management abilities are encouraged. Local healthcare and welfare organisations provide information on health maintenance, physical and social activities and dietary recommendations. In addition, frail people and those with complex care needs receive individual support from a case manager. They jointly develop an individual care and support plan targeting all health-related problems. Before being implemented, the plan is agreed upon by the elderly care team. The case managers monitor changes in medical, psychosocial or living conditions and navigate the plan's delivery. A web-based personal electronic record system supports the elderly care team and provides

Research: The original project was evaluated with a randomized controlled trial with about

Results: The prevalence and severity of health-related problems were significantly decreased among older adults who received case management, while their general health remained

1500 participating older adults and with several qualitative and longitudinal studies.

**3.2. Embrace service for person-centred and integrated primary care (***SamenOud* **in** 

nursing home physician and two case managers: a district nurse and a social worker.

life of elderly people aged 70 and over who are living at home.

approach that fits with the 'culture' of each neighbourhood.

and the other half in the control group.

data for monitoring and evaluation.

**Dutch)**

104 Gerontology

The 'Transitional Care Bridge' project focuses on the interface between primary care and hospital care [18–19]. Today, elderly people are discharged from hospitals sooner than they would have been in the past. After discharge from hospital, many older people experience physical decline. A quarter die within the first 3 months after being discharged from hospital, and about a third suffer further deterioration in their ability to perform basic activities such as walking, eating or dressing. The transitional care bridge aims to provide better care and support at home after elderly patients leave hospital with a so-called warm transfer. This begins with a visit from the home-care nurse while the patient is still in hospital, allowing the home-care nurse to become acquainted with the patient and to obtain information from the geriatric nurse. Within 2 days after leaving the hospital, the elderly person is visited at home again by the home-care nurse. Another four visits follow.

Research: Using a randomized controlled trial, the Transitional Care Bridge was investigated with 674 elderly people (337 in the intervention group and 337 in the control group) from 350 GPs, in three hospitals and home-care organisations. Care was comparable across the three hospitals and determined by screening on admission and a comprehensive geriatric assessment.

Results: 30 days after discharge, there were 37% fewer deaths among the elderly people in the intervention group than among those in the control group. The decrease in mortality was mainly a result of the 'warm' transfer from hospital, the prompt home visit after discharge and a better transfer of medication. Eighty percent of elderly people leave hospital with new medication; about half of these do not cope well with the new medication by themselves. The home-care nurse helped with the proper administration of new medication.

Implementation: The transitional care bridge has already been implemented in half of the hospitals in the Netherlands. It is one of the criteria for becoming a 'senior-friendly hospital', a quality hallmark created to improve hospital care for the elderly.

As home-care nurses are already familiar with 80% of elderly people in their area, a visit to the hospital is not always necessary, provided that the transfer of data and the follow-up visit are conducted within 2 days of discharge. Tools and activities important for successful delivery of the project include a patient letter with information concerning medication and rehabilitation policy, a user-friendly questionnaire to detect vulnerable elderly people and 10 days of training for district nurses. For the purpose of allowing greater freedom for elderly people, elderly associations have developed a form which elderly patients can use to request a geriatric assessment upon admission to hospital and medical information at discharge.

**5. Continuation**

dementia.

oped in the coming years.

cope with their multiple problems.

for the period from 2017 to 2022.

**6. Lessons learned**

The Dutch National Care for the Elderly Programme, which began as a research project, has since become a movement. The results will be implemented further by the consortium Ageing Better (BeterOud in Dutch), a cooperation of 11 organisations including knowledge institutes for long-term care and welfare, elderly associations, regional support networks and housing corporations [3]. The movement's many ambassadors work to advocate the message that old age is a new phase, the logical continuation of your life, in which you still manage your own life and in which you still play the main role. Ageing Better aims to support and inspire every-

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In 2015, Deltaplan Dementia was launched by the Netherlands Organisation for Health Research and Development (ZonMw), a large national programme for fundamental research on dementia and a programme of initiatives to improve care for patients suffering from

In 2018 a new programme on long-term care for frail elderly people and people with physical and mental disabilities will be launched by ZonMw, a programme for the next 4 years.

The Dutch College of General Practitioners has renewed their Vision on General Practice Care for the elderly and developed a National Primary Care Agreement for communication

A national guideline for person-centred and integrated care for elderly patients will be devel-

The Advisory Board for Health and Welfare of the Ministry of Health, Welfare and Sport has recommended introducing a personal care plan to be used for all elderly patients to help them

The Dutch government will set aside EUR 435 million in 2018 for the nursing homes and suggests that in the long term, some 2.1 billion euros can be added to the nursing homes per year. The extra money is intended to improve the quality of nursing home care by appointing more well-trained staff. For district nursing, ambulance care, intensive care and emergency services, the government is putting additional effort into making available 350 million euros

We learned a number of valuable lessons during the programme that was meant to provide care, support and welfare for frail elderly that should fit the elderly as a warm and cosy jacket:

• Participation of the target group in the execution of the programme is the key to success.

• The main priority of frail elderly people is quality of life and well-being, not living longer.

between different care providers and a handbook for elderly care.

one, in person and online, so that we can succeed to assign value to this new phase.

During 'Ageing Better Workshops', elderly people offered their evaluation of the project from the perspective of an elderly person. This has led to changes in the available information for elderly people and their caregivers to use before hospitalization, whenever possible. Suggestions were also made to pay greater attention to welfare aspects.
